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Fires, among other forms of natural and anthropogenic disturbance, play a central role in regulating the location, composition and biomass of forests. Understanding the role of fire in global forest loss is crucial in constraining land‐use change emissions and the global carbon cycle. We analysed the relationship between forest loss and fire at 500 m resolution based on satellite‐derived data for the 2003–2018 period. Satellite fire data included burned area and active fire detections, to best account for large and small fires, respectively. We found that, on average, 38 ± 9% (± range) of global forest loss was associated with fire, and this fraction remained relatively stable throughout the study period. However, the fraction of fire‐related forest loss varied substantially on a regional basis, and showed statistically significant trends in key tropical forest areas. Decreases in the fraction of fire‐related forest loss were found where deforestation peaked early in our study period, including the Amazon and Indonesia while increases were found for tropical forests in Africa. The inclusion of active fire detections accounted for 41%, on average, of the total fire‐related forest loss, with larger contributions in small clearings in interior tropical forests and human‐dominated landscapes. Comparison to higher‐resolution fire data with resolutions of 375 and 20 m indicated that commission errors due to coarse resolution fire data largely balanced out omission errors due to missed small fire detections for regional to continental‐scale estimates of fire‐related forest loss. Besides an improved understanding of forest dynamics, these findings may help to refine and separate fire‐related and non‐fire‐related land‐use change emissions in forested ecosystems., Fire is often a key process when considering the drivers of forest loss. Fire and forest loss can be directly related, such as in wildfires, but also indirectly because of slash burning after tree felling or tree mortality after fire damage. Using a novel approach for combining satellite‐derived forest loss with fire data from burned area and active fire detections, we found that 38 ± 9% of the global forest loss during 2003–2018 was fire‐related. We discuss global patterns and trends in fire‐related forest loss, and compare our results for fire data of different spatial resolutions.

Appendiceal neuroendocrine neoplasms (ANEN) are mostly discovered coincidentally during appendicectomy and usually have a benign clinical course; thus, appendicectomy alone is considered curative. However, in some cases, a malignant potential is suspected, and therefore additional operations such as completion right hemicolectomy are considered. The existing European Neuroendocrine Tumour Society (ENETS) guidelines provide useful data about epidemiology and prognosis, as well as practical recommendations with regards to the risk factors for a more aggressive disease course and the indications for a secondary operation. However, these guidelines are based on heterogeneous and retrospective studies. Therefore, the evidence does not seem to be robust, and there are still unmet needs in terms of accurate epidemiology and overall prognosis, optimal diagnostic and follow-up strategy, as well as identified risk factors that would indicate a more aggressive surgical approach at the beginning and a more intense follow-up. In this review, we are adopting a critical approach of the ENETS guidelines and published series for ANEN, focusing on the above-noted “grey areas”.

Toll-like receptors (TLRs) are a family of transmembrane pattern recognition receptors that are mainly expressed on immune cells. Recognition of various exogenous and endogenous molecular patterns activates the TLR signalling cascade, which orchestrates an inflammatory immune response. Dysfunctional immune responses, including aberrant TLR signalling, are increasingly implicated in the associations between sedentarism, chronic low-grade systemic inflammation and various non-communicable diseases. Conversely, exercise exerts anti-inflammatory effects, which could be conferred through its immunomodulatory properties, potentially affecting TLRs. This study aims to systematically review the effects of exercise on human TLR expression.A systematic literature search of Pubmed, Embase, The Cochrane Library and SPORTDiscus for articles addressing the impact of exercise (as isolated intervention) on TLRs in humans was conducted, ending in February 2020.A total of 66 articles were included. The publications were categorised according to exercise modality and duration: acute resistance exercise (4 studies), acute aerobic exercise (26 studies), resistance training program (9 studies), aerobic training program (16 studies), combined (i.e. resistance and aerobic) training program (8 studies) and chronic exercise not otherwise classifiable (9 studies). Five articles investigated more than one of the aforementioned exercise categories. Several trends could be discerned with regard to the TLR response in the different exercise categories. Acute resistance exercise seemed to elicit TLR upregulation, whereas acute aerobic exercise had less activating potential with the majority of responses being neutral or, especially in healthy participants, downregulatory. Chronic resistance and combined exercise programs predominantly resulted in unaltered or decreased TLR levels. In the chronic aerobic exercise category, mixed effects were observed, but the majority of measurements demonstrated unchanged TLR expression.Currently published research supports an interplay between exercise and TLR signalling, which seems to depend on the characteristics of the exercise. However, there was large heterogeneity in the study designs and methodologies. Therefore, additional research is required to further corroborate these findings, to define its pathophysiological implications and to elucidate the mechanism(s) linking exercise to TLR signalling.

