Intrapulmonary administration of recombinant activated factor VII in pediatric, adolescent, and young adult oncology and hematopoietic cell transplant patients with pulmonary hemorrhage

Introduction

Diffuse alveolar hemorrhage (DAH) is a devastating disease process with 50-100% mortality in oncology and hematopoietic cell transplant (HCT) recipients. High concentrations of tissue factors have been demonstrated in the alveolar wall in acute respiratory distress syndrome and DAH, along with elevated levels of tissue factor pathway inhibitors. Activated recombinant factor VII (rFVIIa) activates the tissue factor pathway, successfully overcoming the tissue factor pathway inhibitor (TFPI) inhibition of activation of Factor X. Intrapulmonary administration (IP) of rFVIIa in DAH is described in small case series with successful hemostasis and minimal complications.

Methods

We completed a single center retrospective descriptive study of treatment with rFVIIa and outcomes in pediatric oncology and HCT patients with pulmonary hemorrhage at a quaternary hematology/oncology hospital between 2011 and 2019. We aimed to assess the safety and survival of patients with pulmonary hemorrhage who received of IP rFVIIa.

Results

We identified 31 patients with pulmonary hemorrhage requiring ICU care. Thirteen patients received intrapulmonary rFVIIa, while eighteen patients did not. Overall, 13 of 31 patients (41.9%) survived ICU discharge. ICU survival (n=6) amongst those in the IP rFVIIa group was 46.2% compared to 38.9% (n=7) in those who did not receive IP therapy (p=0.69). Hospital survival was 46.2% in the IP group and 27.8% in the non-IP group (p=0.45). There were no adverse events noted from use of IP FVIIa.

Conclusions

Intrapulmonary rFVIIa can be safely administered in pediatric oncology patients with pulmonary hemorrhage and should be considered a viable treatment option for these patients.

Leading beyond the Script: A Cross-Sectional Study Exploring Preparedness of Pharmacy Academic Administrators

Limited research exists on the preparedness of pharmacy academic administrators for their roles. This cross-sectional survey aimed to explore the self-perceptions of pharmacy academic administrators, including deans, associate deans, assistant deans, department chairs, and directors, within United States-based Colleges or Schools of Pharmacy. Participants answered questions regarding their demographics, self-perceived readiness for administrative roles, self-perceived leadership skills, and strategies used to develop these skills. Data were analyzed using descriptive statistics, and subgroup comparisons were made using Student's t-test for normally distributed continuous variables, Mann-Whitney tests for ordinal variables or non-normally distributed continuous variables, and Chi-squared tests for nominal variables. A total of 193 responses were analyzed. Respondents reported feeling least prepared in two areas: entrepreneurial revenue and handling grievances and appeals. There were gender differences noted in preparedness to conduct performance reviews, manage unit finances, and develop entrepreneurial revenue, with men rating themselves significantly higher than women in all three areas. Despite high self-ratings of leadership skills in the overall cohort, significant gender differences were noted in micromanagement with men rating themselves lower than women. Seeking advice from senior colleagues was the most used development strategy, and women showed a significantly higher preference for programs facilitated by professional organizations. This study contributes valuable insights into the preparedness of pharmacy academic administrators to inform future strategies that better support individuals to be successful in their roles.

Impact of student-run clinic participation on empathy and interprofessional skills development in medical and pharmacy students

Background

Students participating in student-run clinics (SRCs) have opportunities to develop and practice beneficial skill sets, including empathy and interprofessional collaboration.

Objectives

This study aimed to assess whether participation in an underserved SRC impacts the development of empathy and interprofessional skills in pharmacy and medical students.

Methods

This study assessed empathy and interprofessional skills development through a self-assessment survey. The survey included the Interpersonal Reactivity Index (IRI) to assess empathy, the Attitudes Towards Health Care Teams/Team Skills Scale (ATHCTS/TSS) to assess interprofessional team dynamics, and a free-text response section. Participants were grouped based on whether they participated in the SRC (intervention group) or did not participate in the SRC (control group). A subgroup analysis was performed based on the participants' discipline (medicine vs. pharmacy). To compare differences in IRI, ATHCTS, and TSS scores between study groups, independent samples t-tests were performed. A thematic analysis was used for qualitative data.

Results

There were no statistically significant differences between intervention and control groups in IRI, ATHCTS, or TSS scores. Subgroup analyses showed no significant differences in scores of student pharmacists or medical students. For both disciplines, the thematic analysis revealed the most common positive themes identified were "real-world patient interaction and care," "impact on practice/career development." Alternatively, it revealed the highest reported negative themes identified as "time management and operational difficulties" and "concerns about the quality of/access to care".

Conclusions

This study demonstrates that involvement in an SRC neither improves nor hinders a learner's development of empathy and interprofessional team skills. Qualitatively, students reported that participation in an SRC benefited their learning and helped develop their skills, like empathy and team dynamics, in an interprofessional setting. Future research with longitudinal monitoring or alternative assessment tools is recommended.

Exploring the Relationship Between Imposter Phenomenon and Myers-Briggs Personality Types in Pharmacy Education

OBJECTIVE

To investigate the relationship between imposter phenomenon (IP) and Myers-Briggs Type Indicator (MBTI) personality types in pharmacy students.

METHODS

This was a retrospective, observational study of doctor of pharmacy students who had previously completed MBTI and Clance Imposter Phenomenon Scale (CIPS) assessments. CIPS scores and categories were compared between the 4 MBTI personality type dichotomies using independent samples t tests and chi-square.

RESULTS

Mean CIPS score for included pharmacy students (N = 668) was 62.52 (SD 14.82). Clance Imposter Phenomenon Scale scores were significantly higher in students with MBTI of introversion (mean 64.14, SD 14.27), intuition (mean 63.80, SD 15.78), and perceiving (mean 64.38, SD 15.55) as compared to their dichotomous counterparts. No significant difference in mean CIPS scores was found within the thinking/feeling dichotomy. When analyzing IP risk associated with the various MBTI personality dichotomies, introverts were at a 1.8 times greater risk of high/severe IP than extroverts. Additionally, students with perceiving personality types were at a 1.4 times greater risk of high/severe IP than those with judging personality types.

CONCLUSION

Our study suggests that pharmacy students with introversion, intuitive, and perceptive personality types exhibit higher CIPS scores, and those with introversion or perceptive personality types are at risk for high/severe IP. Given the common MBTI types and a high degree of IP in pharmacy students, our findings underlie the need for open, targeted discussions about IP and proactively incorporating strategies and resources within a curriculum to support students in normalizing and easing anxiety.

