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We present new arcminute-resolution maps of the Cosmic Microwave Background temperature and polarization anisotropy from the Atacama Cosmology Telescope, using data taken from 2013–2016 at 98 and 150 GHz. The maps cover more than 17,000 deg2, the deepest 600 deg2 with noise levels below 10µK-arcmin. We use the power spectrum derived from almost 6,000 deg2 of these maps to constrain cosmology. The ACT data enable a measurement of the angular scale of features in both the divergence-like polarization and the temperature anisotropy, tracing both the velocity and density at last-scattering. From these one can derive the distance to the last-scattering surface and thus infer the local expansion rate, H0. By combining ACT data with large-scale information from WMAP we measure H0 = 67.6±1.1 km/s/Mpc, at 68% confidence, in excellent agreement with the independently-measured Planck satellite estimate (from ACT alone we find H0 = 67.9 ± 1.5 km/s/Mpc). The ΛCDM model provides a good fit to the ACT data, and we find no evidence for deviations: both the spatial curvature, and the departure from the standard lensing signal in the spectrum, are zero to within 1σ; the number of relativistic species, the primordial Helium fraction, and the running of the spectral index are consistent with ΛCDM predictions to within 1.5–2.2σ. We compare ACT, WMAP, and Planck at the parameter level and find good consistency; we investigate how the constraints on the correlated spectral index and baryon density parameters readjust when adding CMB large-scale information that ACT does not measure. The DR4 products presented here will be publicly released on the NASA Legacy Archive for Microwave Background Data Analysis.

We present the temperature and polarization angular power spectra of the CMB measured by the Atacama Cosmology Telescope (ACT) from 5400 deg2 of the 2013–2016 survey, which covers >15000 deg2 at 98 and 150 GHz. For this analysis we adopt a blinding strategy to help avoid confirmation bias and, related to this, show numerous checks for systematic error done before unblinding. Using the likelihood for the cosmological analysis we constrain secondary sources of anisotropy and foreground emission, and derive a “CMB-only” spectrum that extends to ` = 4000. At large angular scales, foreground emission at 150 GHz is ∼1% of TT and EE within our selected regions and consistent with that found by Planck. Using the same likelihood, we obtain the cosmological parameters for ΛCDM for the ACT data alone with a prior on the optical depth of τ = 0.065 ± 0.015. ΛCDM is a good fit. The best-fit model has a reduced χ2 of 1.07 (PTE = 0.07) with H0 = 67.9 ± 1.5 km/s/Mpc. We show that the lensing BB signal is consistent with ΛCDM and limit the celestial EB polarization angle to ψP = −0.07◦ ±0.09◦. We directly cross correlate ACT with Planck and observe generally good agreement but with some discrepancies in TE. All data on which this analysis is based will be publicly released.

