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Background Nutrition therapy is essential in critically ill adults. Little is known about appropriate nutrition therapy in patients with severe coronavirus disease 2019 (COVID‐19) infection. Methods This was a retrospective, observational study in adult patients with confirmed COVID‐19 infection receiving mechanical ventilation. Data regarding patient demographics and nutrition therapy were collected. Patients that received enteral nutrition within 24 hours of starting mechanical ventilation were compared with patients starting enteral nutrition later. The primary outcome was inpatient length of stay. Propensity score matching was conducted to control for baseline differences in patient groups. Results One hundred fifty‐five patients were included in final analysis. Patients who received enteral nutrition within 24 hours received a significantly greater daily amount of calories (17.5 vs 15.2 kcal/kg, P = .015) and protein (1.04 vs 0.85 g/kg, P = .003). There was no difference in length of stay (18.5 vs 23.5 days, P = .37). The propensity score analysis included 100 patients. Following propensity scoring, significant differences in daily calorie (17.7 [4.6] vs 15.1 [5.1] kcal/kg/d, P = .009) and protein (1.03 [0.35] vs 0.86 [0.38] g/kg/d, P = .014) provision remained. No differences in length of stay or other outcomes were noted in the propensity score analysis. Conclusion Initiation of enteral nutrition within 24 hours was not associated with improved outcomes in mechanically ventilated adults with COVID‐19. No harm was detected either. Future research should seek to clarify optimal timing of enteral nutrition initiation in patients with COVID‐19 who require mechanical ventilation.

Parenteral nutrition (PN) is a complex therapy with numerous opportunities for error during the prescribing, preparation, and administration processes. Advances in technology, such as computerized provider order entry (CPOE), electronic health records (EHRs), and clinical decision support (CDS) have helped decrease the risks associated with PN therapy. These technologies can be utilized to guide prescribing, provide automated safety checks, and increase overall safety and accuracy in PN ordering, compounding, and administration. In recent years, increased awareness of the risks associated with PN therapy, in particular issues with ordering and transcription, have magnified the need for improved support of PN ordering within currently available systems. Additionally, drug shortages continue to impact key components of PN admixtures, further increasing the risks associated with this complex therapy. These concerns and risks present an opportunity for the development of new functionality, as well as improvements in and innovative utilization of available technology within systems supporting the PN use process. This discussion will highlight the risks associated with PN, examine the role of drug shortages on the safety of this therapy, describe the application of available technology to manage shortages, and report the experience of using commercially available CDS tools at one academic medical center. It will also include a discussion of the transition from paper orders to CPOE/EHR-based orders for PN and the transition from one commercially available electronic system to another at this particular institution.

Intravenous in-line filters play a critical role in promoting patient safety during parenteral nutrition (PN) administration. Guidelines for using filters for PN have been issued by a number of professional organizations and manufacturers of PN components. Yet despite this guidance, filter use remains controversial. Recent changes in recommendations for filtering lipid injectable emulsions have added to confusion and created considerable variation in practice. This Position Paper aims to review past guidance regarding the filtration of PN, examine the clinical consequences of infusing particulate matter, discuss the challenges and issues related to filtration, and clarify the American Society for Parenteral and Enteral Nutrition (ASPEN) recommendations for the use of filters for PN administration. This paper was approved by the ASPEN Board of Directors.

Parenteral nutrition (PN) is a complex therapeutic modality provided to neonates, children, and adults for various indications. Surveys have shown that current electronic health record (EHR) systems are in need of functionality enhancement for safe and optimal delivery of PN. This is a consensus statement from the American Society for Parenteral and Enteral Nutrition, the Academy of Nutrition and Dietetics, and the American Society of Health-System Pharmacists outlining some of the key challenges to prescribing, order review/verification, compounding, and administration of PN using EHRs today and is a call to action for clinicians and vendors to optimize their EHRs regarding the PN build and workflow.

Rationale and Objectives The aims of our study were (1) to describe a new educational intervention for first-year medical students that gave a substantial, early exposure to radiology and (2) to examine how this early exposure was received by the students. Materials and Methods Our new curriculum incorporated a new 2-week course very early in the M1 year entitled Foundations of Diagnostics and Therapeutics. Among other topics, the course included a substantial introduction to radiology primarily through small-group seminars and online materials, administered using a flipped-classroom approach. The students were given pre- and postcourse surveys that assessed the degree to which they felt prepared to learn about radiology, as well as their interest in radiology. Results were analyzed using the Wilcoxon signed-rank test. Results Survey responses were obtained from 170 students before the course and 65 students afterward. Upon completing the course, students showed significantly increased academic interest in radiology (P = .008) and a heightened perception of the effect of radiology on patient care (P = .04), without a significant change in interest in pursuing radiology as a career. Students showed an overwhelmingly positive response to the course, although some noted that previous anatomy training would have been helpful. Eighty percent agreed or strongly agreed that the flipped-classroom structure was an effective educational model. Conclusions Our study demonstrated that students were very excited to gain exposure to radiology early in their medical school curriculum, and such exposure led to an improved perception of the field.

