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The patient allocation paradigm of nursing care is slowly superseding the task allocation paradigm. A research study reported here upon the introduction of patient allocation in a maternity hospital found that patients experienced few significant changes in their satisfaction; similar to previous studies this research found that the nurses reported significant gains in satisfaction. Following analysis of the 'medical model' assumptions inherent in the two paradigms and the methods used in the studies, it is suggested that a third paradigm of nursing care is emerging, 'patient centre' -- a paradigm within which the patient is a participating individual. [ABSTRACT FROM AUTHOR]

Encephalitis lethargica, an epidemic neurological illness, typically involved a severe sleep disorder and progressive parkinsonism. A century later, our understanding relies on seminal descriptions, more recent historical research and the study of small numbers of possible sporadic cases. Theories around infection, environmental toxins, catatonia and autoimmune encephalitis have been proposed. We aimed to describe the presentation of encephalitis lethargica and test these diagnostic and aetiological theories. Subjects with encephalitis lethargica were identified in the archives of the National Hospital for Neurology and Neurosurgery, UK between 1918 and 1946. Case notes were examined to establish illness temporality, clinical features and cerebrospinal fluid results. Controls from the archives were identified for 10% of cases, matching on discharge year, sex and neurologist. Clinical presentation was compared to modern diagnostic criteria for encephalitis lethargica, catatonia and autoimmune encephalitis. In a case-control design, a multilevel logistic regression was conducted to ascertain whether cases of encephalitis lethargica were associated with febrile illnesses and with environmental exposures. Six hundred and fourteen cases of encephalitis lethargica and 65 controls were identified. Cases had a median age of 29 years (interquartile range 18) and a median time since symptomatic onset of 3.00 years (interquartile range 3.52). Motor features were present in 97.6%, cranial nerve findings in 91.0%, ophthalmological features in 77.4%, sleep disorders in 66.1%, gastrointestinal or nutritional features in 62.1%, speech disorders in 60.8% and psychiatric features in 53.9%. Of the 167 cases who underwent lumbar puncture, 20 (12.0%) had a pleocytosis. The Howard and Lees criteria for encephalitis lethargica had a sensitivity of 28.5% and specificity of 96.9%. Among the cases, 195 (31.8%, 95% confidence interval 28.1-35.6%) had a history of febrile illness within one calendar year prior to illness onset, which was more common than among the controls (odds ratio 2.70, 95% confidence interval 1.02-7.20, P = 0.05), but there was substantial reporting bias. There was no evidence that occupational exposure to solvents or heavy metals was associated with encephalitis lethargica. Two hundred and seventy-six (45.0%) of the cases might meet criteria for possible autoimmune encephalitis, but only 3 (0.5%) might meet criteria for probable NMDA receptor encephalitis. Only 11 cases (1.8%) met criteria for catatonia. Encephalitis lethargica has a distinct identity as a neuropsychiatric condition with a wide range of clinical features. Evidence for a relationship with infectious or occupational exposures was weak. Autoimmune encephalitis may be an explanation, but typical cases were inconsistent with NMDA receptor encephalitis., Competing Interests: J.P.R. reports research funding from Wellcome and NIHR; royalties from Taylor & Francis; payment for reviewing from Johns Hopkins University Press; and speaker fees from the Alberta Psychiatric Association, Grey Nuns Hospital (Edmonton), Infomed Research & Training Ltd., North East London NHS Foundation Trust, TooFar Media and Vanderbilt University Medical Center. He has received support to attend meetings from the British Association for Psychopharmacology and the European Congress of Neuropsychopharmacology. He is a Council member for the British Association for Psychopharmacology, a member of the Medical Advisory Board of the Catatonia Foundation and an Advisor to the Global Neuropsychiatry Group. He conducts expert witness work. M.S.Z. declares honoraria for one lecture each for each of the four mentioned in the last 4 years: Norwegian Neurological Society; Copenhagen Neuropsychological Society, Rigshospitalet; Cygnet Healthcare; and UCB Pharma. M.S.Z. declares travel and hotel support for a stay in Florence from the European Association of Neurology (EAN) for an EAN meeting on autoimmune encephalitis in April 2022. M.S.Z. represents neurology in the UK for the Association of British Neurologists for matters related to COVID in meetings with NHS England and Royal College of Physicians. The other authors declare no conflict of interest., (© The Author(s) 2024. Published by Oxford University Press on behalf of the Guarantors of Brain.)

Exocrine pancreatic insufficiency (EPI) is a complex condition that disrupts normal digestion and absorption. Patients with EPI may suffer from mild to debilitating malabsorption with a constellation of symptoms that can have a significant effect on quality of life and nutrition status. Pancreatic enzyme replacement therapy (PERT) is effective and safe to treat EPI and is the standard of care for this condition. A wide variety and various forms of these products exist, as well as numerous guidelines and recommendations. Obtaining PERT for patients can oftentimes be cost prohibitive. Determining the presence and extent of EPI can be challenging and patient specific, making it difficult for practitioners. This narrative review will explore these issues, as well as several disease states potentially affected by EPI, and review current management strategies., (© 2024 American Society for Parenteral and Enteral Nutrition.)