Farid Chekani,1 Holly M Holmes,2 Michael L Johnson,1 Hua Chen,1 Jeffrey T Sherer,1 Rajender R Aparasu1 1Department of Pharmaceutical Health Outcomes and Policy, College of Pharmacy, University of Houston, Houston, TX 77204-5047, USA; 2Division of Geriatric and Palliative Medicine, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX 77030, USACorrespondence: Rajender R AparasuDepartment of Pharmaceutical Health Outcomes and Policy, College of Pharmacy, University of Houston, Health and Biomedical Sciences Building 2 – Office 4052, 4849 Calhoun Road, Houston, TX 77204-5047, USATel +1832 842-8374Email rraparasu@uh.eduPurpose: According to the 2015 American Geriatrics Society (AGS) Beers criteria, most antipsychotics are inappropriate in Parkinson’s disease (PD) patients due to the risk of worsening Parkinsonian symptoms. This study examined the incidence and predictors of inappropriate antipsychotic use among long-term care residents with PD and comorbid depression.Patients and Methods: This retrospective cohort study utilized 2007– 2009 Minimum Data Set (MDS) linked to Chronic Condition Warehouse (CCW) Medicare data files involving patients with PD and comorbid depression. Using a 12-month baseline and a 24-month follow-up, the study examined incidence of inappropriate atypical antipsychotics, namely asenapine, brexpiprazole, iloperidone, lurasidone, olanzapine, paliperidone, risperidone, or ziprasidone as specified in the 2015 AGS Beers criteria. Appropriate atypical antipsychotic included aripiprazole, clozapine, or quetiapine. Multivariable logistic regression was used to examine various sociodemographic and clinical factors associated with inappropriate antipsychotic use in PD based on the Andersen Behavioral Model.Results: The incidence of atypical antipsychotic use was 17.50% (13,352/76,294) among PD patients over a 2-year follow-up. The percentage of inappropriate use among atypical antipsychotic users was 36.32%. The likelihood of inappropriate antipsychotic use was higher for patients who had dementia (OR=1.22, 95% CI: 1.12– 1.33) or Chronic Obstructive Pulmonary Disease ((OR=1.13, 95% CI: 1.03– 1.24). However, patients who were taking levodopa (OR=0.62, 95% CI: 0.57– 0.67), dopamine agonists (OR=0.90, 95% CI: 0.82– 0.98), Catechol-O-methyltransferase (COMT) inhibitors (OR=0.77, 95% CI: 0.68– 0.86), Monoamine Oxidase (MAO) inhibitors type B (OR=0.72, 95% CI: 0.60– 0.86), or amantadine (OR=0.84, 95% CI: 0.71– 0.98) were less likely to receive inappropriate antipsychotics.Conclusion: More than one-third of PD patients used inappropriate antipsychotics among those who were treated with atypical antipsychotic medications. Various socio-demographics and clinical factors were associated with inappropriate antipsychotic use in older patients with PD. Concerted efforts are needed to reduce inappropriate atypical antipsychotic use among PD patients.Keywords: Parkinson disease, psychotic disorders, antipsychotic agents

OBJECTIVES: Using increasingly stringent criteria, this study evaluated the prevalence of psychotropic polypharmacy among children on the basis of duration of overlap between two or more psychotropic medications. METHODS: The prevalence of psychotropic polypharmacy was defined as receiving >=14 days, >=30 days, >=60 days, and >=90 days of overlapping psychotropic prescription fills. Descriptive analysis was used to compare the prevalence findings on the basis of multistate Medicaid data involving children six to 18 years of age. A sensitivity analysis was also conducted to explore the extent to which the cross-sectional operational definitions of polypharmacy used in the published literature identified patients who were prescribed psychotropic combinations on a long-term basis. RESULTS: The analysis revealed that 282,910 children had at least one psychotropic prescription fill in 2005. Of these patients, 28.8% received psychotropic combinations for at least 14 consecutive days. The observed rate of polypharmacy dropped to 27.2% with 30 days of overlap and to 20.9% with 60 days of overlap. Using a 60-day overlap in psychotropic drugs as a cutoff between short-term and long-term polypharmacy, analyses showed that 14%-46% of patients identified by cross-sectional definitions as receiving polypharmacy had likely received combination treatment on a temporary rather than on a long-term basis. In addition, cross-sectional definitions failed to identify 18%-44% of patients classified as receiving long-term polypharmacy (>=60-day overlap). CONCLUSIONS: The observed rate of polypharmacy dropped with increasingly stringent operational definitions for polypharmacy. The findings suggest that considerable differences arise when comparing rates of polypharmacy across studies with inconsistent operational definitions. (Psychiatric Services 62:1450-1455, 2011). [ABSTRACT FROM AUTHOR]

Background Multiple features in the presentation of randomized controlled trial (RCT) results are known to influence comprehension and interpretation. We aimed to compare interpretation of cancer RCTs with time-to-event outcomes when the reported treatment effect measure is the hazard ratio (HR), difference in restricted mean survival times (RMSTD), or both (HR+RMSTD). We also assessed the prevalence of misinterpretation of the HR. Methods We carried out a randomized experiment. We selected 15 cancer RCTs with statistically significant treatment effects for the primary outcome. We masked each abstract and created three versions reporting either the HR, RMSTD, or HR+RMSTD. We randomized corresponding authors of RCTs and medical residents and fellows to one of 15 abstracts and one of 3 versions. We asked how beneficial the experimental treatment was (0–10 Likert scale). All participants answered a multiple-choice question about interpretation of the HR. Participants were unaware of the study purpose. Results We randomly allocated 160 participants to evaluate an abstract reporting the HR, 154 to the RMSTD, and 155 to both HR+RMSTD. The mean Likert score was statistically significantly lower in the RMSTD group when compared with the HR group (mean difference −0.8, 95% confidence interval, −1.3 to −0.4, P  < 0.01) and when compared with the HR+RMSTD group (difference −0.6, −1.1 to −0.1, P  = 0.05). In all, 47.2% (42.7%−51.8%) of participants misinterpreted the HR, with 40% equating it with a reduction in absolute risk. Conclusion Misinterpretation of the HR is common. Participants judged experimental treatments to be less beneficial when presented with RMSTD when compared with HR. We recommend that authors present RMST-based measures alongside the HR in reports of RCT results. [ABSTRACT FROM AUTHOR]