Objective To compare lesion conspicuity amongst DECT monochromatic series (40, 45, 50 keV), and single-energy CT (SECT) equivalent images in head and neck squamous cell carcinomas (HNSCC). Methods Two readers compared DECT images to 70 keV SECT equivalent series in 39 patients with HNSCC on lesion margin, enhancement, and overall conspicuity. Results The 45 keV and 50 keV images were significantly better (p-values ≤ 0.001) than the SECT equivalent in lesion enhancement, margins, and overall conspicuity for both readers. Readers mostly preferred the 50 keV monochromatic series. Conclusion DECT can provide better lesion visualization than SECT in HNSCC.

Lava tubes are widely distributed in volcanic fields on a planetary surface and they are important means of lava transportation. We have identified 38 sinuous ridges with a lava-tube origin in southeast Tharsis. The lengths vary between ~ 14 and ~ 740 km, and most of them occur in areas with slopes

Introduction Errors have been reported in the literature to occur at each step of the parenteral nutrition (PN) use process, necessitating standardized processes, clinician competence, and open communication for those involved. This study was performed at Central Admixture Pharmacy Services (CAPS®) in collaboration with the American Society for Parenteral and Enteral Nutrition (ASPEN) with the purpose to study the need for and success of PN pharmacist interventions. Methods A survey was developed and sent to all CAPS customers for study enrollment and to identify their demographic and practice characteristics. For those enrolled, CAPS pharmacists reviewed every PN order in a 1-month period using an error/intervention tool to capture data on prescription elements requiring intervention, along with acceptance of that intervention. Results Two hundred thirty-two unique CAPS customers (23% response rate) participated in the study, representing 37,634 unique PN prescriptions. Two hundred forty-eight PN prescriptions (0.66%) from 59 customers required ≥1 intervention. The top 3 intervention types were electrolyte dose clarification, calcium/phosphorus incompatibility, and amino acid dose clarification. A greater number and percentage of interventions were required for neonatal prescriptions, as compared with adult and pediatric prescriptions. No significant difference was found in many of the other customer characteristics. Conclusion This study supports the need for institutions to develop systems to comply with published PN safety recommendations, including knowledgeable and skilled pharmacists to complete the order review and verification steps for this high-alert medication.

Parenteral nutrition (PN) is a complex therapeutic modality provided to neonates, children, and adults for various indications. Surveys have shown that current electronic health record (EHR) systems are in need of functionality enhancement for safe and optimal delivery of PN. This is a consensus statement from the American Society for Parenteral and Enteral Nutrition, the Academy of Nutrition and Dietetics, and the American Society of Health-System Pharmacists outlining some of the key challenges to prescribing, order review/verification, compounding, and administration of PN using EHRs today and is a call to action for clinicians and vendors to optimize their EHRs regarding the PN build and workflow.

In this study, we investigate the fluvial, sedimentary, and volcanic history of Margaritifer basin and the Uzboi-Ladon-Morava outflow channel system. This network of valleys and basins spans more than 8000 km in length, linking the fluvially dissected southern highlands and Argyre basin with the northern lowlands via Ares Vallis. Compositionally, thermophysically, and morphologically distinct geologic units are identified and are used to place critical relative stratigraphic constraints on the timing of geologic processes in Margaritifer basin. Our analyses show that fluvial activity was separated in time by significant episodes of geologic activity, including the widespread volcanic resurfacing of Margaritifer basin and the formation of chaos terrain. The most recent fluvial activity within Margaritifer basin appears to terminate at a region of chaos terrain, suggesting possible communication between surface and subsurface water reservoirs. We conclude with a discussion of the implications of these observations on our current knowledge of Martian hydrologic evolution in this important region.

This is a follow-up survey to reassess the safety and efficacy of nutrition content in the available electronic health record (EHR) systems.Members of the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.), American Society for Nutrition, and the Academy for Nutrition and Dietetics were asked to participate in an online survey. The survey included questions from a 2012 EHR survey on the safety and efficacy in 5 nutrition content areas as well as questions from previous 2003 and 2011 A.S.P.E.N. parenteral nutrition (PN) surveys.Percent of respondents using an EHR and using the EHR for less than 1 year increased between 2012 and 2014 (86%-94%, P.05; 11%-16%, P.05, respectively). However, there was no improvement in the safety and efficacy of the 5 nutrition content areas, with a significant decrease in 2 of these areas, ordering oral nutrition supplements and ordering PN. The top-rated EHR vendors had a higher average favorable response rate in regards to safety and efficacy in the nutrition content areas but even the top-rated EHR vendor had only a 60% average in favorable responses. Reported use of electronic PN ordering and a direct interface between the EHR and the automated compounding device (ACD) significantly increased from 2003 to 2011 to 2014 (29% to 33% to 63% and 16% to 19% to 28%, respectively, P.05).This is a call to action to nutrition support clinicians, societies, and organizations to proactively be involved in initiatives to educate clinicians and collaborate with EHR vendors to enhance the EHR systems to improve the safety and efficacy of providing nutrition therapy in hospitalized patients.

Parenteral nutrition (PN) provision is complex, as it is a high-alert medication and prone to a variety of potential errors. With changes in clinical practice models and recent federal rulings, the number of PN prescribers may be increasing. Safe prescribing of this therapy requires that competency for prescribers from all disciplines be demonstrated using a standardized process. A standardized model for PN prescribing competency is proposed based on a competency framework, the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.)-published interdisciplinary core competencies, safe practice recommendations, and clinical guidelines. This framework will guide institutions and agencies in developing and maintaining competency for safe PN prescription by their staff.