BACKGROUND: Toll-like receptors (TLRs) are a family of transmembrane pattern recognition receptors that are mainly expressed on immune cells. Recognition of various exogenous and endogenous molecular patterns activates the TLR signalling cascade, which orchestrates an inflammatory immune response. Dysfunctional immune responses, including aberrant TLR signalling, are increasingly implicated in the associations between sedentarism, chronic low-grade systemic inflammation and various non-communicable diseases. Conversely, exercise exerts anti-inflammatory effects, which could be conferred through its immunomodulatory properties, potentially affecting TLRs. This study aims to systematically review the effects of exercise on human TLR expression. METHOD: A systematic literature search of Pubmed, Embase, The Cochrane Library and SPORTDiscus for articles addressing the impact of exercise (as isolated intervention) on TLRs in humans was conducted, ending in February 2020. RESULTS: A total of 66 articles were included. The publications were categorised according to exercise modality and duration: acute resistance exercise (4 studies), acute aerobic exercise (26 studies), resistance training program (9 studies), aerobic training program (16 studies), combined (i.e. resistance and aerobic) training program (8 studies) and chronic exercise not otherwise classifiable (9 studies). Five articles investigated more than one of the aforementioned exercise categories. Several trends could be discerned with regard to the TLR response in the different exercise categories. Acute resistance exercise seemed to elicit TLR upregulation, whereas acute aerobic exercise had less activating potential with the majority of responses being neutral or, especially in healthy participants, downregulatory. Chronic resistance and combined exercise programs predominantly resulted in unaltered or decreased TLR levels. In the chronic aerobic exercise category, mixed effects were observed, but the majority of measurements demonstrated unchanged TLR expression. CONCLUSION: Currently published research supports an interplay between exercise and TLR signalling, which seems to depend on the characteristics of the exercise. However, there was large heterogeneity in the study designs and methodologies. Therefore, additional research is required to further corroborate these findings, to define its pathophysiological implications and to elucidate the mechanism(s) linking exercise to TLR signalling.

Several clinical conditions leading to traumatic brain injury can cause hematomas or edemas inside the cerebral tissue. If these are not properly treated in time, they are prone to produce long-term neurological disabilities, or even death. Low-cost, portable and easy-to-handle devices are desired for continuous monitoring of these conditions and Near Infrared Spectroscopy (NIRS) techniques represent an appropriate choice. In this work, we use Time-Resolved (TR) Monte Carlo simulations to present a study of NIR light propagation over a digital MRI phantom. Healthy and injured (hematoma/edema) situations are considered. TR Diffuse Reflectance simulations for different lesion volumes and interoptode distances are performed in the frontal area and the left parietal area. Results show that mean partial pathlengths, photon measurement density functions and time dependent contrasts are sensitive to the presence of lesions, allowing their detection mainly for intermediate optodes separations, which proves that these metrics represent robust means of diagnose and monitoring. Conventional Continuous Wave (CW) contrasts are also presented as a particular case of the time dependent ones, but they result less sensitive to the lesions, and have higher associated uncertainties.

Polysaccharides can be elite carriers for therapeutic molecules due to their versatility and low probability to trigger toxicity and immunogenic responses. Local and systemic therapies can be achieved through particle pulmonary delivery, a promising non-invasive alternative. Successful pulmonary delivery requires particles with appropriate flowability to reach alveoli and avoid premature clearance mechanisms. Polysaccharides can form micro-, nano-in-micro-, and large porous particles, aerogels, and hydrogels. Herein, the characteristics of polysaccharides used in drug formulations for pulmonary delivery are reviewed, providing insights into structure-function relationships. Charged polysaccharides can confer mucoadhesion, whereas the ability for specific sugar recognition may confer targeting capacity for alveolar macrophages. The method of particle preparation must be chosen considering the properties of the components and the delivery device to be utilized. The fate of polysaccharide-based carriers is dependent on enzyme-triggered hydrolytic and/or oxidative mechanisms, allowing their complete degradation and elimination through urine or reutilization of released monosaccharides.