Background: Both Alzheimer's disease (AD) and deliriogenic medications increase the risk of delirium in older adults. This study examined the association between delirium and the subsequent monthly use of anticholinergic, sedative, and opioid medications in the 1 year after delirium in older adults with AD., Methods: This comparative interrupted time series analysis involved adults (aged 65 years and older) with a diagnosis of AD initiating on cholinesterase inhibitors (ChEIs) based on 2013-2017 Medicare data. Separate patient-level segmented regression models were used for each outcome to evaluate changes in the cumulative anticholinergic burden (CAB), sedative load, and opioid load after the delirium/index event using a 12-month baseline and follow-up period among patients who had a delirium event and those without delirium (control group). Propensity score-based stabilized weights were utilized to balance baseline factors in the delirium and control groups., Results: The study included 80,019 older adults with AD with incident ChEI use; 17.11% had delirium. There was an immediate decline in monthly CAB after the delirium event (mean estimate -0.86, p-value: 0.01) compared to the control group. A similar decline was observed when examining the sedative load (-0.06, p-value: 0.002) after the delirium event. However, there was no decline in opioid load (-0.50, p-value: 0.18). In the long term, CAB (0.13; p-value: <0.0001), sedative load (0.01; p-value: <0.001), and opioid load (0.07; p-value: 0.006) increased over the 1-year post-delirium period in the delirium group compared to those without delirium., Conclusion: This study found the burden of deliriogenic medications over the 1-year follow-up showed increasing trends in older adults with AD, even though there was some level shift in CAB and sedative load after the delirium event., (© 2024 Pharmacotherapy Publications, Inc.)

Immediate-use steam sterilization (IUSS) shortens the time of sterilization but may increase the risk of surgical site infection (SSI). Among 23,919 procedures with 416 (1.7%) procedures resulting in SSI, IUSS was associated with a 1.52 (95% CI, 1.10-2.11) times higher risk of SSI. IUSS should be minimized., Competing Interests: All authors report no conflicts of interest relevant to this article., (© The Author(s) 2024.)