Purpose This study evaluated the impact of an admission medication reconciliation process conducted by student pharmacists during an introductory pharmacy practice experience (IPPE). Methods Patients aged 18 years or older admitted to a general medicine service and who received medication reconciliation from a student pharmacist were included. Data were collected retrospectively from electronic medical records. Results Student pharmacists performed medication reconciliation on 21.8% of 6395 patients admitted to the target service, directly involving the majority of patients/caregivers (78.9%) in the process. Potential medication discrepancies were found in 43.8% of patients; the average number of potential discrepancies found per patient was 1.0 ± 1.6. The most common potential discrepancy was “omitted prescription medication.” Prescribers responded to notification about potential discrepancies by correcting or clarifying 74.9% of all potential discrepancies and 77.2% of discrepancies with the potential to causes severe patient discomfort or clinical deterioration. Conclusion IPPE student pharmacists contributed to patient care by performing medication reconciliation on patient admission to hospital. Student pharmacists identified and facilitated correction of unrecognized medication issues that could have adversely impacted patient well-being.

Variations in chemical composition over a planetary surface can be used to study petrologic and aqueous alteration processes. The desire for such data on Mars has prompted investigators to derive chemistry from models of Thermal Emission Spectrometer data. Although chemistry derived from thermal infrared spectral models is reportedly reliable for unaltered igneous rocks, the martian surface has experienced chemical weathering, which can adversely affect models. Here, we examine weathered basalts from Baynton, Australia, for which chemical weathering trends have been previously characterized, to test how well chemistry and chemical trends can be determined from TIR spectra of weathered rocks. The mineralogy of variably weathered rocks was derived from TIR spectra by linear mixing, and major-element chemistry was calculated from those mineral models. Derived chemistries and trends were compared to those measured by X-ray fluorescence. TIR spectroscopy is sensitive to weathering products in weathering rinds because the products are present in a coating geometry, making it a useful technique for remotely detecting weathered surfaces on planetary surfaces such as Mars. This sensitivity results in significant modeled abundances of weathering products (>80% of all phases) from TIR spectra of weathered Baynton surfaces, despite evidence from microscopy and X-ray diffraction showing that igneous minerals dominate the weathering rind. Measured chemical weathering trends show loss of MgO, CaO, Na 2 O, and K 2 O and relative enrichment in Al 2 O 3 and FeO T . The modeled trends are similar to the measured trends, but a closer look at the modeled oxide abundances demonstrates that most oxides (i.e., alkalis, SiO 2 , and FeO T ) are not well modeled, especially for weathered surfaces. The reasons for this are: (1) non-linear mixing and the presence of secondary coatings causes the overestimation of secondary phases in spectral models, and (2) spectral libraries generally lack poorly crystalline and amorphous secondary phases that are common in weathering rinds so that crystalline phases such as phyllosilicates are selected. The martian surface has likely been weathered less pervasively than the Baynton rocks and, therefore, weathering products may be dominated by poorly crystalline and amorphous phases, rather than crystalline phyllosilicates. Adding these phases to spectral libraries could improve bulk chemistry derived from the martian surface; however, if the secondary phases are present in a coating geometry, the derived chemistry will reflect the composition of the coating, and it may be difficult to infer the chemistry of the parent rock.

Purpose To assist the pharmacy clinician engaged in nutrition support in staying current with the most pertinent literature. Methods Several experienced board-certified clinical pharmacists engaged in nutrition support therapy compiled a list of articles published in 2014 and 2015 that they considered to be important to their practice. Only those articles available in print format were considered for potential inclusion. Articles available only in preprint electronic format were not evaluated. The citation list was compiled into a single spreadsheet where the author participants were asked to ascertain whether they considered the paper important to nutrition support pharmacy practice. A culled list of publications was then identified whereby the majority of author participants (at least 5 out of 8) considered the paper to be important. Results A total of 108 articles were identified; 36 of which were considered to be of high importance. An important guideline article published in early 2016, but not ranked, was also included. The top-ranked articles from the primary literature were reviewed. Conclusion It is recommended that the informed pharmacist, who is engaged in nutrition support therapy, be familiar with the majority of these articles.

Models of Thermal Emission Spectrometer (TES) data suggest that poorly-crystalline weathering products allophane and aluminosilicate gel occur in several low-albedo regions of Mars. The presence of allophane in TES models indicates that the martian surface experienced low-temperature chemical weathering at low water-to-rock ratios and mildly acidic to neutral pH on regional scales. The allophane and gel may be ancient and preserved by a persistently dry martian climate. Alternatively, evidence for recent ground ice in these regions suggests that pedogenic processes causing the formation of poorly-crystalline aluminosilicates could be late Amazonian in age and may be active today. While previous models have suggested that global-scale acidic weathering has occurred on Mars for the past 3.5 billion years, the presence of allophane indicates that acidic weathering was not occurring in these low-albedo regions and that mildly acidic to neutral weathering has been an important regional-scale weathering process on the martian surface.