Supplemental Digital Content is available in the text., Uveal melanoma (UM), the most common primary intraocular tumour, is often complicated by exudative retinal detachment (RD). Sometimes, this exudative RD is mistaken for a rhegmatogenous detachment and is subsequently treated with vitrectomy with silicone oil (SiOil) tamponade. As SiOil prevents ultrasound imaging, the diagnosis, treatment planning and/or follow-up of UM underlying the detachment are often severely hindered by the SiOil. We aim to develop and evaluate new MRI methods to image UM patients with a SiOil tamponade and evaluate this in vivo. A dedicated MRI protocol for 3 and 7 T was developed and subsequently evaluated in three patients. The MRI protocol developed was evaluated in three patients. In the first patient, SiOil hindered follow-up and therefore MRI was indicated. No tumour recurrence was found after two follow-up scans. The second and third patient underwent vitrectomy with SiOil for assumed rhegmatogenous RD in another hospital, during which a mass was found. In these cases, MRI was used to determine whether the lesion was UM and perform measurements to plan brachytherapy treatment. In general, the proposed workflow is more complicated on 7 T than on 3 T as the off-resonance effects scale linearly with field strength. For example, the shimming procedure needed modifications at 7 T, whereas at 3 T, the automatic shimming sufficed. However, at 7 T, higher resolution images were obtained compared with 3 T (0.6 vs. 0.8 mm3). A dedicated MRI protocol enables high-resolution imaging of vitrectomized eyes with SiOil tamponade, enabling treatment planning or follow-up in UM patients.

Increased arterial stiffness is a degenerative vascular process, progressing with age that leads to a reduced capability of arteries to expand and contract in response to pressure changes. This progressive degeneration mainly affects the extracellular matrix of elastic arteries and causes loss of vascular elasticity. Recent studies point to significant interference of dietary polyphenols with mechanisms involved in the pathophysiology and progression of arterial stiffness. This review summarizes data from epidemiological and interventional studies on the effect of polyphenols on vascular stiffness as an illustration of current research and addresses possible etiological factors targeted by polyphenols, including pathways of vascular functionality, oxidative status, inflammation, glycation, and autophagy. Effects can either be inflicted directly by the dietary polyphenols or indirectly by metabolites originated from the host or microbial metabolic processes. The composition of the gut microbiome, therefore, determines the resulting metabolome and, as a consequence, the observed activity. On the other hand, polyphenols also influence the intestinal microbial composition, and therefore the metabolites available for interaction with relevant targets. As such, targeting the gut microbiome is another potential treatment option for arterial stiffness.

Recently, the European Neuroendocrine Tumor Society (ENETS) held working sessions composed of members of the advisory board and other neuroendocrine neoplasm (NEN) experts to attempt to identify unmet needs in NENs in different locations or with advanced/poorly differentiated NENs. This report briefly summarizes the main proposed areas of unmet needs in patients with functional and nonfunctional pancreatic NENs.

Background Albuminuria has been classically considered a marker of kidney damage progression in diabetic patients and it is routinely assessed to monitor kidney function. However, the role of a mild GFR reduction on the development of stage ≥3 CKD has been less explored in type 1 diabetes mellitus (T1DM) patients. Aim of the present study was to evaluate the prognostic role of kidney disease measures, namely albuminuria and reduced GFR, on the development of stage ≥3 CKD in a large cohort of patients affected by T1DM. Methods A total of 4284 patients affected by T1DM followed-up at 76 diabetes centers participating to the Italian Association of Clinical Diabetologists (Associazione Medici Diabetologi, AMD) initiative constitutes the study population. Urinary albumin excretion (ACR) and estimated GFR (eGFR) were retrieved and analyzed. The incidence of stage ≥3 CKD (eGFR 30% from baseline was evaluated. Results The mean estimated GFR was 98 ± 17 mL/min/1.73m2 and the proportion of patients with albuminuria was 15.3% (n = 654) at baseline. About 8% (n = 337) of patients developed one of the two renal endpoints during the 4-year follow-up period. Age, albuminuria (micro or macro) and baseline eGFR 90 ml/min/1.73m2 and normoalbuminuria, those with albuminuria at baseline had a 1.69 greater risk of reaching stage 3 CKD, while patients with mild eGFR reduction (i.e. eGFR between 90 and 60 mL/min/1.73 m2) show a 3.81 greater risk that rose to 8.24 for those patients with albuminuria and mild eGFR reduction at baseline. Conclusions Albuminuria and eGFR reduction represent independent risk factors for incident stage ≥3 CKD in T1DM patients. The simultaneous occurrence of reduced eGFR and albuminuria have a synergistic effect on renal function worsening. Electronic supplementary material The online version of this article (10.1186/s12882-018-1136-6) contains supplementary material, which is available to authorized users.