We have made the compound 2O-BaPtO 3 by high-pressure, high-temperature synthesis, determined its structure, and tested its catalytic activity. Compounds of the same stoichiometry have been reported and tentatively identified as hexagonal perovskites, and although no structural model was ever established, 2O-BaPtO 3 is clearly different and, to the best of our knowledge, unique. It features continuous chains of face-sharing PtO 6 octahedra, like the well-known 2H hexagonal perovskite type, but with a staggered offset between the chains that breaks hexagonal symmetry and disrupts the close-packed array of A = Ba and X = O that is a defining characteristic of ABX 3 perovskites. We investigated this structure and its stability vs the conventional 2H form using X-ray and neutron diffraction, X-ray absorption spectroscopy, and ab initio calculations. Catalytic testing of 2O-BaPtO 3 showed that it is active for hydrogen evolution.

The Prevalence of Hepatitis B Markers in Anesthesia Personnel. By Berry AJ, Isaacson IJ, Hunt D, Kane MA. Anesthesiology 1984; 60:6-9 The prevalence of hepatitis B viral markers has increased in some groups of medical workers who are exposed to blood from patients carrying the virus, but this has not been studied critically in physicians and others who administer anesthesia. Physician anesthesiologists (M.D.) and nurse anesthetists and anesthesia assistants (non-M.D.) at four university-affiliated hospitals were evaluated for hepatitis B markers as determined by seropositivity for hepatitis B surface antigen, antibody to the hepatitis B surface antigen, or antibody to the hepatitis B core antigen. In the 86 subjects (38 M.D., 48 non-M.D.) who represented 80.4% of possible participants, the overall prevalence of serologic markers of hepatitis B was 23.3%. The frequency did not differ between M.D. (23.7%) and non-M.D. (22.9%) groups or between men (20.3%) and women (26.9%). Of 81 subjects who had no clinical history of hepatitis, 16 (19.8%) had positive serologic markers. The frequency of seropositivity increased with time since graduation from medical school (M.D.) or nursing school or college (non-M.D.). The prevalence of serologic markers of hepatitis B virus in this study of anesthesia personnel is five to eight times that of the general population but is similar to that of other medical workers who frequently are exposed to blood., (Copyright © 2023 American Society of Anesthesiologists. All Rights Reserved.)

The term 'opioids' refers to both the natural compounds ('opiates') which are extracted from the opium poppy plant ( Papaver somniferum ) and their semi-synthetic and synthetic derivatives. They all possess relatively similar biochemical profiles and interact with the opioid receptors within the human body to produce a wide range of physiological effects. They have historically been used for medicinal purposes, their analgesic and sedative effects, and in the management of chronic and severe pain. They have also been used for non-medicinal and recreational purposes to produce feelings of relaxation, euphoria and well-being. Over the last decade, the emergence of an illegal market in new synthetic opioids has become a major global public health issue, associated with a substantial increase in unintentional overdoses and drug-related deaths. Synthetic opioids include fentanyl, its analogues and emerging non-fentanyl opioids. Their popularity relates to changes in criminal markets, pricing, potency, availability compared to classic opioids, ease of transport and use, rapid effect and lack of detection by conventional testing technologies. This article expands on our previous review on new psychoactive substances. We now provide a more in-depth review on synthetic opioids and explore the current challenges faced by people who use drugs, healthcare professionals, and global public health systems., Competing Interests: The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Drs David Wood and Derek Tracy are members of the Advisory Council on the Misuse of Drugs (ACMD), a report of which is referenced within this paper. Professor Harry Sumnall is a former member of the ACMD but is a co-opted member of the ACMD working group on Cannabis based products for medicinal use., (© The Author(s), 2022.)

The initial melts erupted by a Hawaiian volcano have a range of alkalic compositions but are rarely observed as they are covered by enormous volumes of shield stage tholeiites. A remarkable record of the early evolution of Hawaiian volcanoes, however, is preserved by a volcanic sandstone dredged from the submarine flank of Kilauea, which contains a suite of petrogenetically related pre-shield basanite to nephelinite glasses. Here we show that the systematic variation in the rare earth element (REE) patterns of these samples requires the fractional crystallisation of garnet. A fractionating assemblage of Ca-rich garnet (32%), omphacitic clinopyroxene (63%), and minor phlogopite can explain the variation in the major and trace element contents of the suite. The results suggest fractional crystallisation of eclogite from a primitive Hawaiian melt near the base of the lithosphere (>90 km) and that a deep magma chamber is the first stage in the development of a Hawaiian volcano., (© 2022. The Author(s).)

