Clinical pharmacy services in the emergency department

The emergency department (ED) is a fast-paced, high-risk, and often overburdened work environment. Formal policy statements from several notable organizations, including the American College of Emergency Physicians (ACEP) and the American Society of Health-System Pharmacists (ASHP), have recognized the importance of clinical pharmacists in the emergency medicine (EM) setting. EM clinical pharmacists work alongside emergency physicians and nurses at the bedside to optimize pharmacotherapy, improve patient safety, increase efficiency and cost-effectiveness of care, facilitate antibiotic stewardship, educate patients and clinicians, and contribute to scholarly efforts. This paper examines the history of EM clinical pharmacists and associated training programs, the diverse responsibilities and roles of EM clinical pharmacists, their impact on clinical and financial outcomes, and proposes a conceptual model for EM clinical pharmacist integration into ED patient care. Finally, barriers to implementing EM clinical pharmacy programs and limitations are considered.     

The Influence of the Appendiceal Base Diameter on Appendix Stump Closure in Laparoscopic Appendectomy

Background

Closure of the appendiceal stump is the most critical part of laparoscopic appendectomy. Establishing the average diameter of the inflamed appendix, and forming the appropriate size of clip, endoloop or stapler length, would make this critical phase of laparoscopic appendectomy easier.

Methods

One hundred and fifty consecutive patients, with the diagnosis of acute appendicitis, were included in this study and divided into three groups according to the histological verification of the status of the infection, as follows: phlegmonous, gangrenous and perforated forms of acute appendicitis. The external diameter of the appendiceal base was measured, and the widest part of the appendix with the mesoappendix and the tip, with the help of Vernier callipers, and the measurement was expressed in millimetres.

Results

The average size of the appendiceal base in the phlegmonous form was 10.29 ± 3.13, in the gangrenous form 12.41 ± 3.56, and in the perforated form 12.42 ± 3.64. The maximal size of base was observed in the perforated form, 23.13 mm. The dimensions of the appendiceal base, the central part and the tip in the phlegmonous form were statistically significantly smaller than in the gangrenous and perforated forms of acute appendicitis. The size of the appendix did not differ statistically significantly in the gangrenous and perforated forms of acute appendicitis.

Conclusion

In view of the price, the size of the opening, radiological advantage and biocompatibility, the Hem-o-lok clip is the most effective, although its internal diameter should be increased. The DS clip is also effective, but the size of the opening sometimes makes application difficult, and possibly increasing the length of the legs and the opening would make this clip ideal. Staplers have the best characteristics, but their price means they are an option only for forms where it is not possible to close the stump using other methods.

     

Sequential reordering in condensation copolymers, 2. Melting- and crystallization-induced sequential reordering in miscible poly(butylene terephthalate)/polyarylate blends

A 50/50 (weight ratio (38/62 mole ratio referred to repeating units)) blend of poly(butylene terephthalate) (PBT) and polyarylate (PAr), was studied by means of thermal, solubility, X-ray and nuclear magnetic resonance techniques after annealing procedures that enable transesterification. Prolonged thermal treatment at 290°C gives rise to a copolymer that no longer reveals melting or crystallization. In accordance with previous reports, this effect is attributed to the formation of a random copolymer. Additional annealing of such samples at the relatively low temperature of 140°C results in the reappearance of melting endotherms in the differential scanning calorimetry curves. This effect is explained by crystallization-induced sequential reordering from random to block copolymer by means of transreactions. In that way a PBT/PAr blend was shown to be another polymer system, along with poly(ethylene terephthalate) (PET)/polycarbonate (PC) and PET/PAr blends, in which the entire cycle is realized, from two homopolymers via a block- and random copolymer to a block copolymer. The unusually low temperature at which the crystallization-induced sequential reordering to block polymers takes place is explained by the miscibility of PBT and PAr which enables transreactions to take place in the bulk.     

