Reduction of benztropine use duration in acute psychiatry: A quality improvement initiative.

DISCLAIMER: In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. PURPOSE: Secondary to the risk of antipsychotic-induced acute dystonia, prophylactic use of benztropine is occasionally warranted but is recommended for no longer than 7 days after initiating an antipsychotic, correlating to the period of highest dystonia risk. Despite the associated increased anticholinergic burden, many clinicians continue to order benztropine for periods exceeding the recommended prophylactic duration. We investigated the reduction of benztropine use duration subsequent to implementation of truncated electronic entry orders to improve benztropine prescribing within an acute psychiatric facility. METHODS: Data were collected for psychiatric inpatients admitted between January and June 2020 who were prescribed scheduled benztropine. In a quality improvement initiative implemented in April 2022, electronic orders for benztropine were modified from a 180-day to a 7-day duration, with subsequent postintervention data collection. The primary outcomes included a change in the duration of benztropine use for any indication in the hospital, and a change in the percentage of patients meeting predetermined "unnecessary use" criteria. Secondary analyses included the percentage of patients with discharge prescriptions for scheduled benztropine (either for prophylaxis or for other indications) in the pre- and postintervention periods. RESULTS: 73 pre- and 77 postintervention individual patients/encounters were included. Following the intervention, in-hospital duration of benztropine use for any indication decreased from a median of 14 days to a median of 7.5 days (P < 0.05), and appropriate use increased by 92.9%. The percentage of patients with prescriptions for scheduled benztropine decreased from 67.1% in the preintervention group to 29.9% in the postintervention group. CONCLUSION: Decreased benztropine use duration, by means of truncated order entry sentences, during inpatient psychiatric admissions, appears feasible regardless of dual antipsychotic or first-generation antipsychotic use, and may reduce the rates of benztropine prescriptions written for discharge.

Contrasting Case-Control and Normative Reference Approaches to Capture Clinically Relevant Structural Brain Abnormalities in Patients With First-Episode Psychosis Who Are Antipsychotic Naive.

Importance: To make progress toward precision psychiatry, it is crucial to move beyond case-control studies and instead capture individual variations and interpret them in the context of a normal range of biological systems. Objective: To evaluate whether baseline deviations from a normative reference range in subcortical volumes are better predictors of antipsychotic treatment response than raw volumes in patients with first-episode psychosis (FEP) who were naive to antipsychotic medication. Design, Setting, and Participants: In this prospective longitudinal study, patients with first-episode psychosis who were referred from different clinical settings (emergency department, inpatient units, and outpatient clinics) at the University of Alabama at Birmingham were included. A total of 286 patients were screened, 114 consented, 104 enrolled in the treatment trial, and 85 completed the trial. Patients were observed for 16 weeks. Controls were matched by age and sex. Data were collected between June 2016 and July 2021, and data were analyzed from August 2021 to June 2022. Interventions: Risperidone on a flexible dosing scheme for 16 weeks. There was an option to switch to aripiprazole for excessive adverse effects. Main Outcomes and Measures: The main outcome of this study was to evaluate, in patients with FEP who were naive to antipsychotic medication, the association of baseline raw volumes and volume deviations in subcortical brain regions with response to antipsychotic medication. Raw brain volumes or volume deviation changes after treatment were not examined. Results: Of 190 included participants, 111 (58.4%) were male, and the mean (SD) age was 23.7 (5.5) years. Volumes and deviations were quantified in 98 patients with FEP, and data from 92 controls were used as comparison for case-control contrasts and reference curve calibration. In case-control contrasts, patients with FEP had lower raw thalamus (P = .002; F = 9.63; df = 1), hippocampus (P = .009; F = 17.23; df = 1), amygdala (P = .01; F = 6.55; df = 1), ventral diencephalon (P = .03; F = 4.84; df = 1), and brainstem volumes (P = .004; F = 8.39; df = 1). Of 98 patients, 36 patients with FEP (36%) displayed extreme deviations. Associations with treatment response significantly differed between raw volume and deviation measures in the caudate (z = -2.17; P = .03) and putamen (z = -2.15; P = .03). Conclusions and Relevance: These data suggest that normative modeling allows capture of interindividual heterogeneity of regional brain volumes in patients with FEP and characterize structural pathology in a clinically relevant fashion. This holds promise for progress in precision medicine in psychiatry, where group-level studies have failed to derive reliable maps of structural pathology.

White Matter Neurometabolic Signatures Support the Deficit and Nondeficit Distinction in Antipsychotic-Naïve First-Episode Psychosis Patients.