Assessing Student Perceptions of Blended and Online Learning Courses in Pharmacoeconomics, Management, and Leadership

Objective. Blended learning combines traditional face-to-face education with online instruction. This learner-centered approach has been shown to improve student engagement, critical thinking, and performance outcomes. The objective of this study was to assess and trend student pharmacist perceptions of blended and online learning used to teach pharmacy management, leadership, and economics within a Doctor of Pharmacy (PharmD) curriculum.Methods. Qualitative methods were employed using in-depth, semistructured interviews. Second- and third-year student pharmacists were recruited by purposeful and snowball sampling and interviewed to a point of saturation. The interview guide was based on social cognitive theory. Themes identified through initial deductive thematic analysis were categorized by the three domains of social cognitive theory: cognitive, behavioral, and environmental factors. The coding team additionally analyzed the transcripts using inductive thematic analysis to ensure no themes outside of social cognitive theory were missed.Results. Twenty students were interviewed. Themes reveal perceptions that blended learning facilitated greater understanding of course material, increased motivation among learners, provided more flexibility in workload completion, and was a more enjoyable way to learn compared to traditional didactic instruction. Furthermore, blended learning offered additional distinct advantages over traditional and online-only pedagogies.Conclusion. Student pharmacists perceived blended and online learning positively and acceptable for the delivery of a pharmacy course on management, leadership, and economics over traditional didactic instruction. Blended learning may enhance innovation, leadership, management, and economics content delivery and the student learning experience.

Risk stratification of cytologically indeterminate thyroid nodules with nondiagnostic or benign cytology on repeat FNA: Implications for molecular testing and surveillance

BACKGROUND

Evidence guiding the management of cytologically indeterminate thyroid nodules with nondiagnostic (ND) or benign cytology on repeat fine-needle aspiration (FNA) is limited. This study evaluates the utility of molecular testing and estimates the risk of noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP) and cancer among such nodules.

METHODS

This was a retrospective single-institution review of thyroid nodules from adults that were classified as atypia of undetermined significance (AUS) or follicular neoplasm (FN) on initial FNA and underwent repeat FNA for cytology and Afirma testing (June 2013-July 2021). The association between repeat FNA cytology and RNA yield for Afirma was determined. Histologic outcomes were integrated with Afirma results to define end points for each nodule.

RESULTS

A total of 691 AUS and FN nodules underwent repeat FNA and Afirma testing. Diagnostic Afirma results were obtained in 98% of cases overall and in 91% of nodules with ND cytology on repeat FNA. Using combined molecular and histologic end points, the NIFTP and/or cancer prevalence for nodules with ND cytology on repeat FNA was 9% (95% confidence interval [CI], 0.042-0.182), falling between those nodules classified as benign (5%; 95% CI, 0.029-0.094) and those classified as AUS or FN (18%; 95% CI, 0.140-0.218) on repeat FNA, although not reaching statistical significance from either subgroup (p = .38 and .10, respectively).

CONCLUSIONS

AUS and FN nodules that are ND on repeat FNA have low but nonnegligible risk of NIFTP and/or cancer and may benefit from molecular testing, given the low test failure rate in this subgroup. Conversely, AUS and FN nodules reclassified as benign on repeat FNA have a very low risk of NIFTP and/or cancer and are unlikely to benefit from molecular testing.

Perioperative Indications for Gabapentinoids in Pediatrics: A Narrative Review

In recent years, there has been increased interest in using gabapentinoids (gabapentin and pregabalin) as part of multimodal medication plans or enhanced recovery after surgery protocols to mitigate several perioperative clinical challenges. Outcomes explored in the context of using gabapentinoids perioperatively in children are variable and include acute complications of pain, anxiety, nausea and vomiting, and emergence agitation, as well as the long-term postoperative outcome of chronic postsurgical pain. This narrative review describes the current literature regarding perioperative use of gabapentinoids in pediatric patients and aims to describe the role of gabapentinoids in the perioperative setting for each specific indication.

Examining Preparatory Testing and Other Factors Associated With Performance on the Multistate Pharmacy Jurisprudence Examination

Objective. To evaluate whether the score on the Pre-Multistate Pharmacy Jurisprudence Examination (Pre-MPJE) predicts pharmacy students' performance on the MPJE, and to determine whether demographics, pre-pharmacy school factors, or pharmacy school factors affect MPJE outcomes.Methods. We performed a retrospective review of pharmacy school graduates' (N = 156) MPJE scores, Pre-MPJE scores, demographics, pre-pharmacy school academic performance factors, and pharmacy school academic performance factors. Bivariate and correlational analyses were conducted along with multiple linear regression models to determine the influence of variables on the MPJE total scaled score.Results. A total of 136 pharmacy school graduates were included, with most being female (59%) and non-Hispanic White students (75%). The score on the Pre-MPJE was not significantly correlated with students' first-attempt MPJE pass-fail outcome or total scaled score. Factors that were correlated with passing the MPJE were a younger age at graduation, a higher pharmacy law course grade, Pharmacy Curriculum Outcomes Assessment (PCOA) examination scores, specifically scaled total scores and scaled scores for content areas 1-4 and final pharmacy school grade point average (GPA). The MPJE total scaled score was correlated with a higher pre-pharmacy school GPA, pharmacy law course grade, PCOA total and content area 1-4 scaled scores, and final pharmacy school GPA. However, regression models found that the greatest variance in MPJE total scaled score was contributed by the pharmacy law course grade. The total scaled score on the PCOA contributed to some variance for all MPJE takers, but only the pharmacy law course grade significantly influenced the in-state MPJE total scaled score.Conclusion. The findings did not show that the Pre-MPJE score was a predictor for passing the MPJE or for the MPJE total scaled score. The most important determinant of the MPJE total scaled score was a student's performance in the pharmacy law course.

Changes in Academic Performance after Transitioning to Remote Proctoring: A Before-After Evaluation

Remote proctoring is often used to ensure testing integrity in a distance education environment but may impact academic performance. This quasi-experimental study aimed to evaluate changes in examination scores after transitioning to remote proctoring during the COVID-19 pandemic. Student pharmacists (n = 384) served as their own controls in this before-after analysis of examination scores with in-person versus remote proctoring. To assess differences in examination scores among students with varying levels of testing anxiety, students were classified into low, moderate, or high testing anxiety groups based on their Cognitive Test Anxiety Scale–Second Edition (CTAS-2) score. Students were also stratified into two groups based on their cumulative grade point average (GPA). After transitioning to remote proctoring, examination scores significantly decreased for first-year (P1) students but significantly increased for second-year (P2) students. When stratified by CTAS-2 score, no significant difference in examination scores was found. When stratified by GPA, no significant difference in examination scores was found for P1 students, but a significant improvement was noted for P2 students with remote proctoring. The results of this study indicate that examination scores do not consistently improve or decline after introducing remote proctoring even when considering a student’s GPA and level of testing anxiety.