Trauma in the workplace can be precipitated by a number of tragedies, but death of an employee is the most common occurrence. Bereavement, mourning, and grief are common reactions. In most cases, people successfully cope with the death within two months, but some develop chronic grief, which is also referred to as complicated grief. Principles of grief counseling are outlined along with the need for employee training on trauma.

Rutin intake is associated with a reduced risk of cardiovascular disease (CVD). The exact mechanism by which rutin can protect against CVD development is still enigmatic. Since, rutin is a compound with a relatively short half-life, the direct antioxidant effect of rutin cannot explain the long-lasting effect on human health. We hypothesized that rutin next to its direct antioxidant effect that improves endothelial function, may also induce an adaptive response in endogenous antioxidant systems.In Human Umbilical Vein Endothelial Cells (HUVECs), the direct antioxidant effect was confirmed. During scavenging of Reactive Oxygen Species (ROS), rutin is oxidized into a quinone derivative. HUVECs pretreated with rutin quinone became better protected against a second challenge with oxidative stress 3h later. LC-MS/MS analysis indicated that rutin quinone targets cysteine 151 of Keap1. Moreover, we found that the quinone is an inhibitor of the selenoprotein thioredoxin reductase 1. These properties correlated with an activation of Nrf2 and upregulation of Glutamate Cysteine Ligase, the rate-limiting enzyme of glutathione synthesis, while NF-κB and HIF activation became blunted by rutin treatment. Furthermore, rutin was found to prevent hydrogen peroxide from impairing relaxation of human chorionic plate placental vessels, which may help to protect endothelial function.Rutin functions as an antioxidant and is oxidized into a quinone that upregulates the Nrf2-mediated endogenous antioxidant response. This mechanism suggests that rutin selectively exerts its protective effects in regions with increased oxidative stress, and explains how rutin reduces the risk of developing CVD.The newly found mechanism behind the long-term protection of rutin against cardiovascular disease, the selective upregulation of endogenous antioxidant systems, contributes to the further understanding why rutin can reduce the risk on developing cardiovascular disease.

Educational handouts are becoming routine in health care, helping promote health literacy in patients and their caregivers. To be effective, handouts must be tailored to various target audiences. This article discusses several Web sites that provide accurate information for conditions commonly seen in long-term care.

Telemedicine (TM)-providing health services and information via a telecommunications device to patients or colleagues separated by distance-holds the promise of improving access to care, diagnosis and assessment, patient monitoring, treatment adherence, and positive health outcomes. TM is still evolving, and numerous obstacles must be overcome before it reaches its full potential. Major obstacles include licensure and reimbursement issues along with the development of TM care standards. While many studies have addressed TM's effectiveness, findings, although positive, are tempered because of small sample size and other methodological problems. Successful TM is clinically driven where a need is first identified and then a TM solution fulfills that clinical need.

Almost 70% of adults 60 years of age and older are overweight according to the National Health and Nutrition Examination Survey 2005-2006. While being overweight is linked to numerous comorbidities and functional impairment, few studies have addressed obesity in elders, and even fewer have addressed sarcopenic obesity. Elder obesity requires different strategies, partly because most approved weight-reduction agents and/or surgical interventions are contraindicated in older adults. Strategies and objectives for weight loss are discussed along with the consultant pharmacist's role.