[Figure][1] The standards of the Accreditation Council for Pharmacy Education (ACPE) for doctor of pharmacy programs require pharmacy curricula to provide students with introductory pharmacy practice experiences (IPPEs), which are defined as “practice experiences offered in various

The American Society for Parenteral and Enteral Nutrition defines standards as benchmarks representing a range of performance of competent care that should be provided to assure safe and efficacious nutrition care in most circumstances. Standards are documents that define the structure needed to provide competent care. These Standards for Nutrition Support for Adult Hospitalized Patients are an update of the 2010 Standards. These practice-based standards are intended for use by healthcare professionals charged with the care of adult hospitalized patients receiving nutrition support therapy in any hospital with or without a formal nutrition support service or team. These Standards address professional responsibilities as they relate to patient assessment, diagnosis, education, care plan development, implementation, clinical monitoring, evaluation, and professional issues around nutrition support.

Accepting your first faculty position after completing your formal education and postgraduate training is very exciting and rewarding. As you enter the second year, you will have several new opportunities, responsibilities, and challenges in both the professional and personal sectors of your life. To achieve your professional and personal goals, and to have a successful career, there are several things to consider and evaluate as you enter your second year (and beyond): (1) reflect on the past year and understand what was expected of you, (2) develop a good relationship with your Department Chair and/or manager, (3) find a mentor or mentors, (4) reevaluate short-term and long-term goals, (5) develop and maintain a portfolio for annual evaluations and eventual promotion, (6) learn to manage stress, renew your energy, and take care of yourself, and (7) identify areas for improvement and resources available to address them. It is hoped that the practical advice and resources discussed here will help you achieve your professional and personal goals and help guide you to a successful career.

We examine the possibility that crystalline hematite (α-Fe2O3) deposits on Mars were derived from the precursor iron oxyhydroxide minerals akaganeite (β-FeOOH) or lepidocrocite (γ-FeOOH) and compare them to an earlier study of goethite (α-FeOOH) and magnetite (Fe3O4) precursors. Both the mid-infrared and visible/near infrared spectra of hematite are dependent upon the hematite precursor mineral and the temperature of transformation. Laboratory spectra are compared to spectra from the Mars Global Surveyor Thermal Emission Spectrometer (MGS-TES) and the Mars Exploration Rover (MER) Opportunity Mini-TES and Pancam experiments, allowing us to infer the formation environment of Martian crystalline hematite deposits. Akaganeite and lepidocrocite readily transform to hematite at temperatures of 300 and 500°C, respectively. The visible/near-infrared and mid-infrared spectra of akaganeite-derived hematite are poor matches to data returned from TES, Mini-TES, and Pancam. The spectra of lepidocrocite-derived hematite are slightly better fits, but previously published spectra of goethite-derived hematite still represent the best match to MGS and MER spectral data. The experiments demonstrate that hematite precursor mineralogy, temperature of formation, and crystal shape exert a strong control on the hematite spectra.

Purpose. Characteristics of the ideal drug therapy for postoperative ileus (POI); the pharmacology, efficacy, and safety of currently available nonselective opioid antagonists and the new peripherally selective opioid antagonists methylnaltrexone and alvimopan for the treatment of POI; and formulary considerations associated with the introduction of these new POI drug therapies are discussed. Summary. The ideal drug therapy for treating POI would selectively antagonize the inhibitory effects on the gastrointestinal (GI) tract of all of the potential factors implicated in the pathophysiology of POI (neurogenic, inflammatory, hormonal, and pharmacologic mediators). The most promising target to date is inhibition of the adverse GI effects of endogenous and exogenous opioids. Selective inhibition of the μ-opioid receptors in the GI tract, without reversing centrally mediated opioid-induced analgesia, may be beneficial in reducing POI. The nonselective opioid antagonists naloxone and nalmefene have not been studied for POI, and they cross the blood–brain barrier. Therefore, they are not appropriate for preventing or treating POI. The peripherally selective opioid antagonist methylnaltrexone shortens the duration of POI and the hospital length of stay (LOS). Alvimopan, a more extensively studied peripherally selective opioid antagonist, has been shown to reduce the duration of POI, frequency of postoperative nausea and vomiting, and hospital LOS. Both methylnaltrexone and alvimopan also appear effective for treating opioid-induced constipation. Preliminary results of a long-term study of alvimopan safety have revealed some potential concerns, and the significance of the adverse effects must be understood before the most appropriate role of alvimopan in patient care can be determined. Restricting the prescribing of new POI drug therapies to certain types of patients, surgeries, and prescribers; incorporating these therapies into preoperative and postoperative policies, procedures, and protocols; and the potential cost savings from reducing hospital LOS are among the considerations in adding these agents to health-system formularies. Conclusion. Peripherally selective opioid receptor antagonists are promising new drug therapies that can reduce the clinical and economic burden of POI.