Shed CNTNAP2 ectodomain is detectable in CSF and regulates Ca2+ homeostasis and network synchrony via PMCA2/ATP2B2

Although many neuronal membrane proteins undergo proteolytic cleavage, little is known about the biological significance of neuronal ectodomain shedding (ES). Here, we show that the neuronal sheddome is detectable in human cerebrospinal fluid (hCSF) and is enriched in neurodevelopmental disorder (NDD) risk factors. Among shed synaptic proteins is the ectodomain of CNTNAP2 (CNTNAP2-ecto), a prominent NDD risk factor. CNTNAP2 undergoes activity-dependent ES via MMP9 (matrix metalloprotease 9), and CNTNAP2-ecto levels are reduced in the hCSF of individuals with autism spectrum disorder. Using mass spectrometry, we identified the plasma membrane Ca2+ ATPase (PMCA) extrusion pumps as novel CNTNAP2-ecto binding partners. CNTNAP2-ecto enhances the activity of PMCA2 and regulates neuronal network dynamics in a PMCA2-dependent manner. Our data underscore the promise of sheddome analysis in discovering neurobiological mechanisms, provide insight into the biology of ES and its relationship with the CSF, and reveal a mechanism of regulation of Ca2+ homeostasis and neuronal network synchrony by a shed ectodomain.

Lidocaine infusions and reduced opioid consumption-Retrospective experience in pediatric hematology and oncology patients with refractory pain

BACKGROUND

Despite a more robust experience with lidocaine infusions for pain management in adults and general pediatric population, there is limited evidence of efficacy of lidocaine infusions for pain management in patients with pediatric hematology and oncology diagnoses.

METHODS

Data pertaining to continuous intravenous lidocaine infusions prescribed between January 2009 and June 2019 were reviewed, including patients' demographic characteristics, hematology/oncology and pain diagnoses, concurrent pain medications, and lidocaine infusion dose regimens and duration. Pain scores and opioid consumption calculations based on morphine equivalent doses (mg/kg/day) of patient-controlled analgesia were collected 1 day before infusion (D1), during infusion (D2), and 1 day after infusion (D3).

RESULTS

The mean opioid consumption on D3 was significantly lower than that on D2 (p = .01). The pain scores on D3 were significantly lower than those on D1 when measured as average pain scores per 24 hours (p < .001) or as single pain scores immediately before and after infusions (p < .001). No significant associations were found between cumulative doses of lidocaine (loading dose plus total infusion dose) and either a decrease in the opioid consumption or a decrease in pain scores.

CONCLUSIONS

In this retrospective series of pediatric hematology and oncology cases, we report positive outcomes in reducing opioid consumption and pain scores after lidocaine infusions. Prospective investigations designed in a collaborative, multi-institutional fashion, including a variety of pediatric populations are needed to further investigate the efficacy of lidocaine infusions.

Effects of Remote Proctoring on Composite Examination Performance Among Doctor of Pharmacy Students

Objective. To determine the impact of remote proctoring on the academic performance of Doctor of Pharmacy (PharmD) students.Methods. This was a retrospective, observational study that compared first professional year (P1) and second professional year (P2) pharmacy students' scores on eight composite examinations administered in spring 2020 (n = 387), the final three of which were proctored remotely, to that of a historical cohort of pharmacy students who took the same examinations in spring 2019 (n = 368). To assess whether remote proctoring affected academic performance, spring 2020 scores for examinations 6, 7, and 8 were compared to those of a historical cohort who took the same examinations in person with a proctor present in spring 2019. Academic performance on examinations 1 through 4 was also compared between the two cohorts to evaluate any possible year-to-year variation in academic performance during non-remote circumstances. Mann Whitney tests were used to compare scores between the two cohorts.Results. The median scores of students in the spring 2020 cohort were significantly lower than the scores of the historical cohort on the first composite examination administered to P1 students after the implementation of remote proctoring. In contrast, median scores were significantly higher on two of the three examinations administered to P2 students using remote proctoring.Conclusion. Remote proctoring has minimal impact on pharmacy students' examination performance and its use should be considered to ensure academic honesty and security of testing content in a distance learning environment.

Lidocaine Infusions for Pain Management in Pediatrics

Lidocaine is an amino amide with a well-established role as a local anesthetic agent. Systemic intravenous administration expands its clinical use to include acute and chronic pain circumstances, such as postoperative pain, neuropathic pain, postherpetic neuralgia, hyperalgesia, visceral pain, and centrally mediated pain. For refractory pain that has not responded to conventional therapy or if further escalation of treatment is prevented by contraindications or side effects to standard therapies, a continuous infusion of lidocaine may be considered as a single intervention or as a sequence of infusions. Here, we review and evaluate published data reflecting the use of lidocaine continuous infusions for pain management in the pediatric population.

Evaluation of Aminophylline for the Treatment of Acute Kidney Injury in Pediatric Hematology/Oncology Patients

OBJECTIVE

The purpose of this study was to compare acute kidney injury (AKI)-related outcomes of patients who received aminophylline in addition to standard of care with matched historical controls who received standard of care alone.

METHODS

This was a single center, retrospective, historical control cohort study that included patients treated for AKI. Patients who received aminophylline from January 2017 to June 2018 were matched for age, sex, primary diagnosis, and hematopoietic cell transplant history in a 1:2 ratio to historical controls treated for AKI from July 2015 to September 2016. The primary outcome was improvement in AKI stage at 5 and 10 days from treatment initiation.

RESULTS

Twenty-seven patients who received aminophylline were matched to 54 historical controls. Fifty-eight patients (72%) had recently undergone hematopoietic cell transplant. At day 5, improvement in AKI stage was observed in 56% of patients in each group (p = 1.0); at day 10, improvement in AKI stage was observed in 75% of patients in the aminophylline group vs 70% of historical controls (p = 0.76). By day 10, serum creatinine levels had returned to baseline in 21% of patients in the aminophylline group and 34% of patients in the control group (p = 0.37).

CONCLUSIONS

Findings of this study demonstrated no difference in the rate of AKI resolution or in the proportion of patients with resolved AKI when aminophylline was added to standard of care for the treatment of AKI in this pediatric hematology/oncology population.

"Don't Label Them as Addicts!" Student Pharmacists' Views on the Stigma Associated with Opioid use Disorder

Background:

Student pharmacists represent an important potential population for targeted educational interventions focused on skill and confidence development in order to improve interactions with opioid users and to decrease stigma. The objective of this study was to understand student pharmacists’ perceptions of opioid users.

Methods:

Focus groups were conducted with student pharmacists across Tennessee over two months in 2020. Concepts from the Transtheoretical Mode, Social Cognitive Theory, stigma, and results from a survey sent to student pharmacists were used to develop the open-ended questions. Thematic analysis was conducted to inductively identify main themes. The recruitment of student pharmacists continued until thematic saturation was obtained.

Results:

Three focus groups were conducted with a total of 16 student pharmacists in second, third, and fourth professional years. Thematic analysis revealed two themes: Don’t label them as addicts, Student Insight into OUD-Associated Stigma and five sub-themes: developing a judgment-free environment; unconscious bias; a possible connection between physical appearance and addiction; socio-cultural factors, addiction, and isolation; and motivators to decrease stigma. This study not only presents the pharmacy students experiences and their significance, but also reports their recommendations for addressing the stigma associated with OUD in the pharmacy curriculum.