Background: Neuropsychiatric symptoms are common in Parkinson's disease (PD) and predict poorer outcomes. Reward processing dysfunction is a candidate mechanism for the development of psychiatric symptoms including depression and impulse control disorders (ICDs). We aimed to determine whether reward processing is impaired in PD and its relationship with neuropsychiatric syndromes and dopamine replacement therapy., Methods: The Ovid MEDLINE/PubMed, Embase and PsycInfo databases were searched for articles published up to 5 November 2020. Studies reporting reward processing task performance by patients with PD and healthy controls were included. Summary statistics comparing reward processing between groups were converted to standardised mean difference (SMD) scores and meta-analysed using a random effects model., Results: We identified 55 studies containing 2578 participants (1638 PD and 940 healthy controls). Studies assessing three subcomponent categories of reward processing tasks were included: option valuation (n=12), reinforcement learning (n=37) and reward response vigour (n=6). Across all studies, patients with PD on medication exhibited a small-to-medium impairment versus healthy controls (SMD=0.34; 95% CI 0.14 to 0.53), with greater impairments observed off dopaminergic medication in within-subjects designs (SMD=0.43, 95% CI 0.29 to 0.57). Within-subjects subcomponent analysis revealed impaired processing off medication on option valuation (SMD=0.57, 95% CI 0.39 to 0.75) and reward response vigour (SMD=0.36, 95% CI 0.13 to 0.59) tasks. However, the opposite applied for reinforcement learning, which relative to healthy controls was impaired on-medication (SMD=0.45, 95% CI 0.25 to 0.65) but not off-medication (SMD=0.28, 95% CI -0.03 to 0.59). ICD was the only neuropsychiatric syndrome with sufficient studies (n=13) for meta-analysis, but no significant impairment was identified compared tonon-ICD patients (SMD=-0.02, 95% CI -0.43 to 0.39)., Conclusion: Reward processing disruption in PD differs according to subcomponent and dopamine medication state, and warrants further study as a potential treatment target and mechanism underlying associated neuropsychiatric syndromes., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY. Published by BMJ.)

New psychoactive substances (NPS) are a heterogeneous group of substances. They are associated with a number of health and social harms on an individual and societal level. NPS toxicity and dependence syndromes are recognised in primary care, emergency departments, psychiatric inpatient and community care settings. One pragmatic classification system is to divide NPS into one of four groups: synthetic stimulants, synthetic cannabinoids, synthetic hallucinogens and synthetic depressants (which include synthetic opioids and benzodiazepines). We review these four classes of NPS, including their chemical structures, mechanism of action, modes of use, intended intoxicant effects, and their associated physical and mental health harms. The current challenges faced by laboratory testing for NPS are also explored, in the context of the diverse range of NPS currently available, rate of production and emergence of new substances, the different formulations, and methods of acquisition and distribution., Competing Interests: Conflict of interest statement: The authors declare that there is no conflict of interest., (© The Author(s), 2020.)

Studies investigating alterations of the endocannabinoid system (ECS) in Alzheimer's disease (AD) in humans have reported inconsistent findings so far. We performed a systematic review of studies examining alterations of the ECS specifically within humans with AD or mild cognitive impairment (MCI), including neuroimaging studies, studies of serum and cerebrospinal fluid biomarkers, and post-mortem studies. We attempted to identify reported changes in the expression and activity of: cannabinoid receptors 1 and 2; anandamide (AEA); 2-arachidonoylglycerol (2-AG); monoacylglycerol lipase (MAGL); fatty acid amide hydrolase (FAAH); and transient receptor potential cation channel V1 (TRPV1). Twenty-two studies were identified for inclusion. Mixed findings were reported for most aspects of the ECS in AD, making it difficult to identify a particular profile of ECS alterations characterising AD. The included studies tended to be small, methodologically heterogeneous, and frequently did not control for important potential confounders, such as pathological progression of AD. Eight studies correlated ECS alterations with neuropsychometric performance measures, though studies infrequently examined behavioural and neuropsychiatric correlates. PROSPERO database identifier: CRD42018096249., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Objectives: The main aim of this study was to assess the effectiveness of cognitive behavior therapy (CBT) for comorbid dissociative seizures (DS) in patients with epilepsy., Methods: We conducted a retrospective case note review of 14 patients with epilepsy who underwent outpatient CBT for DS in a tertiary neuropsychiatry service. The diagnosis of DS was confirmed by neurologists clinically and/or following video-telemetry electroencephalogram (EEG). We evaluated the outcome of the CBT treatment with respect to frequency of DS, measures of depression, anxiety, and social functioning., Results: Measures of depression and anxiety significantly reduced following CBT treatment. Overall, frequency of DS reduced following CBT treatment but did not reach statistical significance., Significance: This study provides evidence that CBT can be effective in reducing depression and anxiety in patients with both epilepsy and DS. Anxiety and depression are likely to be associated with DS. Further research in larger samples and longitudinal studies are recommended to evaluate the long-term efficacy of CBT in this patient group., Competing Interests: Declaration of competing interest None of the authors has any conflict of interest to disclose., (Copyright © 2020. Published by Elsevier Inc.)