New measurements of thermal infrared emission spectra (250–1400 cm –1 ; ~7–40 μm) of experimentally shocked basalt and basaltic andesite (17–56 GPa) exhibit changes in spectral features with increasing pressure consistent with changes in the structure of plagioclase feldspars. Major spectral absorptions in unshocked rocks between 350–700 cm –1 (due to Si-O-Si octahedral bending vibrations) and between 1000–1250 cm –1 (due to Si-O antisymmetric stretch motions of the silica tetrahedra) transform at pressures >20–25 GPa to two broad spectral features centered near 950–1050 and 400–450 cm –1 . Linear deconvolution models using spectral libraries composed of common mineral and glass spectra replicate the spectra of shocked basalt relatively well up to shock pressures of 20–25 GPa, above which model errors increase substantially, coincident with the onset of diaplectic glass formation in plagioclase. Inclusion of shocked feldspar spectra in the libraries improves Þ ts for more highly shocked basalt. However, deconvolution models of the basaltic andesite select shocked feldspar end-members even for unshocked samples, likely caused by the higher primary glass content in the basaltic andesite sample.

We investigated the mineralogy of basalt weathering rinds and fresh basaltic rocks using visible/near-infrared (VNIR) ( λ = 0.4–2.5 μm) and thermal emission ( λ = 6–30 μm) spectroscopy to 1) constrain the effects of chemical weathering on rock spectra, and 2) further understand the context of infrared spectra of Mars, which may contain evidence for weathered rocks and particulates derived from them. VNIR spectra of weathered rock surfaces are generally redder and brighter than fresh surfaces. Thermal infrared spectra of weathered basalts show evidence for aluminous opal and clay minerals (or clay precursor mineraloids) in natural surfaces. Supporting VNIR observations generally do not show the same evidence for neoformed clays or silica because of their textural occurrence as thin coatings and microfracture-fill, and possibly due to poor crystallinity of the aluminosilicate weathering products in this context. Spectral trends observed at Mars, such as the detection of low to moderate (10–25%) abundances of silica and clay that are observed in the thermal infrared but not in the VNIR, are therefore consistent with trends observed for natural rock surfaces in the laboratory. The combined use of thermal infrared and VNIR suggest that vast areas of martian dark regions contain sandy–rocky basaltic materials with weathering rinds and thin coatings that could have formed in conditions of relatively low water/rock ratios.

Refeeding syndrome describes a constellation of metabolic disturbances that occur as a result of reinstitution of nutrition to patients who are starved or severely malnourished. Patients can develop fluid and electrolyte disorders, especially hypophosphatemia, along with neurologic, pulmonary, cardiac, neuromuscular, and hematologic complications. We reviewed literature on refeeding syndrome and the associated electrolyte abnormalities, fluid disturbances, and associated complications. In addition to assessing scientific literature, we also considered clinical experience and judgment in developing recommendations for prevention and treatment of refeeding syndrome. The most important steps are to identify patients at risk for developing refeeding syndrome, institute nutrition support cautiously, and correct and supplement electrolyte and vitamin deficiencies to avoid refeeding syndrome. We provide suggestions for the prevention of refeeding syndrome and suggestions for treatment of electrolyte disturbances and complications in patients who develop refeeding syndrome, according to evidence in the literature, the pathophysiology of refeeding syndrome, and clinical experience and judgment.

Purpose. The treatment of electrolyte disorders in adult patients in the intensive care unit (ICU), including guidelines for correcting specific electrolyte disorders, is reviewed. Summary. Electrolytes are involved in many metabolic and homeostatic functions. Electrolyte disorders are common in adult patients in the ICU and have been associated with increased morbidity and mortality, as has the improper treatment of electrolyte disorders. A limited number of prospective, randomized, controlled studies have been conducted evaluating the optimal treatment of electrolyte disorders. Recommendations for treatment of electrolyte disorders in adult patients in the ICU are provided based on these studies, as well as case reports, expert opinion, and clinical experience. The etiologies of and treatments for hyponatremia hypotonic and hypernatremia (hypovolemic, isovolemic, and hypervolemic), hypokalemia and hyperkalemia, hypophosphatemia and hyperphosphatemia, hypocalcemia and hypercalcemia, and hypomagnesemia and hypermagnesemia are discussed, and equations for determining the proper dosages for adult patients in the ICU are provided. Treatment is often empirical, based on published literature, expert recommendations, and the patient’s response to the initial treatment. Actual electrolyte correction requires individual adjustment based on the patient’s clinical condition and response to therapy. Clinicians should be knowledgeable about electrolyte homeostasis and the underlying pathophysiology of electrolyte disorders in order to provide the optimal therapy to patients. Conclusion. Treatment of electrolyte disorders is often empirical, based on published literature, expert opinion and recommendations, and patient’s response to the initial treatment. Clinicians should be knowledgeable about electrolyte homeostasis and the underlying pathophysiology of electrolyte disorders to provide optimal therapy for patients.