Conclusions:

These findings highlight the need to normalize appropriate language when describing patients with OUD and avoid negative labels such as “addict.” The findings also indicate where the roots of stigma lie and provide some of the tools to fight stigma on different fronts. Future research should explore and address potential implicit biases throughout pharmacy curriculum.

Enhancing Student Knowledge of Diabetes through Virtual Choose Your Own Adventure Patient Case Format

Educational strategies to teach pharmacy students about diabetes are necessary to prepare future pharmacists to manage complex patients. The Choose Your Own Adventure (CYOA) patient case format is an innovative activity that presents a patient case in an engaging way. The objectives of this study were (1) to describe the development of the innovative teaching activity and (2) to assess its effect on student knowledge and confidence in outpatient management of diabetes. The CYOA patient case activity was designed by transforming a traditional paper patient case involving outpatient diabetes management into an interactive format utilizing an online platform. The activity was conducted with 186 second-year pharmacy students in a skills-based course. This activity was administered virtually through a combination of small group work and large group discussion. After completion of the activity, students completed an online self-assessment questionnaire. Of 178 completed questionnaires, there was a statistically significant difference in students’ self-ratings after versus before the activity for all survey items (p < 0.001). The CYOA activity improved self-reported knowledge of outpatient diabetes management and increased self-reported confidence in clinical decision-making skills. This format shows promise as an educational tool that may be adapted for other disease states to enhance clinical decision-making skills.

Analysis of an obstetrics point-of-care ultrasound training program for healthcare practitioners in Zanzibar, Tanzania

Background

A point-of-care ultrasound education program in obstetrics was developed to train antenatal healthcare practitioners in rural Zanzibar. The study group consisted of 13 practitioners with different training backgrounds: physicians, clinical officers, and nurse/midwives. Trainees received an intensive 2-week antenatal ultrasound course consisting of lectures and hands-on practice followed by 6 months of direct supervision of hands-on scanning and bedside education in their clinical practice environments. Trainees were given a pre-course written exam, a final exam at course completion, and practical exams at 19 and 27 weeks. Trainees were expected to complete written documentation and record ultrasound images of at least 75 proctored ultrasounds. The objective of this study was prospectively to analyze the success of a longitudinal point-of-care ultrasound training program for antepartum obstetrical care providers in Zanzibar.

Results

During the 6-month course, trainees completed 1338 ultrasound exams (average 99 exams per trainee with a range of 42–128 and median of 109). Written exam scores improved from a mean of 33.7% (95% CI 28.6–38.8%) at pre-course assessment to 77.5% (95% CI 71–84%) at course completion (P < 0.0001). Practical exam mean scores improved from 71.2% at course midpoint (95% CI 62.3–80.1%) to 84.7% at course completion (95% Cl 78.5–90.8%) (P < 0.0005). Eight of the 13 trainees completed all training requirements including 75 proctored ultrasound exams.

Conclusion

Trainees improved significantly on all measures after the training program. 62% of the participants completed all requirements. This relatively low completion rate reflects the challenges of establishing ultrasound capacity in this type of setting. Further study is needed to determine trainees’ long-term retention of ultrasound skills and the impact of the program on clinical practice and health outcomes.

Methadone for Cancer Pain in Pediatric End-of-Life Care

BACKGROUND

The goal of adequate pain control becomes increasingly salient for children with cancer and their families as the patients approach the end of life. Methadone is one option that is particularly desirable in end-of-life care given its long duration of action and NMDA antagonism that may help in controlling pain refractory to conventional opioids. The purpose of this study was to describe a single institution's experience with methadone for the treatment of cancer pain in pediatric end-of-life care.

METHODS

This retrospective, observational, single-center study included all patients during a 9-year period who died in the inpatient setting and were receiving methadone in their last 30 days of life.

RESULTS

Twenty patients were identified, 18 (90%) of whom received methadone for nociceptive pain. The median duration of methadone use was 32 days (range 2-323 days). Methadone doses ranged from 0.09 to 7.76 mg/kg per day. There were no instances of discontinuing methadone due to an increased QTc interval. No episodes of torsades de pointes were observed.

CONCLUSION

In patients with pediatric cancer who are nearing the end of life, methadone is a valuable adjunctive therapy to treat nociceptive and neuropathic pain and to prevent opioid-induced hyperalgesia and opioid tolerance. An individualized approach to dosage and route should be considered based on specific clinical circumstances.

Stigma of Opioid Use Disorder and Its Indirect Effects on Student Pharmacists' Perceptions and Attitudes

Objectives: Pharmacists play a vital role in serving patients during the ongoing nationwide opioid epidemic, and so it is also critical to educate the next generation of pharmacists on opioids and opioid use disorder (OUD). The primary objective of this study was to quantitatively characterize student perceptions of opioid use and the stigma associated with OUD. Secondary aims were to determine whether differences in perceptions exist based upon the student’s year in the Doctor of Pharmacy program or employment in a community pharmacy. Methods: First-, second-, third-, and fourth-year student pharmacists voluntarily completed an electronic survey regarding perceptions of opioid use and stigma associated with OUD. Results: Of the 9 survey items, students were most uncomfortable referring patients to community resources for addiction support and/or treatment (25.3% comfortable or very comfortable). Students working in a community pharmacy were significantly more comfortable talking to patients attempting to refill opioids early and providing opioid counseling as compared to their peers not working in community pharmacy. Fourth-year students reported a higher level of comfort talking to a patient attempting to refill an opioid prescription early, counseling a patient on an opioid prescription, and providing information about alternatives to opioids. Third-year students responded most favorably to the items regarding how well the curriculum has prepared them to interact with patients taking opioids and those with OUD. Conclusions: These findings reveal that students are comfortable counseling on opioids and discussing alternative options. Differences in perceptions were observed based upon the student’s year in the program and whether or not they were employed in a community pharmacy setting.

Therapeutic Drug Monitoring of Inhaled Tobramycin in a Post-Hematopoietic Cell Transplant Patient With Bronchiolitis Obliterans and End-Stage Renal Disease

There are no widely accepted dose alterations for inhaled tobramycin in the setting of renal dysfunction, and serum concentrations are not typically monitored. Herein we describe a case report of a 16-year-old female with a history of 2 hematopoietic cell transplants and a kidney transplant who received inhaled tobramycin for chronic Pseudomonas aeruginosa management. The patient developed chronic kidney disease, and tobramycin concentrations were monitored. Initially she received a reduced dose of inhaled tobramycin, with repeated doses based on serum concentrations. The dose was increased, but serum concentrations obtained the following day remained higher than desired, leading to a suspicion of delayed systemic absorption. Tobramycin administration was changed from immediately prior to dialysis to the evening prior to the next day's dialysis session, and serum concentrations were consistently <1 mg/L postdialysis. In conclusion, systemic absorption of inhaled tobramycin in non-cystic fibrosis (CF) patients may differ compared to that observed in CF patients. Renal dysfunction may lead to systemic accumulation of inhaled tobramycin, and the timing of inhaled tobramycin administration with respect to dialysis has a potentially significant influence on drug clearance. Thus, monitoring may be required. Further cases are required to verify these observations.

