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Introduction: Homeless patients tend to visit Emergency Departments (EDs) more frequently than the non-homeless population. The goal of this study was to assess differences in chief complaint, medical conditions, and disposition between homeless patients compared to non-homeless patients presenting to an urban ED.Methods: This was a retrospective cohort of homeless patients ages ≥18 years compared to non-homeless controls from January 1, 2017 to December 31, 2017. Exclusion criteria were as follows: direct admission to hospital floor, repeat visits, or leaving without being seen. The primary endpoint of this study was to assess differences in chief complaint of homeless versus non-homeless patients upon presentation to the ED. Our secondary endpoints included differences in ED utilization between the two groups, in terms of length of stay, ambulance use, diagnosis, and disposition.Results: Homeless patients were more likely present to the ED for a psychiatric evaluation (homeless group 34% vs. non-homeless group 4%, p < 0.01) and have a history of a psychiatric diagnosis (56% vs. 10%, p < 0.01) compared to non-homeless controls. Homeless patients also tended to require more ambulance transport (46% vs. 16%, p < 0.01). More homeless patients were transferred to a psychiatric facility (40% vs. 1%, p < 0.01), while the majority of non-homeless patients were discharged home (50% vs. 93%, p < 0.01).Conclusion: This study found that homeless patients had a significantly higher association with psychiatric diagnoses and greater ED utilization than non-homeless. This suggests the importance of increased access to consistent psychiatric care and follow up within the homeless population. [ABSTRACT FROM AUTHOR]

Bosch–Boonstra–Schaaf Optic Atrophy Syndrome (BBSOAS) is an autosomal dominant neurodevelopmental disorder caused by loss‐of‐function variants in NR2F1 and characterized by visual impairment, developmental delay, and intellectual disability. Here we report 18 new cases, provide additional clinical information for 9 previously reported individuals, and review an additional 27 published cases to present a total of 54 patients. Among these are 22 individuals with point mutations or in‐frame deletions in the DNA‐binding domain (DBD), and 32 individuals with other types of variants including whole‐gene deletions, nonsense and frameshift variants, and point mutations outside the DBD. We corroborate previously described clinical characteristics including developmental delay, intellectual disability, autism spectrum disorder diagnoses/features thereof, cognitive/behavioral anomalies, hypotonia, feeding difficulties, abnormal brain MRI findings, and seizures. We also confirm a vision phenotype that includes optic nerve hypoplasia, optic atrophy, and cortical visual impairment. Additionally, we expand the vision phenotype to include alacrima and manifest latent nystagmus (fusional maldevelopment), and we broaden the behavioral phenotypic spectrum to include a love of music, an unusually good long‐term memory, sleep difficulties, a high pain tolerance, and touch sensitivity. Furthermore, we provide additional evidence for genotype–phenotype correlations, specifically supporting a more severe phenotype associated with DBD variants. [ABSTRACT FROM AUTHOR]

Nuances for preparing a publishable manuscript in an efficient and productive manner are often learned experientially and over many years. The purpose of this "how‐to" guide is to assist new practitioner pharmacists, as well as pharmacy residents and students, with effectively writing a research manuscript for publication. General considerations for scientific writing are presented, including target journal selection; the intentional process of writing fast, bad, and wrong; editing with a focus; and methods to convey messages in the most unambiguous and accurate ways possible. Then elements and nuances to writing the common manuscript sections (ie, introduction, methods, results, discussion, conclusion, and abstract) are elucidated. Finally, guidance on documents that accompany a manuscript (ie, cover letter and response to reviewer comments) is provided. [ABSTRACT FROM AUTHOR]