The Thermal Emission Spectrometer (TES) has observed a high-silica material in the dark regions of Mars that is spectrally similar to obsidian glass and may have a volcanic origin. An alternate interpretation is that the spectrally amorphous material consists of clay minerals or some other secondary material, formed by chemical alteration of surface rocks. The regions where this material is observed (e.g., Acidalia Planitia) have relatively high spectral contrast, suggesting that the high-silica material exists as coarse particulates, indurated soils or cements, within rocks, or as indurated coatings on rock surfaces. The geologic interpretation of this spectral result has major implications for understanding magmatic evolution and weathering processes on Mars. One of the complications in interpreting spectral observations of glasses and clay minerals is that both are structurally and compositionally complex. In this study, we perform a detailed spectroscopic analysis of indurated smectite clay minerals and relate their thermal emission spectral features to structural and crystal chemical properties. We examine the spectral similarities and differences between smectite clay minerals and obsidian glass from a structural-chemical perspective, and make further mineralogical interpretations from previous TES results. The results suggest that neither smectite clays nor any clay mineral with similar structural and chemical properties can adequately explain TES observations of high-silica materials in some martian dark regions. If the spectrally amorphous materials observed by TES do represent an alteration product, then these materials are likely to be poorly crystalline aluminosilicates. While all clay minerals have Si/O ratios ⩽0.4, the position of the emissivity minimum at Mars suggests a Si/O ratio of 0.4–0.5. The spectral observation could be explained by the existence of a silica-rich alteration product, such as Al- or Fe-bearing opal, an intimate physical mixture of relatively pure silica and other aluminosilicates (such as clay minerals or clay precursors), or certain zeolites. The chemical alteration of basaltic rocks on Mars to phyllosilicate-poor, silica-rich alteration products provides a geologically reasonable and consistent explanation for the global TES surface mineralogical results.

Phosphorus (P) and calcium (Ca) serve vital roles in the human body and are essential components of nutrition support therapy. Regulation of P and regulation of Ca in the body are closely interrelated, and P and Ca homeostasis can be affected by several factors, including disease states, clinical condition, severity of illness, and medications. Nutrition support clinicians must understand these factors to prevent and treat P and Ca disorders in patients receiving nutrition support therapy. This review provides an overview of P and Ca for the adult nutrition support clinician, with some emphasis on the hospitalized inpatient.

Shortages of parenteral nutrition (PN) components have been common in recent years. Effects on patient management and outcomes have not been well documented. This study aimed to determine the effect of a parenteral magnesium shortage, and an institutional decision to omit magnesium from adult PN, on magnesium and potassium doses and serum concentrations.This was a retrospective cohort study of adult surgical patients during two 6-month periods: prior to the magnesium shortage (2011) and during the shortage (2012). The relation between study period and electrolyte doses was evaluated by unadjusted and adjusted mixed models, while the relation between study period and hypokalemia and hypomagnesemia exposure was evaluated by Student's t tests and multiple linear regression.During the shortage, patients received more supplemental magnesium (0.11-0.12 mEq/kg/d, P.0001) but received less total daily magnesium (0.08-0.09 mEq/kg/d, P.0001) and had greater exposure to hypomagnesemia (9.6-14.2 h·mcg/dL/h, P.05 for all comparisons except multivariate analysis in a matched subpopulation). Patients received similar amounts of potassium in PN (0.06-0.08 mEq/kg/d less, P.05 for full cohort but P.05 for matched cohort), in supplemental doses (0.01-0.05 mEq/kg/d less, P.05), and in total (0.07-0.14 mEq/kg/d less, P.05), and they had similar exposure to hypokalemia.Daily magnesium doses were lower and hypomagnesemia exposure was greater during the shortage, but the differences were numerically small and their clinical significance was questionable. Potassium doses and hypokalemia exposure were not higher during the shortage. This supports the strategy of omitting magnesium from PN of select patients and supplementing as clinically necessary.

Purpose To assist the pharmacy clinician engaged in nutrition support in staying current with the most pertinent literature. Methods Several experienced board-certified clinical pharmacists in nutrition support compiled a list of publications published in 2013 that they considered to be important to their practice. The citation list was compiled into a Web-based survey whereby pharmacist members of the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.), GI-Liver-Nutrition Practice Research Network of the American College of Clinical Pharmacy, and the Pharmacy and Pharmacology Section of the Society of Critical Care Medicine were asked to rank each article according to level of importance in their practice. Results A total of 30 articles were identified by the author group. Thirty-six participants responded to the survey. The top-ranked papers by participants from the Web-based survey were reviewed by the authors. Due to its high level of importance, the parenteral nutrition safety consensus recommendations article, to be published in 2014 by A.S.P.E.N., was also reviewed. Conclusion It is recommended that the informed pharmacist, who is engaged in nutrition support therapy, be familiar with the majority of these publications.

The Imager for Mars Pathfinder (IMP) windsock experiment measured wind speeds at three heights within 1.2 m of the Martian surface during Pathfinder landed operations. These wind data allowed direct measurement of near-surface wind profiles on Mars for the first time, including determination of aerodynamic roughness length and wind friction speeds. Winds were light during periods of windsock imaging, but data from the strongest breezes indicate aerodynamic roughness length of 3 cm at the landing site, with wind friction speeds reaching 1 m/s. Maximum wind friction speeds were about half of the threshold-of-motion friction speeds predicted for loose, fine-grained materials on smooth Martian terrain and about one third of the threshold-of-motion friction speeds predicted for the same size particles over terrain with aerodynamic roughness of 3 cm. Consistent with this, and suggesting that low wind speeds prevailed when the windsock array was not imaged and/or no particles were available for aeolian transport, no wind-related changes to the surface during mission operations have been recognized. The aerodynamic roughness length reported here implies that proposed deflation of fine particles around the landing site, or activation of duneforms seen by IMP and Sojourner, would require wind speeds >28 m/s at the Pathfinder top windsock height (or >31 m/s at the equivalent Viking wind sensor height of 1.6 m) and wind speeds >45 m/s above 10 m. These wind speeds would cause rock abrasion if a supply of durable particles were available for saltation. Previous analyses indicate that the Pathfinder landing site probably is rockier and rougher than many other plains units on Mars, so aerodynamic roughness length elsewhere probably is less than the 3-cm value reported for the Pathfinder site.