Status Epilepticus: The Slow and Agonizing Death of Phenytoin

Since its introduction in 1950, phenytoin (PHT) has been the premier parenteral anticonvulsant used in the management of generalized convulsive status epileptics (GCSE) that is refractory to benzodiazepines. Without question, its arrival was vital to the care of patients with acute seizures and was a welcomed alternative to paraldehyde and phenobarbital. However, after more than half a century of use, there continues to be insufficient evidence-based data to support its efficacy over other anticonvulsants as a first-line agent in pediatric or adult patients with GCSE. This coupled with its narrow mechanism of action, complex pharmacokinetics and pharmacogenomics, drug-drug interactions, unique adverse effects, and formulation issues that make administration difficult mandates that PHT be replaced by safer and superiorly effective anticonvulsants for the treatment of GCSE when benzodiazepines are ineffective. We believe that levetiracetam should become the preferred agent for seizures unresponsive to or recurring after treatment with a benzodiazepine as it is at least equally effective to PHT and has several important advantages. PHT has overstayed its welcome and it is simply time for it to exit the realm of acute seizure management as a first-line agent for benzodiazepine-refractory GCSE.

Ultrasound evaluation of the airway in the ED: a feasibility study

Background

Recognition of the difficult airway is a critical element of emergency practice. Mallampati score and body mass index (BMI) are not always predictive and they may be unavailable in critically ill patients. Ultrasonography provides high-resolution images that are rapidly obtainable, mobile, and non-invasive. Studies have shown correlation of ultrasound measurements with difficult laryngoscopy; however, none have been performed in the Emergency Department (ED) using a consistent scanning protocol.

Objectives

This study seeks to determine the feasibility of ultrasound measurements of the upper airway performed in the ED by emergency physicians, the inter-rater reliability of such measurements, and their relationship with Mallampati score and BMI.

Methods

A convenience sample of volunteer ED patients and healthy volunteers with no known airway issues, aged > 18 years, had images taken of their airway using a standardized ultrasound scanning protocol by two EM ultrasound fellowship trained physicians. Measurements consisted of tongue base, tongue base-to-skin, epiglottic width and thickness, and pre-epiglottic space. Mean and standard deviation (SD) were used to summarize measurements. Inter-rater reliability was assessed by intraclass correlation coefficients (ICCs). Analysis of variance with linear contrasts was used to compare measurements with Mallampati scores and linear regression with BMI.

Results

Of 39 participants, 50% were female, 50% white, 42% black, with median age 32.5 years (range 19–90), and BMI 26.0 (range 19–47). Mean ± SD for each measurement (mm) was as follows: tongue base (44.6 ± 5.1), tongue base-to-skin (60.9 ± 5.3), epiglottic width (15.0 ± 2.8) and thickness (2.0 ± 0.37), and pre-epiglottic space (11.4 ± 2.4). ICCs ranged from 0.76 to 0.88 for all measurements except epiglottis thickness (ICC = 0.57). Tongue base and tongue base-to-skin thickness were found to increase with increasing Mallampati score (p = .04, .01), whereas only tongue-to-skin thickness was loosely correlated with BMI (r = .38).

Conclusions

A standardized ultrasound scanning protocol demonstrates that the airway can be measured by emergency sonologists with good inter-operator reliability in all but epiglottic thickness. The measurements correlate with Mallampati score but not with BMI. Future investigation might focus on ultrasound evaluation of the airway in patients receiving airway management to determine whether ultrasound can predict challenging or abnormal airway anatomy prior to laryngoscopy.

A Randomized Trial of the Effectiveness of Using Incentives to Reinforce Parolee Attendance in Community Addiction Treatment

This study was a randomized effectiveness trial of the use of incentives to improve treatment retention and post-treatment outcomes among parolees in community treatment. Parolees entering community treatment were randomized to incentives ( N = 104) or brief education ( N = 98). It was hypothesized that the use of incentives to increase treatment retention would result in improved post-treatment outcomes (i.e., arrest, employment, and drug use), but at 18 months post-intake, there were no group differences for any outcome. In secondary analyses, rearrest by 18 months post-intake was predicted by substance use, greater number or severity of psychological symptoms, treatment non-completion, unemployment, and younger age. Contrary to expectations, results indicated that participants who received incentives for attendance had arrest, employment, and drug use outcomes similar to those who received a brief education session. Our findings, in concert with those of several other researchers, suggest that there may be certain populations or settings where incentives may not be effective.

A Randomized Study of Incentivizing HIV Testing for Parolees in Community Aftercare

HIV risk-behaviors are high in criminal justice populations and more efforts are necessary to address them among criminal justice-involved substance abusers. This study examines the role of incentives in promoting HIV testing among parolees. Participants were randomly assigned to either an incentive (n = 104) or education group (control; n = 98), where the incentive group received a voucher for testing for HIV. Bivariate comparisons showed that a larger proportion of those in the incentive group received HIV testing (59% versus 47%), but this was not statistically significant (p = .09). However, in a multivariate logistic regression model controlling for covariates likely to influence HIV-testing behavior, those in the incentive group had increased odds of HIV testing in comparison to those in the education group (OR = 1.99, p < .05, CI [1.05, 3.78]). As a first of its kind, this study provides a foundation for further research on the utility of incentives in promoting HIV testing and other healthy behaviors in criminal justice populations.

Heterogeneous photoredox synthesis of N-hydroxy-oxazolidinones catalysed by metal–organic frameworks

The photocatalytic conversion ofN-hydroxy-carbamates toN-hydroxy-oxazolidinones using metal–organic frameworks is reported herein.

The Sorting Receptor SorCS1 Regulates Trafficking of Neurexin and AMPA Receptors

The formation, function, and plasticity of synapses require dynamic changes in synaptic receptor composition. Here, we identify the sorting receptor SorCS1 as a key regulator of synaptic receptor trafficking. Four independent proteomic analyses identify the synaptic adhesion molecule neurexin and the AMPA glutamate receptor (AMPAR) as major proteins sorted by SorCS1. SorCS1 localizes to early and recycling endosomes and regulates neurexin and AMPAR surface trafficking. Surface proteome analysis of SorCS1-deficient neurons shows decreased surface levels of these, and additional, receptors. Quantitative in vivo analysis of SorCS1-knockout synaptic proteomes identifies SorCS1 as a global trafficking regulator and reveals decreased levels of receptors regulating adhesion and neurotransmission, including neurexins and AMPARs. Consequently, glutamatergic transmission at SorCS1-deficient synapses is reduced due to impaired AMPAR surface expression. SORCS1 mutations have been associated with autism and Alzheimer disease, suggesting that perturbed receptor trafficking contributes to synaptic-composition and -function defects underlying synaptopathies.