Purpose To elucidate the considerations pharmacists have when using concomitant vancomycin and piperacillin/tazobactam (VPT) and strategies implemented across hospitals in response to published data on this phenomenon. Methods: A survey of pharmacist members of the infectious diseases and critical care (CC) practice and research networks of the American College of Clinical Pharmacy was conducted. Participants were grouped based on their belief (yes or no) in the association between VPT and acute kidney injury (AKI) and queried regarding AKI with VPT, antimicrobial stewardship practices, and demographics. Descriptive statistics were performed. Between‐group responses were compared using χ2 or Fisher's exact tests. Results: There were 238 responses. Most (88.7%) respondents believed combination VPT is associated with greater expected odds of AKI development than vancomycin monotherapy or with cefepime. Nonbelievers more commonly practiced in CC or emergency medicine (P =.006) and less frequently recommended the combination in patients already experiencing AKI (64% vs 7.4%, P <.001) and in patients with chronic kidney disease class III or IV (56.9% vs 3.7%, P <.001). Opinions varied regarding risk factors for and odds of AKI development in specific scenarios. Respondents who believed combination VPT is associated with greater odds of AKI development more frequently provided formal (18% vs 0, P =.01) and informal (73% vs 33.3%, P <.001) education on potential AKI from combination VPT and discouraged empiric combination VPT in favor of other combination(s) (40.8% vs 14.8%, P =.01). Other AMS strategies were used to a similar extent regardless of belief in the association of VPT with AKI. Conclusion: Most respondents, particularly those practicing in CC and emergency medicine, believe combination VPT is associated with AKI development. These beliefs have affected antimicrobial recommendations and educational efforts. The impact of these beliefs on patient outcomes and health care expenditures requires further investigation. [ABSTRACT FROM AUTHOR]

While single‐center research serves multiple purposes for the provision of patient care and identification of testable hypotheses, the importance of multicenter research is well established. The purpose of this "how‐to" guide is to assist pharmacists with the various steps in performing and coordinating multicenter, observational research. The steps that are reviewed include identifying a precise and appropriate research question; determining the expected final products or deliverables from the project and the timeline needed to satisfactorily achieve each step in the process toward these deliverables; establishing the research team structure and recognition of project contributions; navigating the institutional review board approval and data sharing and storage processes; collecting, cleaning, and analyzing data; evaluating additional project management considerations; avoiding and resolving pitfalls of multicenter research; and wrapping up the project. Resources are provided to encourage and support pharmacist principal investigators in their research efforts. [ABSTRACT FROM AUTHOR]

Study Objective: Stroke mimics may be difficult distinguish from acute ischemic strokes and are often treated with alteplase though not by intent. We report the characteristics, frequency, and outcomes of stroke mimics treated at our institution. Using our data, we then explore how the inclusion of stroke mimics in stroke outcomes research may be an important source of bias.Methods: We retrospectively identified all patients treated with alteplase in our emergency department from August 2013 to December 2017 for suspected acute ischemic stroke. We collected the following variables: gender, age, risk factors (hypertension, diabetes, and atrial fibrillation), admission glucose, admission National Institute of Health Stroke Scale, admission mean arterial pressure, onset-to-treatment time, adverse events, discharge diagnosis, length of stay, discharge NIHSS, discharge destination, and 3 month modified Rankin score.Results: One hundred and eighteen patients were treated with alteplase for suspected acute ischemic stroke of which 33 (27.9%) were stroke mimics. Compared to ischemic strokes, stroke mimics were younger (median age 53 versus 69; P < .0003); were less likely to have vascular risk factors (hypertension [51.5% versus 78.8%; P < .005] diabetes (9.1% versus 32.9%; P < .007), and atrial fibrillation (3.0% versus 23.5%; P < .006). The most common stroke mimic was transient ischemic attack (33.3%). Stroke mimics were significantly more likely to be discharged home (75.8% versus 41.2%; P < .002). Outcomes unadjusted for stroke mimics led to artificial inflation of a favorable discharge destination.Conclusions: Inclusion of stroke mimics led to an artificial inflation of a favorable discharge destination for our entire cohort. Our study highlights the potential for bias in reporting favorable outcomes if appropriate adjustment accounting for stroke mimics does not occur. [ABSTRACT FROM AUTHOR]

This study examines health outcomes in burn patients with sepsis. We hypothesized that burn patients with sepsis would have an increased odds risk for in-hospital death and longer intensive care unit (ICU) stays. This was a retrospective cohort of consecutive patients admitted to the burn ICU with total BSA (TBSA) ≥10% and/or inhalation injury between January 2008 and March 2015. Overall 407 burn patients were included; the case-rate for sepsis was 39.1% (n = 159); 20.1% (n = 82) patients were septic and 18.9% (n = 77) patients experienced septic shock. Patients with septic shock had the highest mortality rate (13.31% no sepsis vs 3.7% sepsis vs 49.4% septic shock, P < .01). Median 28-day ICU-free days was higher in patients without sepsis (23 days [Interquartile range (IQR) 14-27] no sepsis vs 0 days [IQR 0-10] sepsis vs 0 days [IQR 0-0] septic shock, P < .01). Sepsis (with or without shock) increased odds of in-hospital death (odds ratio 7.04, 95% confidence interval 1.93-25.7) in reference to the no sepsis group. With each incremental Sequential Organ Failure Assessment (SOFA) score or 10% TBSA increase, the odds risk for in-hospital death increased by 56 and 75%, respectively. Our study characterized outcomes in patients with sepsis after severe burn injury. The odds risk for in-hospital death was greater in patients with sepsis, increasing burn severity according to TBSA and SOFA score. [ABSTRACT FROM AUTHOR]