The Earth's transition zone, at depths of 410-660 km, while being composed of nominally anhydrous magnesium silicate minerals, may be subject to significant hydration. Little is known about the mechanism of hydration, despite the vital role this plays in the physical and chemical properties of the mantle, leading to a need for improved structural characterization. Here we present an ab initio random structure searching (AIRSS) investigation of semihydrous (1.65 wt % H 2 O) and fully hydrous (3.3 wt % H 2 O) wadsleyite. Following the AIRSS process, k-means clustering was used to select sets of structures with duplicates removed, which were then subjected to further geometry optimization with tighter constraints prior to NMR calculations. Semihydrous models identify a ground-state structure (Mg3 vacancies, O1-H hydroxyls) that aligns with a number of previous experimental observations. However, predicted NMR parameters fail to reproduce low-intensity signals observed in solid-state NMR spectra. In contrast, the fully hydrous models produced by AIRSS, which enable both isolated and clustered defects, are able to explain observed NMR signals via just four low-enthalpy structures: (i) a ground state, with isolated Mg3 vacancies and O1-H hydroxyls; (ii/iii) edge-sharing Mg3 vacancies with O1-H and O3-H species; and (iv) edge-sharing Mg1 and Mg3 vacancies with O1-H, O3-H, and O4-H hydroxyls. Thus, the combination of advanced structure searching approaches and solid-state NMR spectroscopy is able to provide new and detailed insight into the structure of this important mantle mineral.

The locus coeruleus (LC), the major origin of noradrenergic modulation of the central nervous system, may play an important role in neuropsychiatric disorders including Parkinson's disease and Alzheimer's disease. The pattern of age-related change of the LC across the life span is unclear. We obtained normalized, mean LC signal intensity values, that is, contrast ratios (CRs), from magnetization transfer-weighted images to investigate the relationship between LC CR and age in cognitively normal healthy adults (N = 605, age range 18-88 years). Study participants were part of the Cambridge Centre for Ageing and Neuroscience-an open-access, population-based data set. We found a quadratic relationship between LC CR and age, the peak occurring around 60 years, with no differences between males and females. Subregional analyses revealed that age-related decline in LC CR was confined to the rostral portion of the LC. Older adults showed greater variance in overall LC CR than younger adults, and the functional and clinical implications of these observed age-related differences require further investigation. Visualization of the LC in this study may inform how future scanning parameters can be optimized, and provides insight into how LC integrity changes across the life span., (Copyright © 2018 Elsevier Inc. All rights reserved.)

A case of acute dyskinesia in a 42-year-old man with a history of cocaine use and schizophrenia is described. He had discontinued clozapine approximately 1 month before presenting to the emergency department displaying signs of psychosis, with generalised choreiform and dystonic movements. Urinary toxicology was positive for cocaine. Clozapine treatment was reinitiated, and within 2 weeks the dyskinesia had subsided. Review of his records revealed two previous episodes of similar dyskinesia, both of which were temporally associated with cocaine use. Dyskinesia occurring in the context of cocaine use, and clozapine withdrawal-associated dyskinesia were considered to be the main differential diagnoses. A range of differential diagnoses should be considered in patients presenting with an acute-onset movement disorder who have a history of long-term exposure to antipsychotic medication., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2018. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: The objective of this study was to evaluate AKI incidence with concomitant vancomycin and piperacillin/tazobactam (PTZ) compared to vancomycin and cefepime (FEP) in critically ill patients., Materials and Methods: A retrospective, cohort study was conducted in adult critically ill patients from January 1, 2014 to December 31, 2017. The primary aim was to compare the incidence of AKI during concomitant therapy or until hospital discharge. Secondary analyses included AKI severity, time to AKI as well as recovery, and clinical outcomes., Results: Overall, 333 patients were evaluated. The AKI rate in the vancomycin/PTZ group and vancomycin/FEP group were similar (19.5% vs. 17.3%, respectively, p = .612). Renal replacement therapy (RRT) was initiated in 10.0% and 3.8% administered vancomycin/PTZ and vancomycin/FEP groups, respectively (p = .04). Multivariate regression found vancomycin/PTZ was not associated with an increased risk of developing AKI although the presence of shock was identified as an independent risk factor (odds ratio, 3.22; 95% CI, 1.66-6.26). No significant differences in hospital or ICU length of stay or in-hospital mortality were observed between study groups., Conclusions: Concomitant PTZ and vancomycin in ICU patients was not associated with an increased risk of developing AKI compared to FEP and vancomycin combinations. More patients administered vancomycin/PTZ received RRT., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objectives: This review provides a broad overview of the effectiveness of interventions for subjective cognitive decline (SCD) in improving psychological well-being, metacognition and objective cognitive performance., Methods: Databases including PubMed, Web of Science and Cochrane Systematic Reviews were searched up to August 2017 to identify randomised controlled trials evaluating interventions for SCD. Interventions were categorised as psychological, cognitive, lifestyle or pharmacological. Outcomes of interest included psychological well-being, metacognitive ability and objective cognitive performance. To assess the risk of bias, three authors independently rated study validity using criteria based on the Critical Appraisal Skills Programme. Random-effects meta-analyses were undertaken where three or more studies investigated similar interventions and reported comparable outcomes., Results: Twenty studies met inclusion criteria and 16 had sufficient data for inclusion in the meta-analyses. Of these, only seven were rated as being high quality. Group psychological interventions significantly improved psychological well-being (g=0.40, 95% CI 0.03 to 0.76; p=0.03) but the improvement they conferred on metacognitive ability was not statistically significant (g=0.26, 95% CI -0.22 to 0.73; p=0.28). Overall, cognitive training interventions led to a small, statistically significant improvement in objective cognitive performance (g=0.13, 95% CI 0.01 to 0.25; p=0.03). However, the pooled effect sizes of studies using active control groups (g=0.02, 95% CI -0.19 to 0.22; p=0.85) or reporting global cognitive measures (g=0.06, 95% CI -0.19 to 0.31; p=0.66) were non-significant., Conclusions: There is a lack of high-quality research in this field. Group psychological interventions improve psychological well-being and may also improve metacognition. A large, high-quality study is indicated to investigate this further. There is no evidence to suggest that cognitive interventions improve global cognitive performance and the clinical utility of small improvements in specific cognitive domains is questionable. There is a lack of research considering lifestyle interventions and poor quality evidence for pharmacological interventions., Prospero Registration Number: CRD42017079391., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2018. Re-use permitted under CC BY. Published by BMJ.)