Effectiveness of Using Incentives to Improve Parolee Admission and Attendance in Community Addiction Treatment

This study is a randomized effectiveness trial of the use of incentives to improve treatment utilization among parolees in community treatment. In prison, Admission phase parolees were randomized to Admission Incentive (N=31) or Education (N=29). Attendance phase parolees entering community treatment were randomized to Attendance Incentive (N=104) or Education (N=98). There was no main effect for incentives in either study phase. Neither admission to community treatment (Incentive 60%, Education 64%; p =.74), nor intervention completion (Incentive 22%; Education 27%; p =.46) appeared to be impacted. Time-in-treatment was predicted by age, first arrest age, and type of parole status (Cox regression p<.05), but not by treatment group. Providing incentives did not increase the likelihood that parolees enrolled in or stayed in community treatment. In light of this finding, criminal justice practitioners who are considering incentives to increase admission or retention should be aware that they may not produce the desired outcomes.

Effect of an organizational linkage intervention on staff perceptions of medication-assisted treatment and referral intentions in community corrections

INTRODUCTION

Medication-assisted treatment (MAT) is effective for alcohol and opioid use disorders but it is stigmatized and underutilized in criminal justice settings.

METHODS

This study cluster-randomized 20 community corrections sites to determine whether an experimental implementation strategy of training and an organizational linkage intervention improved staff perceptions of MAT and referral intentions more than training alone. The 3-hour training was designed to address deficits in knowledge, perceptions and referral information, and the organizational linkage intervention brought together community corrections and addiction treatment agencies in an interagency strategic planning and implementation process over 12 months.

RESULTS

Although training alone was associated with increases in familiarity with pharmacotherapy and knowledge of where to refer clients, the experimental intervention produced significantly greater improvements in functional attitudes (e.g. that MAT is helpful to clients) and referral intentions. Corrections staff demonstrated greater improvements in functional perceptions and intent to refer opioid dependent clients for MAT than did treatment staff.

CONCLUSION

Knowledge, perceptions and information training plus interorganizational strategic planning intervention is an effective means to change attitudes and intent to refer clients for medication assisted treatment in community corrections settings, especially among corrections staff.

An Evaluation of Six Brief Interventions that Target Drug-Related Problems in Correctional Populations

Finding brief effective treatments for criminal justice populations is a major public need. The CJ-DATS Targeted Intervention for Corrections (TIC), which consists of six brief interventions (Communication, Anger, Motivation, Criminal Thinking, Social Networks, and HIV/Sexual Health), were tested in separate federally-funded randomized control studies. In total, 1,573 criminal justice-involved individuals from 20 correction facilities participated (78% males; 54% white). Multi-level repeated measures analyses found significant gains in knowledge, attitudes, and psychosocial functioning (criteria basic to Knowledge, Attitude, and Practices (KAP) and TCU Treatment Process Models). While improvements were less consistent in criminal thinking, overall evidence supported efficacy for the TIC interventions.

Reinforcing Abstinence and Treatment Participation among Offenders in a Drug Diversion Program: Are Vouchers Effective?

This study assessed a 26-week voucher-based intervention to reinforce abstinence and participation in treatment-related activities among substance-abusing offenders court referred to outpatient treatment under drug diversion legislation (California's Substance Abuse and Crime Prevention Act). Standard treatment consisted of criminal justice supervision and an evidence-based model for treating stimulant abuse. Participants were randomly assigned to four groups, standard treatment (ST) only, ST plus vouchers for testing negative, ST plus vouchers for performing treatment plan activities, and ST plus vouchers for testing negative and/or performing treatment plan activities. Results indicate that voucher-based reinforcement of negative urines and of treatment plan tasks (using a flat reinforcement schedule) showed no statistically significant effects on measures of retention or drug use relative to the standard treatment protocol. It is likely that criminal justice contingencies had a stronger impact on participants' treatment retention and drug use than the relatively low-value vouchers awarded as part of the treatment protocol.

Use of vouchers to reinforce abstinence and positive behaviors among clients in a drug court treatment program

In response to the growing number of drug offenders cycling in and out of the criminal justice system without treatment for underlying drug problems, the judicial system has increasingly adopted drug courts as a strategy to divert these offenders from incarceration to supervised drug treatment. Our aim was to determine if drug court treatment effectiveness could be improved using contingency management, in the form of twice-weekly vouchers, to reinforce abstinence and positive behaviors for 163 clients over 26 weeks. We found no significant differences in outcomes among the study groups, although the Treatment Plan Group that received reinforcement for positive behaviors showed a trend toward poorer performance. We suspect that the influence of the judge within the courtroom had a stronger impact on drug court clients' attitudes, drug use behaviors, and other outcomes than the relatively low-value vouchers awarded as part of the treatment protocol.

A compact functional quantum Dot-DNA conjugate: preparation, hybridization, and specific label-free DNA detection

In this letter, we report the preparation of a compact, functional quantum dot (QD)-DNA conjugate, where the capturing target DNA is directly and covalently coupled to the QD surface. This enables control of the separation distance between the QD donor and dye acceptor to within the range of the Förster radius. Moreover, a tri(ethylene glycol) linker is introduced to the QD surface coating to effectively eliminate the strong, nonspecific adsorption of DNA on the QD surface. As a result, this QD-DNA conjugate hybridizes specifically to its complementary DNA with a hybridization rate constant comparable to that of free DNAs in solution. We show this system is capable of specific detection of nanomolar unlabeled complimentary DNA at low DNA probe/QD copy numbers via a "signal-on" fluorescence resonance energy transfer (FRET) response.

Mitochondrial cholesterol transport: A possible target in the management of hyperlipidemia

Sterol 27-hydroxylase (CYP27A1) may defend cells against accumulation of excess cholesterol, making this enzyme a possible target in the management of hyperlipidemia. The study objective was to analyze cholesterol homeostatic responses to increases in CYP27A1 activity in HepG2 cells and primary human hepatocytes. Increasing CYP27A1 activity by increasing enzyme expression led to significant increases in bile acid synthesis with compensatory increases in HMG-CoA reductase (HMGR) activity/protein, LDL receptor (LDLR) mRNA, and LDLR-mediated cholesterol uptake. Under these conditions, only a small increase in cellular 27-hydroxycholesterol (27OH-Chol) concentration was observed. No changes were detected in mature sterol regulatory element-binding proteins (SREBP) 1 or 2. Increasing CYP27A1 activity by increasing mitochondrial cholesterol transport (i.e., substrate availability) led to greater increases in bile acid synthesis with significant increases in cellular 27OH-Chol concentration. Mature SREBP 2 protein decreased significantly with compensatory decreases in HMGR protein. No change was detected in mature SREBP 1 protein. Despite increasing 27OH-Chol and lowering SREBP 2 protein concentrations, LDLR mRNA increased significantly, suggesting alternative mechanisms of LDLR transcriptional regulation. These findings suggest that regulation of liver mitochondrial cholesterol transport represents a potential therapeutic strategy in the treatment of hyperlipidemia and atherosclerosis.