Background: Cumulative anticholinergic burden refers to the cumulative effect of multiple medications with anticholinergic properties. However, concomitant use of cholinesterase inhibitors (ChEIs) and anticholinergic burden can nullify the benefit of the treatment and worsen Alzheimer's disease (AD). A literature gap exists regarding the extent of the cumulative anticholinergic burden and associated risk factors in AD. Therefore, this study evaluated the prevalence and predictors of cumulative anticholinergic burden among patients with AD initiating ChEIs., Methods: A retrospective longitudinal cohort study was conducted using the Medicare claims data involving parts A, B, and D from 2013 to 2017. The study sample included older adults (65 years and older) diagnosed with AD and initiating ChEIs (donepezil, rivastigmine, or galantamine). The cumulative anticholinergic burden was calculated based on the Anticholinergic Cognitive Burden scale and patient-specific dosing using the defined daily dose over the 1 year follow-up period after ChEI initiation. Incremental anticholinergic burden levels were dichotomized into moderate-high (sum of standardized daily anticholinergic exposure over a year (TSDD) score ≥ 90) versus low-no (score 0-89). The Andersen Behavioral Model was used as the conceptual framework for selecting the predictors under the predisposing, enabling, and need categories. A multivariable logistic regression model was used to evaluate the predictors of high-moderate versus low-no cumulative anticholinergic burden. A multinomial logistic regression model was also used to determine the factors associated with patients having moderate and high burdens compared to low/no burdens., Results: The study included 222,064 older adults with AD with incident ChEI use (mean age 82.24 ± 7.29, 68.9% females, 83.6% White). Overall, 80.48% had some anticholinergic burden during the follow-up, with 36.26% patients with moderate (TSDD scores 90-499), followed by 24.76% high (TSDD score > 500), and 19.46% with low (TSDD score 1-89) burden categories. Predisposing factors such as age; African American, Asian, or Hispanic race; and need factors included comorbidities such as dyslipidemia, syncope, delirium, fracture, pneumonia, epilepsy, and claims-based frailty index were less likely to be associated with the moderate-high anticholinergic burden. The factors that increased the odds of moderate-high burden were predisposing factors such as female sex; enabling factors such as dual eligibility and diagnosis year; and need factors such as baseline burden, behavioral and psychological symptoms of dementia, depression, insomnia, urinary incontinence, irritable bowel syndrome, anxiety, muscle spasm, gastroesophageal reflux disease, heart failure, and dysrhythmia. Most of these findings remained consistent with multinomial logistic regression.  CONCLUSION: Four out of five older adults with AD had some level of anticholinergic burden, with over 60% having moderate-high anticholinergic burden. Several predisposing, enabling, and need factors were associated with the cumulative anticholinergic burden. The study findings suggest a critical need to minimize the cumulative anticholinergic burden to improve AD care., (© 2024. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

Purpose of Review: Modern methods of communication and engagement, such as social media, video games, and online shopping, use a variety of behavioral techniques to encourage and reward frequent use, opening the door to addiction. The technological addictions (TAs) are a set of disorders that accompany the technological advances that define the digital age. The TAs are an active source of research in the literature, with promising treatment options already available., Recent Findings: There are promising therapeutic and psychopharmacologic treatments for a broad range of TAs. Stimulants, antidepressants, and cognitive therapies may all be effective for internet gaming disorder (IGD). Cognitive therapies may be effective for other TAs, such as social media addiction (SMA), online shopping addiction (OSA), and online porn addiction. Society's dependence on addictive technologies will only increase. Many of the TAs can be addressed with medication and therapy, with more research and literature developing at a rapid pace., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Using qualitative research and a collaborative academic service partnership, we created an innovative 120-hour perioperative nursing summer internship for eight undergraduate nursing students in 2016. Recognizing that perioperative exposure is limited in the traditional baccalaureate program, this unpaid internship served to clarify student perceptions of perioperative nursing care and encourage graduates to meet perioperative workforce demands. We based the theoretical and practical student learning experiences on the AORN Periop 101 learning modules and included faculty-led discussions, student journaling, and onsite precepted clinical activities. Evaluation data revealed that students achieved an enhanced awareness of perioperative nursing, and a majority of the participants expressed a desire to enter the perioperative field after graduation. We suggest that stakeholders continue to strategize ways to maximize educational preparation to address the evolving health care market supply and demand., (© AORN, Inc, 2018.)

Extrapyramidal symptoms are an uncommon but well-recognized side effect after the administration of general anesthesia in patients without a significant neurologic history. Several case reports implicate propofol as the likely causative agent producing these symptoms, which include ballismus, dystonia, choreoathetosis, and opisthotonus. Currently, there is no clear consensus on first-line treatment of these symptoms. In each of the published cases, anticholinergic medications and benzodiazepines were central to initial management, although the speed and extent of symptom resolution were variable. Here we present a case of a 17-year-old boy with ulcerative colitis who presented with ballismus, torticollis, tongue thrusting, and oculogyric movements after colonoscopy under general anesthesia with propofol. The patient responded promptly to treatment with diphenhydramine. This is the first reported case in which diphenhydramine was successfully used as the primary treatment of severe extrapyramidal symptoms in a pediatric patient after propofol administration., (Copyright © 2017 by the American Academy of Pediatrics.)