Background: Medication safety strategies involving trigger alerts have demonstrated potential in identifying drug-related hazardous conditions (DRHCs) and preventing adverse drug events in hospitalized patients. However, trigger alert effectiveness between intensive care unit (ICU) and general ward patients remains unknown. The objective was to investigate trigger alert performance in accurately identifying DRHCs associated with laboratory abnormalities in ICU and non-ICU settings., Methods: This retrospective, observational study was conducted at a university hospital over a 1-year period involving 20 unique trigger alerts aimed at identifying possible drug-induced laboratory abnormalities. The primary outcome was to determine the positive predictive value (PPV) in distinguishing drug-induced abnormal laboratory values using trigger alerts in critically ill and general ward patients. Aberrant lab values attributed to medications without resulting in an actual adverse event ensuing were categorized as a DRHC., Results: A total of 634 patients involving 870 trigger alerts were included. The distribution of trigger alerts generated occurred more commonly in general ward patients (59.8%) than those in the ICU (40.2%). The overall PPV in detecting a DRHC in all hospitalized patients was 0.29, while the PPV in non-ICU patients (0.31) was significantly higher than the critically ill (0.25) ( p = 0.03). However, the rate of DRHCs was significantly higher in the ICU than the general ward (7.49 versus 0.87 events per 1000 patient days, respectively, p < 0.0001). Although most DRHCs were considered mild or moderate in severity, more serious and life-threatening DRHCs occurred in the ICU compared with the general ward (39.8% versus 12.4%, respectively, p < 0.001)., Conclusions: Overall, most trigger alerts performed poorly in detecting DRHCs irrespective of patient care setting. Continuous process improvement practices should be applied to trigger alert performance to improve clinician time efficiency and minimize alert fatigue., Competing Interests: Conflict of interest statement: The authors declare that there is no conflict of interest.

Lateral variations of seismic wave speeds and attenuation (dissipation of strain energy) in the Earth's upper mantle have the potential to map key characteristics such as temperature, major-element composition, melt fraction and water content. The inversion of these data into meaningful representations of physical properties requires a robust understanding of the micromechanical processes that affect the propagation of seismic waves. Structurally bound water (hydroxyl) is believed to affect seismic properties but this has yet to be experimentally quantified. Here we present a comprehensive low-frequency forced-oscillation assessment of the seismic properties of olivine as a function of water content within the under-saturated regime that is relevant to the Earth's interior. Our results demonstrate that wave speeds and attenuation are in fact strikingly insensitive to water content. Rather, the redox conditions imposed by the choice of metal sleeving, and the associated defect chemistry, appear to have a substantial influence on the seismic properties. These findings suggest that elevated water contents are not responsible for low-velocity or high-attenuation structures in the upper mantle. Instead, the high attenuation observed in hydrous and oxidized regions of the upper mantle (such as above subduction zones) may reflect the prevailing oxygen fugacity. In addition, these data provide no support for the hypothesis whereby a sharp lithosphere-asthenosphere boundary is explained by enhanced grain boundary sliding in the presence of water.

Objective: To provide an up-to-date review of the available evidence regarding management of elderly patients after transcatheter aortic valve replacement (TAVR)., Data Sources: A PubMed search of articles published (September 1969-December 2016) was done using a combination of the following words: aortic valve stenosis, geriatric, elderly, transcatheter aortic valve replacement, surgical aortic valve replacement, transcatheter aortic valve implantation (TAVI), and dual antiplatelet therapy., Study Selection/data Extraction: Relevant original research, review articles, and guidelines were assessed for the management of elderly patients after TAVR. References from the above literature were also evaluated. Articles were selected for inclusion based on relevance to the topic, detailed methods, and complete results., Data Synthesis: Aortic valve stenosis is common in the geriatric population. While patients were historically treated with surgical aortic valve replacement (AVR), more patients are now undergoing TAVR. This article reviews the current literature regarding outcomes and pharmacotherapy between surgical and TAVR in the elderly population., Conclusion: Appropriate management of pharmacotherapy after surgical or TAVR can help improve outcomes in elderly patients, and pharmacists can provide guidance regarding evidence-based therapy.