Recently, many studies have demonstrated pleotropic effects of vitamin D, including immune modulation and cardiovascular system activity. Sufficient vitamin D concentrations and supplementation of vitamin D may be of benefit in burn-injured patients. Low 25(OH)D has been observed in nearly all pediatric and most adult burn patients. Vitamin D has primarily been studied in pediatric burn patients, focusing on bone marker measurements and the incidence of fractures. The preferred vitamin D dose, formulation, and route of administration remain unknown, and there is limited data on the impact of vitamin D status on clinical outcomes. Further research should focus on determining optimal monitoring strategies, supplementation regimens and clinical outcomes like mortality, length of stay and incidence of sepsis. [ABSTRACT FROM AUTHOR]

Among a multitude of hormonal and metabolic complications, individuals with Prader‐Willi syndrome (PWS) exhibit significant bone abnormalities, including decreased BMD, osteoporosis, and subsequent increased fracture risk. Here we show in mice that loss of Magel2, a maternally imprinted gene in the PWS critical region, results in reduced bone mass, density, and strength, corresponding to that observed in humans with PWS, as well as in individuals suffering from Schaaf‐Yang syndrome (SYS), a genetic disorder caused by a disruption of the MAGEL2 gene. The low bone mass phenotype in Magel2‐/‐ mice was attributed to reduced bone formation rate, increased osteoclastogenesis and osteoclast activity, and enhanced trans‐differentiation of osteoblasts to adipocytes. The absence of Magel2 in humans and mice resulted in reduction in the fatty acid amide bone homeostasis regulator, N‐oleoyl serine (OS), whose levels were positively linked with BMD in humans and mice as well as osteoblast activity. Attenuating the skeletal abnormalities in Magel2‐/‐ mice was achieved with chronic administration of a novel synthetic derivative of OS. Taken together, Magel2 plays a key role in modulating bone remodeling and mass in PWS by affecting OS levels and activity. The use of potent synthetic analogs of OS should be further tested clinically as bone therapeutics for treating bone loss. © 2018 American Society for Bone and Mineral Research. [ABSTRACT FROM AUTHOR]

Purpose: Screening of patients with sepsis is needed to increase recognition and allow for earlier interventions. There is no consensus on whether the addition of lactate to the critical result laboratory’s call list should be a standard practice. Materials and Methods: This was a retrospective cohort study that compared management and outcomes of patients with sepsis having lactate ≥4 mmol/L before (group 1) and after (group 2) the addition of a critical result threshold of lactate of ≥4 mmol/L to the critical result laboratory’s call list and its effects on time to antibiotics and intravenous fluids (IVFs). Results: One hundred twenty-one patients were included. Lactate was higher in group 1 (7.0 ± 4.3 vs 5.6 ± 2.0, P = 0.03). More patients in group 2 received hydrocortisone (1.9% vs 22.4%, P = .001). Hospital mortality, 30-day mortality, and 90-day mortality were significantly lower in group 2 (59.3% vs 32.8%, P = .003; 68.5% vs 37.3%, P ≤ .001; 68.5% vs 41.8%, P = .002). There were no significant differences in total volume of IVFs (2400.8 ± 1720.0 vs 2483.7 ± 2155.7, P = 0.83), time to start IVFs (184.0 ± 283.2 vs 115.6 ± 190.5, P = 0.27), or antibiotics (184.8 ± 187.1 vs 133.7 ± 137.4, P = 0.16). Conclusion: Addition of lactate to the critical result laboratory’s call list did not lead to a statistically significant improvement in time to IVFs or antibiotics, although the average time to antibiotics and IVFs decreased by 51.1 and 68.4 minutes, respectively. Hospital mortality, 30-day mortality, and 90-day mortality were lower in group 2, which may be, in part, due to increased recognition of severe sepsis by critical result notification and earlier intervention. [ABSTRACT FROM AUTHOR]