Rock coatings can be used to constrain the rate of abrasion by wind on Mars. The susceptibility to abrasion for potential rock coatings on Mars (salt/salt-cemented coatings, rock varnish, and amorphous silica) were determined experimentally. Rock coatings generally abrade more easily than the host rock, although amorphous silica is an exception. If coatings exist on rocks at the Mars Pathfinder landing site, then the rate of abrasion is extremely low, consistent with previous studies of erosion rates. Alternatively, rock varnish or silica coatings could protect the rocks from sandblasting, although this may require coating formation under current to recent conditions. The Pathfinder area may lack efficient abrasive particles, and the observed duneforms may be composed of sand-size dust aggregates rather than crystalline particles.

Surface features related to the wind are observed in the vicinity of the Mars Pathfinder (MPR landing site data from the lander and in data from orbit by the Viking Orbiter and Mars Global Surveyor missions. Features seen from the surface include wind tails associated with small rocks, barchanoid duneforms, ripplelike patterns, and ventifact flutes cut into some rocks. Features seen from orbit include wind tails associated with impact craters, ridges inferred to be duneforms, and modified crater rims interpreted to have been eroded and mantled by windblown material. The orientations of these features show two prevailing directions. One is inferred to represent winds from the northeast, which is consistent with strongest winds predicted by a general circulation model to occur during the Martian northern winter under current conditions. A second wind blowing from the ESE was responsible for modifying the crater rims and cutting some of the ventifacts. The two wind regimes could reflect a change in climate related to Mars' obliquity or some other, unknown factor. Regardless of the cause, the MPF area has been subjected to a complex pattern of winds and supply of small particles, and the original surface formed by sedimentary processes from Tiu and Ares Vallis flooding events has been modified by repeated burial and exhumation.

About half of the rocks at the Mars Pathfinder Ares Vallis landing site appear to be ventifacts, rocks abraded by windborne particles. Comparable resolution images taken by the Imager for Mars Pathfinder (IMP) camera and the Viking landers show that ventifacts are more abundant at the Pathfinder site. The ventifacts occur in several forms, including rocks with faceted edges, finger-like projections, elongated pits, flutes, grooves, and possible rills. The trends of elongated pits, flutes, grooves, and rills cluster at ∼280–330° clockwise from north and generally dip 10–30° away from their trend direction. These orientations are indicative of southeast to northwest winds and differ from the trend of wind tails at the landing site, the direction of local wind streaks, and predictions of the Global Circulation Model, all of which indicate northeast to southwest winds. The disparity between these data sets strongly suggests that local circulation patterns have changed since the abrasion of the ventifacted rocks. The greater number of ventifacts at the Pathfinder site compared to either of the Viking sites is most easily explained as being due to a larger supply of abrading particles, composed of either sand-sized grains or indurated dust aggregates, and higher surface roughness, which should increase the momentum of saltating grains. The Pathfinder ventifacts may have formed shortly after the deposition of outflow channel sediments nearly 2 Gry ago, when a large local supply of abrading particles should have been abundant and atmospheric conditions may have been more conducive to rock abrasion from saltating grains. Based on how ventifacts form on Earth, the several ventifact forms seen at the Pathfinder site and their presence on some rocks but not on others are probably due to local airflow conditions, original rock shape, exposure duration, rock movement, and to a lesser extent, rock lithology. The abundance of ventifacts at the Pathfinder site, together with other evidence of weathering, indicates that unaltered rock surfaces are rare on Mars.

The Mars Pathfinder landing site contains abundant features attributed to aeolian, or wind, processes. These include wind tails, drift deposits, duneforms of various types, ripplelike features, and ventifacts (the first clearly seen on Mars). Many of these features are consistant with formation involving sand-size particles. Although some features, such as dunes, could develop from saltating sand-size aggregates of finer grains, the discovery of ventifact flutes cut in rocks strongly suggests that at least some of the grains are crystalline, rather than aggregates. Excluding the ventifacts, the orientations of the wind-related features correlate well with the orientations of bright wind steaks seen on Viking Orbiter images in the general area. They also correlate with wind direction predictions from the NASA-Ames General Circulation Model (GCM) which show that the strongest winds in the area occur in the northern hemisphere winter and are directed toward 209°.

Background: Alkalinized Viokase pancreatic enzyme tablets restored patency to 71.9% of occluded Dobhoff tubes in a prospective study. After removal of Viokase tablets from the US market, the hospital protocol for unclogging enteral feeding tubes was adapted to use Creon pancreatic enzyme delayed-release capsules, despite the lack of published data. Objective: To evaluate the effectiveness of a Creon-based protocol to clear occluded enteral feeding tubes. Methods: This retrospective study included all adult and pediatric patients seen in the emergency department or in an inpatient setting who received Creon 12 000 units lipase delayed-release capsule dissolved in a solution of sodium bicarbonate 650 mg and sterile water for clearing occluded enteral feeding tubes between May 1 and November 30, 2010. The Creon protocol was deemed effective if tube clearance was documented in the medical record or if enteral feedings were resumed with no note regarding tube replacement. Results: Alkalinized Creon delayed-release capsules were administered to 83 patients with a total of 118 clogged tubes. Three poorly documented cases and 5 tubes with mechanical clogs were excluded from data analysis. Patency was restored to 53 of 110 (48.2%) occluded tubes. More than 1 treatment course was attempted in 5 cases, with success in 3. Conclusion: An alkalinized Creon pancreatic enzyme protocol was effective in clearing approximately half of the occluded enteral feeding tubes in this retrospective study, an efficacy rate much less than that previously reported in the literature with a Viokase-based protocol.