We present the first oxygen fugacity (fO 2 ) profile through the cratonic lithospheric mantle under the Panda kimberlite (Ekati Diamond Mine) in the Lac de Gras kimberlite field, central Slave Craton, northern Canada. Combining this data with new and existing data from garnet peridotite xenoliths from an almost coeval kimberlite (A154-N) at the nearby Diavik Diamond Mine demonstrates that the oxygen fugacity of the Slave cratonic mantle varies by several orders of magnitude as a function of depth and over short lateral distances. The lower part of the diamond-bearing Slave lithosphere (>120-130 km deep) has been oxidized by up to 4 log units in fO 2 , and this is clearly linked to metasomatic enrichment. Such coupled enrichment and oxidation was likely caused by infiltrating carbonate-bearing, hydrous, silicate melts in the presence of diamond, a process proposed to be critical for "pre-conditioning" deep lithospheric mantle and rendering it suitable for later generation of kimberlites and other SiO 2 -undersaturated magmas.

The structural chemistry of materials containing low levels of nonstoichiometric hydrogen is difficult to determine, and producing structural models is challenging where hydrogen has no fixed crystallographic site. Here we demonstrate a computational approach employing ab initio random structure searching (AIRSS) to generate a series of candidate structures for hydrous wadsleyite (β-Mg2SiO4 with 1.6 wt% H2O), a high-pressure mineral proposed as a repository for water in the Earth's transition zone. Aligning with previous experimental work, we solely consider models with Mg3 (over Mg1, Mg2 or Si) vacancies. We adapt the AIRSS method by starting with anhydrous wadsleyite, removing a single Mg(2+) and randomly placing two H(+) in a unit cell model, generating 819 candidate structures. 103 geometries were then subjected to more accurate optimisation under periodic DFT. Using this approach, we find the most favourable hydration mechanism involves protonation of two O1 sites around the Mg3 vacancy. The formation of silanol groups on O3 or O4 sites (with loss of stable O1-H hydroxyls) coincides with an increase in total enthalpy. Importantly, the approach we employ allows observables such as NMR parameters to be computed for each structure. We consider hydrous wadsleyite (∼1.6 wt%) to be dominated by protonated O1 sites, with O3/O4-H silanol groups present as defects, a model that maps well onto experimental studies at higher levels of hydration (J. M. Griffin et al., Chem. Sci., 2013, 4, 1523). The AIRSS approach adopted herein provides the crucial link between atomic-scale structure and experimental studies.

Hyperglycemia is a frequent manifestation of critical and surgical illness, resulting from the acute metabolic and hormonal changes associated with the response to injury and stress (Umpierrez and Kitabchi, Curr Opin Endocrinol. 11:75-81, 2004; McCowen et al., Crit Care Clin. 17(1):107-24, 2001). The exact prevalence of hospital hyperglycemia is not known, but observational studies have reported a prevalence of hyperglycemia ranging from 32 to 60 % in community hospitals (Umpierrez et al., J Clin Endocrinol Metab. 87(3):978-82, 2002; Cook et al., J Hosp Med. 4(9):E7-14, 2009; Farrokhi et al., Best Pract Res Clin Endocrinol Metab. 25(5):813-24, 2011), and 80 % of patients after cardiac surgery (Schmeltz et al., Diabetes Care 30(4):823-8, 2007; van den Berghe et al., N Engl J Med. 345(19):1359-67, 2001). Retrospective and randomized controlled trials in surgical populations have reported that hyperglycemia and diabetes are associated with increased length of stay, hospital complications, resource utilization, and mortality (Frisch et al., Diabetes Care 33(8):1783-8, 2010; Kwon et al., Ann Surg. 257(1):8-14, 2013; Bower et al., Surgery 147(5):670-5, 2010; Noordzij et al., Eur J Endocrinol. 156(1):137-42, 2007; Mraovic et al., J Arthroplasty 25(1):64-70, 2010). Substantial evidence indicates that correction of hyperglycemia reduces complications in critically ill, as well as in general surgery patients (Umpierrez et al., J Clin Endocrinol Metab. 87(3):978-82, 2002; Clement et al., Diabetes Care 27(2):553-97, 2004; Pomposelli et al., JPEN J Parented Enteral Nutr. 22(2):77-81, 1998). This manuscript reviews the pathophysiology of stress hyperglycemia during anesthesia and the perioperative period. We provide a practical outline for the diagnosis and management of preoperative, intraoperative, and postoperative care of patients with diabetes and hyperglycemia.