Walking appears to be a simple innate ability, but it is an extraordinarily complex process involving three major afferent systems (visual, proprioception, and vestibular). Humans' unique gait is established around age seven. Velocity and step-length change with age, but the overall package we call "gait" remains stable. Age is the single most important factor in changing gait, with some normal changes expected. Gait disorders, beyond what are normal age-related changes, are common among elders. At 60 years of age, 15% of elders have gait problems, increasing to 82% for those 85 years of age and older. Abnormal gait movement can be broadly defined as hyperkinetic (too much movement) and hypokinetic (too little movement). Gait disorders are classified into lowest level (affecting one afferent system), middle level (more afferent system involvement), and highest level (characterized by planning deficits) disorders. Gait disturbances may be a manifestation of underlying conditions or may be drug-induced. To treat gait disorders appropriately, clinicians must review the patient's disease progression, medication status, and environmental conditions. Physical therapy, medication changes, and, rarely, surgery can help improve gait.

Aging is associated with physical decline, often accompanied by pathology and disability that can cause unhappiness and dissatisfaction. Despite this, many elders report a high level of satisfaction. This article discusses the anxiety associated with aging that some people experience, highlights research findings and models of aging, and pays particular attention to how elders compensate and cope with loss. Long-term care practitioners can help residents deflect negative stereotypes and improve their own attitudes about aging.

When tragic circumstances force families to focus on an individual's right to refuse treatment, society is forced to reexamine its views on life and death; these circumstances may result in legal rulings and state statutes. During media coverage of high-profile cases, reporters frequently used distinct terms like "brain dead," "persistent vegetative state," and coma interchangeably, but they are clinically different. Today, most bioethicists believe the right to refuse treatment is legally and ethically settled, but decision-making in individual circumstances often may remain less clear and emotionally charged. Even in the best situations, abatement of nutrition during the end-stage of illness continues to be difficult, often colored by religious, cultural, and racial or ethnic perspectives. Decision-making to withhold or withdraw feeding tubes for younger patients is even more difficult and raises many additional questions. Once a decision to withdraw a feeding tube is made, clinicians and the patient's loved ones need to know what to expect.

Characterized by chronic, widespread pain and heightened pain sensitivity, fibromyalgia affects up to 10 million adults. It is physically disabling and often is accompanied by chronic fatigue and psychiatric comorbidities. Individuals frequently see multiple providers before finding an answer about their condition; diagnosis is often a process of elimination. Etiology is unknown, but studies suggest fibromyalgia is a centrally mediated neurosensory disorder. Despite its recognition as an independent condition, debate continues with critics arguing fibromyalgia is a variant of other known disorders. Treatment consists of pharmacotherapy, psychotherapy, and exercise.

PROBLEM: We're so busy taking care of others that we rarely have time to focus on our own health needs. I've read that many companies have employee wellness programs (EWPs). Do they really work? Is this something we should consider? SOLUTION: Getting chubby? Smoking too much? Stressed? Health in decline? Dragging yourself to work even if you're too sick to be productive, EWPs can help. Today, up to 90% of employers have at least one activity promoting wellness, ranging from printed material to in-house fitness centers and one-on-one counseling. Implementing a successful wellness program, however, can be challenging, especially in health care, where almost any employee activity competes with direct patient care.

Today's prisons are vastly overcrowded and ill prepared for the fastest growing segment of the inmate population: those 50 years of age and older. Collectively, such inmates present with age-related illnesses earlier, and often their conditions are more complex than similar nonincarcerated people. Prisons focus on discipline and order; as a result, they have had to adapt to the health care needs of aging inmates, especially those with physical impairments. While some prisons have created special units for older inmates, demand for such units outpaces supply. Medication errors are common as is medication nonadherence. Continuity of care is compromised both within the system and at the point of community release. Regardless, the prison setting offers many opportunities for pharmacists to expand their practices in ways that are rewarding.

Approximately 134,000 amputations occur annually in the United States, resulting mostly from peripheral vascular disease. The risk of amputation increases with age, peaking among those 85 years of age and older. As a lifesaving and life-defining procedure, amputations result in physical and emotional changes affecting quality of life. Phantom pain is problematic for many patients, and agents approved by the Food and Drug Administration for phantom pain are nonexistent. Pharmacists should be knowledgeable about weight-based dosing as well as patient education guidelines.

Optimism is linked to positive health outcomes, although its mechanism is largely unknown. Evidence supports two independent types of optimism: dispositional optimism, which is similar to other personality traits, and explanatory optimism, which affects an individual's interpretation of success and failure. Generally, individuals scoring high on optimism have better health outcomes, and when confronted with life-threatening illnesses, cope with the illness in a healthier manner. Cognitive behavioral therapy offers one potential intervention that may increase a person's level of optimism, with a corresponding increase in health outcomes.