Parenteral nutrition (PN) serves as an important therapeutic modality that is used in adults, children, and infants for a variety of indications. The appropriate use of this complex therapy aims to maximize clinical benefit while minimizing the potential risks for adverse events. Complications can occur as a result of the therapy and as the result of the PN process. These consensus recommendations are based on practices that are generally accepted to minimize errors with PN therapy, categorized in the areas of PN prescribing, order review and verification, compounding, and administration. These recommendations should be used in conjunction with other A.S.P.E.N. publications, and researchers should consider studying the questions brought forth in this document.

Venous thromboembolism (VTE) is the leading cause of preventable death in hospitalized patients. Educational videos have been effectively used to increase patient satisfaction and knowledge. This study examined possible benefits of an educational video about VTE.Medical patients receiving VTE prophylaxis were screened within 48 h of admission. Upon enrollment, patients were randomly assigned to either watch a 5 min educational video on VTE or not, in addition to standard VTE education. Within 24-48 h after randomization, all patients completed a survey assessing VTE prophylaxis knowledge and satisfaction.Patients who watched the video averaged 83% correct responses to knowledge-based questions (regarding VTE risk, symptoms, and preventative measures) versus an average score of 62% for patients in the no video group (p0.001). Patients who watched the video were more satisfied with their VTE education (4.8 vs. 3.4 out of 5, p0.001).This educational video effectively provided baseline information to patients about VTE and improved patient satisfaction.A VTE educational video can be an effective tool for improving patient knowledge of the condition.

[1] We have identified several exposed dikes in Thaumasia Planum Mars using THEMIS, CTX, HiRISE and CRISM data. These dikes extend from tens to ∼100 kilometers in length with average widths of ∼50 m. They display classic ‘en echelon’ patterns while cross-cutting preexisting geologic features, including extensive wrinkle ridges. Both the dikes and associated fissure eruption products have very blocky morphologies with ∼38% higher thermal inertia than the surrounding regions. The dikes are all enriched in Mg-rich olivine relative to surrounding terrain, and a subset also contains elevated high-calcium pyroxene, both of which indicate relatively primitive magma compositions. We propose that these dikes might have served as feeders for the olivine-enriched flood basalts in this region, and may be derived from the Tharsis plume. These observations provide further evidence that the opening of Valles Marineris was facilitated by tectonic stresses following paths of preferential weakness along preexisting structures such as fractures and faults like those indicated by these dikes.

Vasopressors used for the management of septic shock are often dosed according to body weight. Use of vasopressin for physiologic replacement in patients with septic shock is usually administered as a standard non-weight-based dose. We hypothesized that the efficacy of vasopressin may be influenced by body weight.The primary objective was to determine if the effects of vasopressin on other vasopressor dosing requirements is related to body weight. Secondary objectives included evaluation of blood pressure and heart rate after the start of vasopressin infusion.A retrospective, cohort study in a large academic health center was conducted. Sixty-four adult inpatients with septic shock (26 medical intensive care unit and 38 surgical intensive care unit) who required vasopressor administration including vasopressin therapy were included. Dosing requirements of vasopressors were captured 1 hour before and during the hour of vasopressin initiation and 2 and 4 hours later. Other information collected during the study period included blood pressure, mean arterial pressure, and heart rate.Most of the patients (n = 61) received vasopressin at a dose of 0.04 U/min. Changes in vasopressor dosing were significantly correlated with weight-adjusted vasopressin at 2 hours (correlation coefficient = -0.36, P = .03) and 4 hours (correlation coefficient = -0.46, P.001). Use of vasopressin was associated with significant increases in systolic blood pressure, diastolic blood pressure, and mean arterial pressure at each time point compared with baseline.Effects of vasopressin on catecholamine dosing requirements in the setting of septic shock may be influenced by body weight. Prospective studies are needed to examine weight-based dosing of vasopressin in this setting.

Critically ill patients who are subjected to high stress or with severe injury can rapidly break down their body protein and energy stores. Unless adequate nutrition is provided, malnutrition and protein wasting may occur, which can negatively affect patient outcome. Enteral nutrition (EN) is the mainstay of nutrition support therapy in patients with a functional gastrointestinal (GI) tract who cannot take adequate oral nutrition. EN in critically ill patients provides the benefits of maintaining gut functionality, integrity, and immunity as well as decreasing infectious complications. However, the ability to provide timely and adequate EN to critically ill patients is often hindered by GI motility disorders and complications associated with EN. This paper reviews the GI complications and intolerances associated with EN in critically ill patients and provides recommendations for their prevention and treatment. It also addresses the role of commonly used medications in the intensive care unit and their impact on GI motility and EN delivery.