Background: Approximately 18% to 25% of patients with alcohol use disorders admitted to the hospital develop alcohol withdrawal syndrome (AWS). Symptom-triggered dosing of benzodiazepines (BZDs) seems to lead to shorter courses of treatment, lower cumulative BZD dose, and more rapid control of symptoms in non-critically ill patients. This study compares the outcomes of critically ill patients with AWS when treated using a protocolized, symptom-triggered, dose escalation approach versus a nonprotocolized approach., Methods: This is a retrospective pre-post study of patients 18 years or older with AWS admitted to an intensive care unit (ICU). The preintervention cohort (PRE) was admitted between February 2008 and February 2010. The postintervention cohort (POST) was admitted between February 2012 and January 2013. The PRE patients were treated by physician preference and compared with POST patients who were given escalating doses of BZDs and/or phenobarbital according to an AWS protocol, titrating to light sedations (Richmond Agitation Sedation Scale score of 0 to -2)., Results: There were 135 episodes of AWS in 132 critically ill patients. POST patients (n = 75) were younger (50.7 [13.8] years vs. 55.7 [8.7] years, p = 0.03) than PRE patients (n = 60). Sequential Organ Failure Assessment (SOFA) scores were higher in the PRE group (6.1 [3.7] vs. 3.9 [2.9], p = 0.0004). There was a significant decrease in mean ICU length of stay from 9.6 (10.5) days to 5.2 (6.4) days (p = 0.0004) in the POST group. The POST group also had significantly fewer ventilator days (5.6 [13.9] days vs. 1.31 [5.6] days, p < 0.0001) as well as a significant decrease in BZD use (319 [1,084] mg vs. 93 [171] mg, p = 0.002). There were significant differences between the two cohorts with respect to the need for continuous sedation (p < 0.001), duration of sedation (p < 0.001), and intubation secondary to AWS (p < 0.001). In all of these outcomes, the POST cohort had a notably lower frequency of occurrence., Conclusion: A protocolized treatment approach of AWS in critically ill patients involving symptom-triggered, dose escalations of diazepam and phenobarbital may lead to a decreased ICU length of stay, decreased time spent on mechanical ventilation, and decreased BZD requirements., Level of Evidence: Epidemiologic study, level III; therapeutic study, level IV.

Pulmonary arterial hypertension (PAH) remains a progressive disease without a cure, despite the development of several treatment options over the past several decades. Its management strategy consists of the endothelin receptor antagonists (ambrisentan, bosentan, macitentan), phosphodiesterase-5 inhibitors (sildenafil, tadalafil, vardenafil), and prostacyclin analogs (epoprostenol, treprostinil, iloprost). Treprostinil, a stable prostacyclin analog, displays vasodilatory effects in the pulmonary vasculature, as well as antiplatelet aggregation properties. Clinical practice guidelines recommend oral endothelin receptor antagonist or phosphodiesterase inhibitor therapy in mild to moderate PAH. Epoprostenol is specifically suggested as first-line therapy in moderate to severe PAH patients (ie, World Health Organization/New York Heart Association functional class III-IV). However, treprostinil may be an alternative option in these severe PAH patients. The longer half-life and stability at room temperature with treprostinil may be associated with lower risk of pulmonary hemodynamic worsening as a result of abrupt infusion discontinuation and less frequent drug preparation. These characteristics make treprostinil an attractive alternative to continuous infusion of epoprostenol, due to convenience and patient safety. The purpose of this review is to evaluate the safety and efficacy of continuous infusion of treprostinil as well as the inhaled and oral routes of administration in PAH.

Pancreatic stimulation and therefore digestion is a tightly controlled and hormonally mediated process. Any alterations affecting any of the systematic steps for successful digestion and absorption to occur will impair appropriate pancreatic enzymatic secretion, entry into the bowel lumen, functionality once inside the lumen, and thus appropriate mixing with foods and nutrients. Many causes of pancreatic insufficiency may require the initiation of pancreatic enzyme therapy, including but not limited to cystic fibrosis, pancreatic cancer, acute and chronic pancreatitis, and pancreatic surgery. This purpose of this article is to help clarify the conditions that cause pancreatic insufficiency, how to determine if the patient is malabsorbing, and the best use of pancreatic enzyme replacement therapy for treatment in these conditions. The first step in determining if pancreatic enzyme therapy is appropriate is to determine if the patient is malabsorbing specifically due to pancreatic exocrine insufficiency. An overview of the methods used to determine pancreatic insufficiency is provided, as well as appropriate treatment methods. Recent Food and Drug Administration regulations require a more thorough process, including randomized controlled trials to prove the safety and efficacy of pancreatic enzymes, to approve them for use. The studies used to verify efficacy also are examined. Last, dosing guidelines and some unconventional ways to administer pancreatic enzymes, such as during enteral feedings, are reviewed.