Studies link involuntary outpatient commitment with improved patient outcomes, fueling debate on its ethical justification. This study compares inpatient utilization for committed outpatients in the 1990s with those who were not under outpatient civil commitment orders. Findings reveal committed outpatients had higher utilization of inpatient services and restraint episodes prior to their commitment compared with a control group. Committed outpatients also were more likely to have been on discharge status at the time of admission, have been admitted involuntarily under emergency legal procedures, and have had a greater number of admissions and hospital days prior to their commitment. Following commitment, patients had fewer hospitalizations, shorter lengths of stay, fewer seclusion episodes and hours, and fewer restraint episodes and hours. Findings are discussed within the context of parens patriae and therapeutic jurisprudence, and support medical and public policy justifications for ethical uses of outpatient civil commitment laws for seriously mentally ill patients.

When groups of people relocate from their homelands to other nations, especially if the movement is involuntary, minority populations are created in the countries that receive them. The issues related to these diaspora and diasporic communities--any groups that have been dispersed outside their traditional homelands--are financial, social, historical, political, or religious. In health care, issues include heritable diseases, cultural barriers, patients' health care beliefs, and unique disease presentations. In long-term care, many residents and health care providers have relocated to the United States from other countries.

PROBLEM: In the long-term care facilities where I work, I've noticed certain ways health care providers converse with residents, and I am starting to pick up these speech patterns myself. Are these language changes helpful, or are they communication hazards? SOLUTION: Although most people pick up on the special language caregivers often use with long-term care residents and elders in general, few question its appropriateness until they are old enough to be subjected to it. Since the late 1980s, however, researchers have been examining this vernacular. It has acquired a number of names, such as "secondary baby talk" or "overaccommodative speech," but the tag used most often is "elderspeak."

More than 70% of nursing home residents spend at least part of their day in wheelchairs. Ideally, each resident would be fitted for his or her own wheelchair. A well-fitted chair can improve mobility, safety, and comfort. Wheelchairs that are ill fitting, however, can cause or exacerbate medical problems. These include posture-related complications like poor breathing or dysphagia, falls, pressure sores, and several other conditions. Pharmacists who are involved with quality improvement activities can make wheelchair use and selection a priority, improving care for wheelchair-bound residents.

Despite significant improvement in the management of atherosclerosis, this slowly progressing disease continues to affect countless patients around the world. Recently, the mechanistic target of rapamycin (mTOR) has been identified as a pre‐eminent factor in the development of atherosclerosis. mTOR is a constitutively active kinase found in two different multiprotein complexes, mTORC1 and mTORC2. Pharmacological interventions with a class of macrolide immunosuppressive drugs, called rapalogs, have shown undeniable evidence of the value of mTORC1 inhibition to prevent the development of atherosclerotic plaques in several animal models. Rapalog‐eluting stents have also shown extraordinary results in humans, even though the exact mechanism for this anti‐atherosclerotic effect remains elusive. Unfortunately, rapalogs are known to trigger diverse undesirable effects owing to mTORC1 resistance or mTORC2 inhibition. These adverse effects include dyslipidaemia and insulin resistance, both known triggers of atherosclerosis. Several strategies, such as combination therapy with statins and metformin, have been suggested to oppose rapalog‐mediated adverse effects. Statins and metformin are known to inhibit mTORC1 indirectly via 5' adenosine monophosphate‐activated protein kinase (AMPK) activation and may hold the key to exploit the full potential of mTORC1 inhibition in the treatment of atherosclerosis. Intermittent regimens and dose reduction have also been proposed to improve rapalog's mTORC1 selectivity, thereby reducing mTORC2‐related side effects.

Vertigo is a common balance deregulation symptom among elders. Its etiology may be peripheral vestibular disease or a central vestibular disorder. Symptom onset, severity, and duration are distinguishing characteristics. The majority of peripheral vestibular disorders include benign paroxysmal positional vertigo, vestibular neuronitis, Meniere's disease, and perilymph fistula. Medication regimen review is necessary to identify possible drug-induced etiology. Treatment options include pharmacotherapy, canalith repositioning procedures, surgery, vestibular rehabilitation therapy, and dietary interventions.