Detection of the steroidogenic acute regulatory protein, StAR, in human liver cells

Overexpressing StAR (a mitochondrial cholesterol transporter) increases (>5-fold) the rate of 27-hydroxylation of cholesterol and the rates of bile acid synthesis in primary rat hepatocytes; suggesting that the transport of cholesterol into mitochondria is rate-limiting for bile acid biosynthesis via the CYP27A1 initiated 'acidic' pathway. Our objective was to determine the level of StAR expression in human liver and whether changes in StAR would correlate with changes in CYP27A1 activity/bile acid synthesis rates in human liver tissues. StAR mRNA and protein were detected in primary human hepatocytes and HepG2 cells by RT-PCR/Northern analysis and by Western analysis, respectively. In immunocompetition assays, liver StAR was competed away with the addition of purified human adrenal StAR. Overexpressing CYP27A1 in both cell types led to >2-fold increases in liver StAR concentration. StAR protein levels also increased approximately 2-fold with the addition of 27-hydroxycholesterol to HepG2 cell culture medium. Overexpressing StAR increased the rates of 27-hydroxylation of cholesterol/bile acid synthesis in both cell lines and increased intracellular levels of 27-hydroxycholesterol. In conclusion, human liver cells contain regulable StAR protein whose level of expression appears capable of regulating cellular cholesterol homeostasis, representing a potential therapeutic target in the management of hyperlipidemia.

Assessment of the fifth ligand-binding repeat (LR5) of the LDL receptor as an analytical reagent for LDL binding

The fifth ligand binding repeat (LR5) of the low density lipoprotein (LDL) receptor was assessed ex vivo as an 'analytical reagent' to distinguish LDL state, in atherosclerosis risk monitoring. LR5 was immobilized to mercaptoundecanoic acid modified gold surfaces via a glycine linker. Surface plasmon resonance (SPR) was used to monitor LDL binding. Unfolded LR5 was ineffectual as an affinity ligand for LDL but refolded LR5 showed a high affinity for native LDL but little affinity for oxidized LDL. LR5 refolded in the presence of calcium or EDTA gave the equivalent LDL binding capacity. However, EDTA-LR5 was less stable than Ca-LR5 at pH 5 and, from tryptophan fluorescence evidence, they appeared to involve different regions of LR5 and/or LDL in the binding. Involvement of amino acid residues of the calcium cage of LR5 was tested in LDL binding by monitoring calcium ion release with a calcium ionophore. The results were consistent with approximately 7-8 LR5 binding per LDL, of which only some induce calcium release (a maximum of approximately 25 mol% calcium, based on LR5, was released during LDL binding). For LDL binding to the LDL receptor in vivo more than one ligand-binding repeat is needed and this may be consistent with LR5 acting here also at binding sites which other LRs normally occupy in the LDL-LDL receptor complex. This initial study is encouraging for the use of a minimum peptide repeat array based on the conserved region of the LRs as an affinity surface for atherosclerosis risk monitoring.

Phasor transform to extract glucose and ascorbic acid data in an amperometric sensor

A method for separating the signals from glucose and ascorbic acid on a single recognition surface using an ac immittance technique is presented. It is proposed that each oxidation process can be represented by a unique vector based on psi and YO, and that the concentration of each analyte can be determined by monitoring the change in the admittance magnitude in the direction of the characteristic angle for that particular species. The total Faradaic admittance (YF,total) for all electroactive species present is given by a linear combination of the independent vectors from the different species. In the system tested, the analytes are glucose and ascorbic acid, the former being estimated via the measurand, hydrogen peroxide. Thus, one of the electroactive species (hydrogen peroxide) is not a bulk solution species, but is 'generated' in the enzyme matrix. The admittance measurements from ascorbic acid and the enzyme-generated hydrogen peroxide showed the characteristic phase angles of each oxidation signal, allowing for good spatial resolution. The behaviour of each of these analytes is presented and calibration curves tested. Based on the calibration curves and the basis vectors, samples containing both glucose and ascorbic acid were measured by transforming the measured total admittance from the complex Cartesian space into 'analyte space', where the X-Y axes are given by the basis vectors ŷEGHP,GOD and ŷAA,GOD, respectively.

Detection of PCR products using PNA strand invasion

The unique ability of homopyrimidine peptide nucleic acid (PNA) to strand invade homopurine sites of duplex DNA offers a potential alternative to existing techniques for rapid detection of PCR products. From gel shift studies, PNA was found to specifically strand invade homopurine sites that had been incorporated into an amplicon during the PCR cycle. This was achieved by adding a homopyrimidine sequence to the 5'-terminus of a PCR primer. The position of the strand invasion sites at the termini of the DNA duplex offers kinetic advantages for PNA strand invasion, since the termini of DNA duplexes are known to be unwound. This unwound state was demonstrated using a novel assay that determined single-stranded regions within the amplicon. The presence of the PNA moiety in strand invasion complexes was confirmed by a novel electroblot, an Enzyme Linked Nucleic Acid assay and by an increase in stability as demonstrated by T(m)studies with the Idaho RapidCycler. Since the strand invasion sites can be controlled through selection of the homopurine sequence there is great flexibility for designing strand invasion motifs unique to a particular PCR amplicon, thus providing a huge potential for differentiating and detecting multiplex PCR products.

Producing "self-plasticizing" ion-selective membranes

Polymer membranes have been explored for the analysis of ions that do not require plasticizers and with photocurable properties. This work was focused on investigating the viability of the methacrylic-acrylic copolymers as new self-plasticizing membrane matrixes for ion-selective electrodes or other ion-sensor applications. Copolymers with glass transition temperatures ranging from -20 to -44 degrees C could be prepared without added plasticizer and were found to be functional as ion-selective membranes. Both free-radical solution polymerization and photopolymerization could be used, and "self-plasticizing" behavior of copolymers was observed with a high alkylacrylate (R = C4) content. This was found to be compatible with most commercially available ionophores, and sensors for potassium, sodium, calcium and pH were fabricated entirely by photocure procedures; single-step procedures for the immobilization of benzo-15-crown-5 ionophore on these self-plasticizing copolymer matrixes were also developed. Even though the ionophore was immobilized, potentiometric studies revealed that the ionophore remained functional, and thus, these copolymers have the advantage of suffering neither leaching of ionophore nor plasticizers. All these sensors exhibited a Nernstian or near Nernstian response with selectivity comparable to plasticized PVC membranes or other plasticized and photocurable polymer membranes. The long-term response of the potassium sensor with immobilized ionophore and the sodium sensor showed little deterioration for as long as one month and three months, respectively, under continuous use.