Context: Lacerations are a common occurrence in urgent care and emergency room settings. The types of lacerations repaired in these settings range from superficial and linear to deep and stellate. Healthcare professionals are required to describe these wounds in documentation and part of that description is length. In a busy clinical setting, many providers use a visual estimation of wound length for documentation. The purpose of this exploratory pilot study was to systematically examine the factors (e.g., sex, residency year, prior laceration training) associated with overall accuracy of five laceration length estimates made on a series of five identically-marked linear dummy torso sutured lacerations by a convenience sample of Emergency Medicine (EM) resident physicians. Before the study, the authors hypothesized that laceration estimates from later-year residents and/or those with more prior laceration training would be more accurate., Methods: The EM residents who attended a statewide educational session were encouraged to participate in the study by independently entering information concerning their a) personal characteristics, and b) five laceration length estimates from five dummy torso sutured lacerations onto hard copy forms during break and lunch periods of the daylong conference. The use of any types of measurement devices was prohibited., Results: A total non-probability convenience sample of 107 participants (93 EM resident physicians and 14 medical student attendees) from 14 different Michigan-based EM residency programs completed a 10-item survey during the educational conference. Results for both composite and individual actual-to-estimated (AE) laceration differences varied widely within the sample, with up to 58.9% of laceration over estimates hypothetically having resulted in overbilling of payers for the laceration repair., Conclusions: The considerable range in laceration estimates obtained from these EM clinicians indicate the complexity of attempting to estimate lacerations without measuring devices, as well as the potential for over-billing under such conditions. Larger resident samples recording laceration length estimates, with testing of potential interaction effects on AE patterns, are needed in the future to provide additional evidence concerning this aspect of EM billing., Competing Interests: The authors declare no conflict of interest.

We investigated whether altering Warburg metabolism (aerobic glycolysis) by treatment with the metabolic agent dichloroacetate (DCA) could increase the X-ray-induced cell killing of the radiation-resistant human non-small-cell lung cancer (NSCLC) cell lines A549 and H1299. Treatment with 50mM DCA decreased lactate production and glucose consumption in both A549 and H1299, clear indications of attenuated aerobic glycolysis. In addition, we found that DCA treatment also slowed cell growth, increased population-doubling time, and altered cell cycle distribution. Furthermore, we report that treatment with 50mM DCA significantly increased single and fractionated X-ray-induced cell killing of A549 and H1299 cells. Assay of DNA double-strand break repair by neutral comet assays demonstrated that DCA inhibited both the fast and the slow kinetics of X-ray-induced DSB repair in both A549 and H1299 NSCL cancer cells. Taken together the data suggest a correlation between an attenuated aerobic glycolysis and enhanced cytotoxicity and radiation-induced cell killing in radiation-resistant NSCLC cells., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objective: This study examined off-label and evidence-based use of second-generation antipsychotic agents among elderly nursing home residents and factors associated with off-label use., Methods: This study involved a retrospective, cross-sectional analysis of data from the 2004 National Nursing Home Survey (NNHS). The sample included nursing home residents 65 years and older who received second-generation antipsychotic agents. This study used an indication-based definition of off-label use established by the U.S. Food and Drug Administration (FDA). Evidence-based use included FDA-approved indications and indications for which the Agency of Healthcare Research and Quality found at least moderate strength of evidence of effectiveness. Descriptive statistics were used to examine the prevalence of off-label and evidence-based use. Multiple logistic regression was used to examine the patient and facility factors associated with off-label use of second-generation antipsychotics., Results: According to the 2004 NNHS, 308,990 (23.5%) elderly nursing home residents received at least one second-generation antipsychotic agent. Of those using second-generation antipsychotics, 86.3% received them for off-label indications and 56.9% received them for an evidence-based use. Multivariate analysis found that age (> or =75 years), self-pay for nursing home care, diagnosis of dementia, and residing in a nonprofit nursing home were positively associated with off-label use, whereas receiving Medicaid benefits was negatively associated with such use., Conclusions: Although second-generation antipsychotics were frequently used for off-label indications, most of the usage was evidence based among elderly nursing home residents. However, the high level of non-evidence-based use combined with recent safety and efficacy data suggests an urgent need to address the evidence base for this vulnerable population.