Long-term care facilities have tracked resident data for decades. Using those data, researchers have been able to identify and track trends. Resident demographics, facility information, and types of deficiencies uncovered by state surveys are three types of data of interest to consultant pharmacists. Examining trends can provide clues about areas where improved training, greater scrutiny, or targeted interventions may next be needed.

Medical applications (apps) for smart phones have grown in popularity, with minimal oversight by regulatory agencies. A few Web-based resources exist that evaluate apps using peer review or certification standards. Eight clinical apps are presented along with brief explanations of each. Many users believe apps improve patient care and clinical decision-making, but until additional research is conducted, these assertions remain untested assumptions.

The possible complications of wisdom-tooth removal must be considered, because it is the most common surgical intervention in dental practices. This retrospective study assessed the complications occurring during the removal of 1,562 maxillary wisdom teeth in 1,212 patients. A total of 543 cases of surgical removal and 1,019 cases of non-surgical removal were analyzed. In all cases, a pre-operative panoramic radiograph was taken. Anatomical and clinical parameters were included in the evaluation. 106 complications occurred in 92 patients (5.9%) of the total 1,562 operations. Of these complications, 5.1% were intra-operative and 0.8% postoperative. An oroantral fistula (OAF) was found in 38 cases (2.4%), and alveolar osteitis occurred post-operatively in 6 cases (0.4%). The risk of OAF correlated with increasing patient age (p=0.0368). Root fractures also increased the risk of OAF. On the basis of the analysis of pre-operative panoramic radiographs, it was shown that radiological projection of the root tips to the sinus floor is a reliable criterion to assess the risk of OAF.

The knowledge of potential complications after surgical removal of third molars and adequate risk assessment is indispensable in oral surgery. The present retrospective study analyzed the influence of different parameters, such as the patient’s age and gender, retention type, and radiological projection (using orthopantomography) of wisdom teeth on the mandibular canal on postoperative complications after the removal of 1,199 wisdom teeth. Overall, 101 (8.4%) complications occurred: 50 cases of alveolar osteitis (4.2%), 12 temporary (1%) and 6 persistent (0.5%) sensation disorders, 15 abscesses (1.25%), 7 dehiscences (0.6%), 5 cases of post-operative bleeding (0.4%), 4 sequestra (0.32%), 1 fistula (0.08%) and 1 hematoma (0.08%). The risk for developing alveolar osteitis was 6% for patients who suffered from a previous pericoronal infection and was higher for female than male patients. Smoking showed no influence on alveolar osteitis. A significant correlation (p0.0001) could be shown between the radiological projection of wisdom teeth on the mandibular canal and post-operative sensation disorders. The experience of the surgeon and pre-operative 3-dimensional imaging (cone- beam computed tomography, computed tomography) did not reduce this risk. No correlation was found for patient’s age and gender. In conclusion, the surgical decision to remove wisdom teeth must be made with caution in cases of complete radiological projection of the wisdom tooth on the mandibular canal.

The malaria parasite Plasmodium goes through two life stages in the human host, a non-symptomatic liver stage (LS) followed by a blood stage with all clinical manifestation of the disease. In this study, we investigated a series of 2-alkynoic fatty acids (2-AFAs) with chain lengths between 14 and 18 carbon atoms for dual in vitro activity against both life stages. 2-Octadecynoic acid (2-ODA) was identified as the best inhibitor of Plasmodium berghei parasites with ten times higher potency (IC50 = 0.34 μg/ml) than the control drug. In target determination studies, the same compound inhibited three Plasmodium falciparum FAS-II (PfFAS-II) elongation enzymes PfFabI, PfFabZ, and PfFabG with the lowest IC50 values (0.28-0.80 μg/ml, respectively). Molecular modeling studies provided insights into the molecular aspects underlying the inhibitory activity of this series of 2-AFAs and a likely explanation for the considerably different inhibition potentials. Blood stages of P. falciparum followed a similar trend where 2-ODA emerged as the most active compound, with 20 times less potency. The general toxicity and hepatotoxicity of 2-AFAs were evaluated by in vitro and in vivo methods in mammalian cell lines and zebrafish models, respectively. This study identifies 2-ODA as the most promising antiparasitic 2-AFA, particularly towards P. berghei parasites. © 2014 Elsevier Ltd. All rights reserved.