Ethyl glucuronide (EtG) and fatty acid ethyl esters (FAEEs) are alcohol metabolites measured in hair and are after a decade of research thought to be the best markers in hair to indicate alcoholism and abstinence Forensic Sci. Int. 218 (2012) 2. A great body of work concerning EtG and FAEEs detection in hair has been performed. However, no recent extensive comparison has been made concerning washing and extraction procedures. This work shows that the washing procedure of dichloromethane followed by a methanol rinse of the hair sample removes more than 16% of the FAEEs and 50% of the total EtG that is present in and on the hair. A review of ten washing protocols (where the removal is categorised: high, medium or low) showed that a relatively high percentage of FAEEs was removed and "medium" amount of EtG compared to the other washing protocols. This work shows promising results for the extraction of the FAEEs and the combined extraction of FAEEs and EtG by using 30min of sonication with methanol. More FAEEs were recovered from hair with methanol than with any other extraction solvent including the commonly used dimethyl sulfoxide/heptane mixture. When the sonication time was increased a higher percentage of transesterification of the FAEEs was observed, the extraction was "dirtier" as solids and a colour change was observed whereas the extraction efficiency did not increase. Therefore, washing the hair sample with dichloromethane and methanol followed by an addition of 1ml of methanol and sonication for 30min to extract the FAEEs and EtG from hair is recommended for FAEEs as well as for the combined analysis of EtG and FAEEs. A linear calibration curve (r(2)>0.99) was obtained for all analytes., (Copyright © 2014 Elsevier B.V. All rights reserved.)

Background: Cervical spinal cord injury (CSCI) is often complicated by autonomic instability and life-threatening bradycardia. β-adrenergic receptors offer a potential target for modulating cardiac vagal activity and heart rate. Enteral albuterol may mitigate symptomatic bradycardia in CSCI patients. The purpose of this study was to examine the effect of enteral albuterol on the frequency of symptomatic bradycardia and the need for rescue therapy in CSCI patients., Methods: The charts of CSCI patients admitted to a Level I trauma center from February 2008 through March 2012 were reviewed for demographics, episodes of symptomatic bradycardia (defined as heart rate < 60 beats per minute and systolic blood pressure < 90 mm Hg), use of enteral albuterol, hospital days requiring chronotropic use, and total atropine administered. In the albuterol group, patients received scheduled enteral albuterol after experiencing symptomatic bradycardia, with chronotropic agents used as needed for rescue treatment. In the no-albuterol group, only chronotropic agents were used as needed for rescue treatment. The albuterol and no-albuterol groups were compared using independent-samples Kruskal-Wallis test for total number of bradycardic episodes, hospital days requiring chronotropic use, and total atropine administered., Results: Eighteen patients with CSCI-induced bradycardia were identified. Eight patients received treatment with enteral albuterol, and 10 patients did not. The median age did not differ significantly between the two groups. However, the median Injury Severity Score (ISS) was higher in the albuterol group (median ISS, 36.5; interquartile range, 35-66.5 vs. median ISS 26; interquartile range, 27-37.25 in no-albuterol group). Patients receiving albuterol experienced 1.8 symptomatic bradycardic episodes versus 4.3 episodes in those patients not receiving albuterol (p = 0.08). Hospital days on chronotropic agents were significantly less in the albuterol group (1.8 vs. 8.6, p = 0.01). One patient, in the no-albuterol group, required pacemaker placement., Conclusion: Enteral albuterol may reduce the frequency of symptomatic bradycardia in patients with CSCI, resulting in less rescue therapy using chronotropic agents., Level of Evidence: Therapeutic study, level IV.

Pancreatic surgery is a complicated procedure leaving postoperative patients with an altered gastrointestinal (GI) anatomy and a potential for further surgical complications such as leaks and fistulas. Beyond surgical complications, these patients are prone to delayed gastric emptying, fat malabsorption, and hyperglycemia, with early satiety and poor appetite further compromising nutrition status. Many of these patients are malnourished prior to this major surgical procedure, and significant weight loss is common postoperatively. Does this affect their outcome? There seems to be a lack of consensus in this patient population regarding how to optimize nutrition and limit potential deleterious effects of this surgery. It is important to first understand the underlying disease condition and the effects to the gland, different forms of surgery with subsequent GI alterations, and common surgical and digestive complications. Once this is reviewed, existing nutrition support literature will be explored in attempts to determine the best nutrition management in this patient population.

(25)Mg NMR parameters have been determined for two polymorphs of enstatite (MgSiO(3)), an important magnesium silicate phase present as a major component of the Earth's upper mantle. The crystal structures of both polymorphs contain two crystallographically distinct magnesium sites; however, only a single resonance is observed in (25)Mg MAS NMR spectra recorded at 14.1 and 20.0 T. First-principles calculations performed on geometry-optimised crystal structures reveal that the quadrupolar interaction for the second site is expected to be very large, resulting in extensive broadening of the spectral resonance, explaining its apparent absence in the NMR spectrum. (25)Mg QCPMG NMR experiments employing variable offset cumulative spectroscopy (VOCS) are used to observe the broadened site and enable measurement of NMR parameters. The large difference in quadrupolar interaction between the two crystallographic magnesium sites is rationalised qualitatively in terms of the distortion of the local coordination environment as well as longer-range effects using a simple point charge model., (Copyright © 2011 Elsevier Inc. All rights reserved.)