Dipicolinic acid (DPA) assay revisited and appraised for spore detection

Delayed gate fluorescence detection of dipicolinic acid (DPA), a universal and specific component of bacterial spores, has been appraised for use in a rapid analytical method for the detection of low concentrations of bacterial spores. DPA was assayed by fluorimetric detection of its chelates with lanthanide metals. The influence of the choice and concentration of lanthanide and buffer ions on the fluorescence assay was studied as well as the effects of pH and temperature. The optimal system quantified the fluorescence of terbium monodipicolinate in a solution of 10 microM terbium chloride buffered with 1 M sodium acetate, pH 5.6 and had a detection limit of 2 nM DPA. This assay allowed the first real-time monitoring of the germination of bacterial spores by continuously quantifying exuded DPA. A detection limit of 10(4) Bacillus subtilis spores ml-1 was reached, representing a substantial improvement over previous rapid tests.

Surface Plasmon Resonance Measurement of the Binding of Low-Density Lipoprotein at a Heparin Surface

Low-density lipoprotein (LDL) adsorption to heparin-like surface is of wide clinical interest since such a mechanism might be responsible for cholesterol accumulation in the arterial wall. By modifying the surface plasmon resonance sensor surface with heparin and albumin (BSA) LDL adsorption to this surface was investigated and characterized. Heparin was seen to be a potentially useful ligand for LDL detection and analysis in a clinical context. It was found that N-acetylheparin had a lower affinity for LDL than heparin and that the binding strength of LDL to N-acetylheparin was reduced. Assuming a random distribution of heparin on the surface, it was calculated from the data obtained that a maximum of 4.0 x 10(9) heparin or 4.8 x 10(9) N-acetylheparin "rods" can be found on a millimeter square and that one LDL molecule (380 nm(2)) covers on average only 1.5 heparin molecules or 1.8 N-acetylheparin molecules, yet maximum LDL binding cannot be increased beyond a surface coverage of 7.5 or 5.8% for heparin and N-acetyl heparin, respectively. This could lead to the suggestion that the glycosaminoglycan-LDL atheroclerosis mechanism would involve only 1-2 heparin molecules in "binding" each LDL, but 20-30 molecules are required to attract it to the surface in the first place. Copyright 1999 Academic Press.

Surface plasmon resonance sensor for heparin measurements in blood plasma

Surface plasmon resonance (SPR) was used as an affinity biosensor to determine absolute heparin concentrations in human blood plasma samples. Protamine and polyethylene imine (PEI) were evaluated as heparin affinity surfaces. Heparin adsorption onto protamine in blood plasma was specific with a lowest detection limit of 0.2 U/ml and a linear window of 0.2-2 U/ml. Although heparin adsorption onto PEI in buffer solution had indicated superior sensitivity to that on protamine, in blood plasma it was not specific for heparin and adsorbed plasma species to a steady-state equilibrium. By reducing the incubation time and diluting the plasma samples with buffer to 50%, the non-specific adsorption of plasma could be controlled and a PEI pre-treated with blood plasma could be used successfully for heparin determination. Heparin adsorption in 50% plasma was linear between 0.05 and 1 U/ml so that heparin plasma levels of 0.1-2 U/ml could be determined within a relative error of 11% and an accuracy of 0.05 U/ml.

A lactulose sensor based on coupled enzyme reactions with a ring electrode fabricated from tetrathiafulvalen-tetracyanoquinodimetane

A dual enzyme electrode is explored for measuring lactulose in milk. A ring electrode (diameter = 3 mm; ring width = 10-20 microns) is proposed onto which tetrathiafulvalen-tetracyanoquinodimetane (TTF-TCNQ) salt was physically packed. The electrode is a band electrode with dimensions approaching those for micro electrodes, so that the improved faradaic current/charging current ratio lead to improved detection limits. Fructose dehydrogenase (FDH) and beta-galactosidase (beta-gal) were immobilized by covering the electrode surface with a dialysis membrane. Lactulose was hydrolyzed to D-fructose and D-galactose by beta-gal. The hydrolyzed D-fructose was oxidized by FDH which was simultaneously reduced to the reduced form (FDH-PQQH2). The FDH-PQQH2 was directly reoxidized by TTF-TCNQ on the ring electrode, whose current was monitored at 200 mV vs Ag/AgCl. The detection limit of the lactulose sensor was 1.0 microM and the selectivity for lactulose was at least 1000 times higher than that for lactose. Pasteurized, UHT and sterilized milks were applied to the lactulose sensor, showing good accuracy and precision and, furthermore, good correlation to a reference photometric method, even though no rigorous procedure for the electrode fabrication has presently been addressed.

Platinum-catalyzed enzyme electrodes immobilized on gold using self-assembled layers

The bonding of enzymes to self-assembled monolayers (SAMs) of alkanethiols onto gold electrode surfaces is exploited to produce an enzyme biosensor. The attachment of glucose oxidase to a SAM of 3-mercaptopropionic acid was achieved using carbodiimide coupling. The resultant biosensor showed good sensitivity to glucose and a large dynamic range when measured amperometrically via the p-benzoquinone mediator. On the other hand, subsequent platinization of the enzyme-SAM electrode allowed hydrogen peroxide produced in the enzyme reaction to be detected directly, thus obviating the need for an artificial redox mediator. The performance of such sensors constructed on bulk gold electrodes was evaluated and finally compared to that of some preliminary thin-film gold electrodes. Biosensors constructed using the two alternative electrode surfaces have quite different sensitivities, thus reflecting the influence of the anchoring surface on the performance of the biosensor.

Clinical characteristics and management of acute stroke in patients with atrial fibrillation admitted to US university hospitals

The optimal evaluation and management of patients with atrial fibrillation who suffer an acute ischemic stroke remains controversial.

METHODS

Medical records of 171 consecutive patients with atrial fibrillation and acute stroke at six U.S. university hospitals were reviewed. Data collected included the use of antithrombotic therapy, brain and cardiac imaging, bleeding complications, stroke risk factors, and contraindications to anticoagulation.

RESULTS

Mean age was 75.4 years. Cardiovascular risk factors associated with increased stroke risk were present in 87%; 35% had at least one contraindication to anticoagulation. Half of the patients with stroke risk factors and no contraindications to anticoagulation were not receiving any antithrombotic therapy at the time of admission. Of the 22 patients who were treated with warfarin, and had INR values on admission, 16 had levels of < 2.0; only six had INR values between 2.0 and 3.0. Transthoracic echocardiography was performed in 107 patients (63%); intracardiac thrombi were visualized in only 5%. Initial brain imaging revealed hemorrhagic transformation in nine. Heparin was used in 93 patients (54%), usually within 48 hours of stroke onset. Patients who received delayed heparin typically did not have repeat brain imaging prior to starting heparin. One patient had a delayed symptomatic cerebral hemorrhage. Of the survivors, 47% were discharged and treated with warfarin (or warfarin plus aspirin), 28% with ASA, 7% with other antithrombotic therapies, and 18% with no antithrombotic therapy.

CONCLUSION

Antithrombotic therapy was underutilized and inadequately monitored in atrial fibrillation patients prior to stroke onset. After hospital admission, a wide range of diagnostic and management strategies, which often did not follow current recommendations, were employed.