The complete spectrum of pentalogy of Cantrell in one of a set of dizygotic twins: A case report of a rare congenital anomaly

Rationale:Pentalogy of Cantrell (POC) is an extremely rare syndrome with an estimated incidence of 1:65,000 to 200,000 live births. Its complete form includes a midline epigastric abdominal wall defect, defects affecting the lower sternum, anterior diaphragm, diaphragmatic pericardium, and various intracardiac defects.Patient concerns:We report a case of complete POC affecting only the first-born of a set of premature dizygotic twins.Diagnosis:A giant omphalocele with an eviscerated liver and bowel on prenatal, obstetric ultrasonography at 24 gestational weeks was observed. At birth, physical examination confirmed a massive (10 × 8 cm) epigastric omphalocele in which a significant part of the liver was seen. A postnatal echocardiogram revealed the presence of an ostium secundum atrial septal defect, perimembranous ventricular septal defect, and moderate pulmonary stenosis. X-ray showed an abnormal intrathoracic positioned stomach, which was confirmed with a plain x-ray of the upper intestinal tract with hydrosoluble contrast. Computed tomography (CT) scan revealed the sternum''s absence and a close connection between the pericardial sac and the stomach wall.Interventions:The patient underwent surgical intervention at 18 days of age.Outcomes:Despite adequate and appropriate postoperative treatment, the baby rapidly deteriorated and died 72 hours after surgery.Lessons:POC is a complex, high-mortality syndrome whose management requires a multidisciplinary approach and meticulous planning. Despite all efforts, POC carries a poor prognosis, particularly in patients affected by its complete form.     

Sleep and interrogation: does losing sleep impact criminal history disclosure?

Study ObjectivesDespite centuries of using sleep deprivation to interrogate, there is virtually no scientific evidence on how sleep shapes behavior within interrogation settings. To evaluate the impact of sleeplessness on participants’ behavior during investigative interviews, an experimental study examined the impact of sleep restriction on disclosure of past illegal behavior.MethodsHealthy participants from a university community (N = 143) either maintained or curbed their sleep (up to 4 h a night) across 2 days with sleep monitored via actigraphy. They were then asked to disclose past illegal acts and interviewed about them. Next, they were reinterviewed following an example of a detailed memory account (model statement). Disclosures were blindly coded for quantity and quality by two independent raters.ResultsSleep-restricted individuals reported similar offenses, but less information during their disclosure with slightly less precision. Model statement increased disclosure but did not reduce the inhibiting impact of sleep loss. Mediation analysis confirmed the causal role of sleep as responsible for experimental differences in amount of information, and participants’ reports suggested impaired motivation to recall information played a role.ConclusionsThe findings suggest that even moderate sleep loss can inhibit criminal disclosure during interviews, point to motivational factors as responsible, and suggest investigators should be cautious when interrogating sleepy participants.     

Update on pathogenesis and predictors of response of therapeutic strategies used in inflammatory bowel disease

The search for biomarkers that characterize specific aspects of inflammatory bowel disease(IBD), has received substantial interest in the past years and is moving forward rapidly with the help of modern technologies. Nevertheless, there is a direct demand to identify adequate biomarkers for predicting and evaluating therapeutic response to different therapies. In this subset, pharmacogenetics deserves more attention as part of the endeavor to provide personalized medicine. The ultimate goal in this area is the adjustment of medication for a patient's specific genetic background and thereby to improve drug efficacy and safety rates. The aim of the following review is to utilize the latest knowledge on immunopathogenesis of IBD and update the findings on the field of Immunology and Genetics, to evaluate the response to the different therapies. In the present article, more than 400 publications were reviewed but finally 287 included based on design, reproducibility(or expectancy to be reproducible and translationable into humans) or already measured in humans. A few testshave shown clinical applicability. Other, i.e., genetic associations for the different therapies in IBD have not yet shown consistent or robust results. In the close future it is anticipated that this, cellular and genetic material, as well as the determination of biomarkers will be implemented in an integrated molecular diagnostic and prognostic approach to manage IBD patients.