Problem I'm beginning to feel technologically illiterate. When I see younger staff using wireless devices to access databases, update information, schedule appointments, and send messages to colleagues, I have no idea how they do so much electronically. Any suggestions? Solution Has the information age left you behind? If you were educated before 1990 you've been challenged-and probably frustrated-by rapidly evolving technology. Few older pharmacists have had formal training in using new technology, and many have taught themselves by trial and error. This is a problem in all fields. One small study found that among senior clinicians using computers, only 36% received formal course training.1 Recognizing that their senior staff risked technological illiteracy, corporate entities have addressed this problem with "reverse mentoring" programs-a rare approach in health care-but one that can propel career development.

PROBLEM Most nursing homes are aware of the pandemonium an outbreak of scabies can cause-the laundry alone occupies staff for days. Debilitated residents and those who have poor selfcare skills require considerable help with the activities associated with the eradication of Sarcoptes scabiei. How can a consultant pharmacist help? SOLUTION Consultant pharmacists should cultivate a "high index of suspicion" for scabies. Scabies mites live their entire lives on the human host as obligate parasites. They are able to survive elsewhere for only up to 48 hours, making transmission via fomite (blankets, towels, or any object that can transmit infectious agents) possible, but unlikely. Transmission follows close personal contact, and passing contact like handshaking is insufficient to pass the mites. Crowded living conditions, such as those associated with emergency shelters, and close and repeated contact, like that which occurs in classrooms, fuel cluster outbreaks.

Ethylene dibromide (1,2-dibromoethane, EDB) is metabolized by two routes: a conjugative route catalyzed by glutathione S -transferases (GST) and an oxidative route catalyzed by cytochrome P450 (P450). The GST route is associated with carcinogenicity. An approach is presented to use human purified GST and P450 enzymes to explore the importance of these metabolic pathways for man in vivo. This strategy basically consists of four steps: (i) identification of the most important isoenzymes in vitro, (ii) scaling to rate per milligram cytosolic and microsomal protein, (iii) scaling to rate per gram liver, and (iv) incorporation of data in a physiologically based pharmacokinetic (PBPK) model. In the first step, several GST isoenzymes were shown to be active toward EDB and displayed pseudo-first-order kinetics, while the EDB oxidation was catalyzed by CYP2E1, 2A6, and 2B6, which all displayed saturable kinetics. In the second step, the predictions were in agreement with the measured activity in a batch of 21 human liver samples. In the third step, rat liver P450 and GST metabolism of EDB was predicted to be in the same range as human metabolism (expressed per gram). Interindividual differences in GST activity were modeled to determine “extreme cases.” For the most active person, an approximately 1.5-fold increase of the amount of conjugative metabolites was predicted. Lastly, it was shown that the GST route, even at low concentrations, will always contribute significantly to total metabolism. In the fourth step, a PBPK model describing liver metabolism after inhalatory exposure to EDB was used. The saturation of the P450 route was predicted to occur faster in the rat than in man. The rat was predicted to have a higher turnover of EDB from both routes. Nevertheless, when all data are combined, it is crucial to recognize that the GST remains significantly active even at low EDB concentrations. The limitations and advantages of the presented strategy are discussed.

The aim of this study was to optimize the metabolic conditions for planar myocardial fluorine-l8 fluorodeoxyglucose (FDG) imaging. The effects of high and low insulin levels during euglycaemic clamping on myocardial and femoral muscle FDG uptake were compared since insulin plays a major role in glucose metabolism. FDG uptake in 11 patients was studied using planar scintigraphy. Patients were studied twice: in the low-dose insulin protocol (LDI), insulin was infused at a rate of 20 mU/kg per hour, starting 1 h before FDG administration, while in the high-dose insulin protocol (HDI) it was infused at a rate of 100 mU/kg per hour. Glucose infusion rate was adjusted according to frequently determined blood glucose levels. Somatostatin was infused to block endogenous insulin release. Planar images were obtained from the thorax region and femoral muscles. Regions of interest were drawn over normal and abnormal myocardial areas (based on angiographic and thallium-201 data) and over lung, liver and muscle areas. After clamping, insulin levels during LDI and HDI at t=60 were 30.6±13.3 and 129.6±30.5 mU/1 respectively (P