Background: Antipsychotic utilization in elderly nursing home residents has increased substantially in recent years, primarily due to the use of atypical antipsychotic agents. However, few studies have examined antipsychotic utilization patterns in nursing home residents in the United States since the introduction of atypical agents in the 1990s., Objective: The goal of this study was to examine the prevalence of and the factors associated with antipsychotic drug use among elderly nursing home residents in the United States., Methods: This study involved a cross-sectional analysis of prescription and resident data files from the 2004 National Nursing Home Survey (NNNHS). The analysis focused on the use of 11 typical and 6 atypical antipsychotic agents among a nationally representative sample of elderly patients (aged > or =65 years). Descriptive weighted analysis was performed to examine antipsychotic prevalence patterns. Multiple logistic regression analysis within the conceptual framework of the Andersen behavioral model was used to examine the factors associated with antipsychotic drug use among the elderly nursing home residents., Results: According to the 2004 NNHS, 0.32 million elderly nursing home residents received antipsychotic medications, for an overall prevalence of 24.82%. Most received atypical agents (23.45%), while 1.90% received typical agents. Frequently reported diagnoses among the elderly using an antipsychotic agent were dementia (70%), depression (41%), and anxiety (18%). Among the predisposing characteristics, female gender and age (> or =85 years) were negatively associated with antipsychotic drug use. Need factors such as increasing dependence in decision-making ability regarding tasks of daily life, depressed mood indicators, behavioral symptoms, history of falls, and bowel incontinence were positively associated with antipsychotic drug use. In addition to the use of antipsychotic agents in schizophrenia and bipolar mania, this study found high use in conditions such as dementia, anxiety, depression, and parkinsonism in the elderly., Conclusions: Nearly 1 in 4 elderly nursing home residents in the United States received antipsychotic agents. Predisposing and need factors played a vital role in determining the use of antipsychotic agents in these elderly patients. Overall, the study findings suggest that there is a need to monitor antipsychotic drug use by elderly patients in US nursing homes in light of recent efficacy and safety data on atypical agents.

Heparin-induced thrombocytopenia requires immediate alternative anticoagulation to prevent or treat thromboembolic complications. Argatroban was approved based on multiple-center studies from the 1990s, but subsequent changes in prevailing awareness, diagnostic testing and therapeutic strategies for heparin-induced thrombocytopenia might affect results of argatroban therapy. Charts were retrospectively reviewed from patients administered argatroban for suspected heparin-induced thrombocytopenia over 22 months at a single large university hospital. Twenty-seven patients, most in intensive care units, received a median 0.5 microg/kg/min argatroban over a median 5.5 days. Patients had isolated heparin-induced thrombocytopenia (n = 10), had heparin-induced thrombocytopenia with thrombosis (n = 9), or lacked active heparin-induced thrombocytopenia (n = 8) on final analysis. New thromboses (14.8%), progression of preexisting thromboses (0%), amputation secondary to heparin-induced thrombocytopenia (0%), death (22.2%), bleeding requiring transfusion (3.7%), and any bleeding (22.2%) compared favorably with older multiple-center reports. Deaths occurred mainly with preexisting multiple-organ failure. In contemporary "real world" use, argatroban provides safe and effective anticoagulation, strengthening the mandate to initiate alternative anticoagulation whenever heparin-induced thrombocytopenia appears likely.

Objective: To review the use of pentoxifylline for the prevention and treatment of acute vasoocclusive episodes (VOEs) in sickle-cell disease (SCD)., Data Sources: Searches of MEDLINE (1965-April 2000), International Pharmaceutical Abstracts (1970-April 2000), and Science Citation Index Expanded (1989-April 2000) were performed using the key search terms sickle-cell disease, pentoxifylline, oxypentifylline, and Trental., Data Synthesis: Patients with SCD commonly suffer from painful VOEs. Pentoxifylline may be useful in this condition due to its ability to increase red blood cell deformability and inhibit platelet aggregation. Laboratory evidence, an animal model, and case reports suggest a benefit, but available clinical studies are methodologically poor, and data analysis is often inappropriate or absent. Limited data suggest that pentoxifylline is beneficial for treatment of a VOE in progress, but no data exist demonstrating a reduction in the number of VOEs with chronic pentoxifylline therapy., Conclusions: Documentation of the efficacy of pentoxifylline for VOE prevention and treatment of SCD is poor, further studies are needed before its routine use is recommended.