The deficit syndrome is thought to be a more homogenous clinical subgroup within the syndrome of schizophrenia that is characterized by enduring negative symptoms. It is hypothesized that distinct pathophysiological processes underlie the subtypes, where the deficit syndrome reflects an early onset nonprogressive developmental process, and the nondeficit form of the illness is characterized by attenuated neuroplasticity secondary to elevated glutamate levels. We used single-voxel magnetic resonance spectroscopy (PRESS; TE: 30 ms) to measure left frontal white matter neurometabolite levels in 61 antipsychotic-naïve first-episode psychosis patients (39 who did not display deficit features, 22 who did display deficit features, assessed with the Schedule for the Deficit Syndrome) and 59 healthy controls. Metabolite levels were quantified with the LCModel. We used a MANCOVA to determine neurometabolite differences between healthy controls, deficit syndrome patients, and nondeficit patients. We report a significant group difference when all metabolites were considered jointly (F[10,208] = 2.16; P = .02). Post hoc analyses showed that patients presenting without deficit features had higher glutamate levels than patients with deficit features and controls. Patients presenting without deficit features also had significantly higher myoinositol levels than controls; myoinositol levels were trend-level higher in patients presenting with deficit features compared to controls. Our data support the idea that the pathophysiology of patients presenting without deficit features may differ from those presenting with deficit features.

Ultraviolet absorption of contaminants in water.

Contaminants in water were studied using ultraviolet absorption with light emitting diode and deuterium lamp sources, and a thresholding detector. The absorption spectra of potassium hydrogen pthalate, clothianidin, tryptophan, thiamethoxam, uric acid and metaldehyde were obtained in the range 200-360 nm. Only metaldehyde was not suitable for detection in this range. For the other contaminants, and mixtures of pairs of compounds, the transmitted signal could be approximately described with a simple spectral model of the source-absorption-detector system. Combined measurements at two wavelengths could allow relative concentrations in certain mixtures to be determined, and real-time absorption measurements were demonstrated in a flume.

Work function of GaAs(hkl) and its modification using PEI: mechanisms and substrate dependence.

Spin-coating of poly(ethylenimine) (PEI) has been used to reduce the work function of GaAs (001), (110), (111)A and (111)B. The magnitude of the reduction immediately after coating varies significantly from 0.51 eV to 0.69 eV and depends on the surface crystal face, on the GaAs bulk doping and on the atomic termination of the GaAs. For all samples, the work function reduction shrinks in ambient air over the first 20 hours after spin coating, but reductions around 0.2-0.3 eV persist after 1 year of storage in air. Core-level photoemission of thin film PEI degradation in air is consistent with a two-stage reaction with CO2 and H2O previously proposed in carbon capture studies. The total surface dipole from PEI coating is consistent with a combination of internal neutral amine dipole and an interface dipole whose magnitude depends on the surface termination. The contact potential difference measured by Kelvin probe force microscopy on a cleaved GaAs heterostructure is smaller on p-doped regions. This can be explained by surface doping due to the PEI, which increases the band bending on p-doped GaAs where Fermi level pinning is weak. Both surface doping and surface dipole should be accounted for when considering the effect of PEI coated on a semiconductor surface.

Self-Identified African Americans and prostate cancer risk: West African genetic ancestry is associated with prostate cancer diagnosis and with higher Gleason sum on biopsy.

Concerns about overtreatment of clinically indolent prostate cancer (PrCa) have led to recommendations that men who are diagnosed with low-risk PrCa be managed by active surveillance (AS) rather than immediate definitive treatment. However the risk of underestimating the aggressiveness of a patient's PrCa can be a significant source of anxiety and a barrier to patient acceptance of AS. The uncertainty is particularly keen for African American (AA) men who are about 1.7 times more likely to be diagnosed with PrCa than European American (EA) men and about 2.4 times more likely to die of this disease. The AA population, as many other populations in the Americas, is genetically heterogeneous with varying degrees of admixture from West Africans (WAs), Europeans, and Native Americans (NAs). Recommendations for PrCa screening and management rarely consider potential differences in risk within the AA population. We compared WA genetic ancestry in AA men undergoing standard prostate biopsy who were diagnosed with no cancer, low-grade PrCa (Gleason Sum 6), or higher grade PrCa (Gleason Sum 7-10). We found that WA genetic ancestry was significantly higher in men who were diagnosed with PrCa on biopsy, compared to men who were cancer-negative, and highest in men who were diagnosed with higher grade PrCa (Gleason Sum 7-10). Incorporating WA ancestry into the guidelines for making decisions about when to obtain a biopsy and whether to choose AS may allow AA men to personalize their approach to PrCa screening and management.

Ketamine induced changes in regional cerebral blood flow, interregional connectivity patterns, and glutamate metabolism.

Several imaging studies have attempted to characterize the contribution of glutamatergic dysfunction to functional dysconnectivity of large-scale brain networks using ketamine models. However, findings from BOLD imaging studies are conflicting, in part because the signal stems from a complex interaction between blood flow, blood volume, and oxygen consumption. We used arterial spin labelling imaging to measure regional cerebral blood flow (rCBF) in a group of healthy volunteers during a saline and during a ketamine infusion. We examined changes in rCBF and interregional connectivity patterns, as well as their associations with clinical symptom severity and Glx (glutamate + glutamine) assessed with magnetic resonance spectroscopy. We report a regionally selective pattern of rCBF changes following ketamine administration and complex changes in interregional connectivity patterns. We also found that the increase in rCBF in the bilateral putamen and left hippocampus was positively correlated with ketamine induced clinical symptom severity while anterior cingulate rCBF during the ketamine challenge was negatively correlated with change in hippocampal Glx. Our study adds to the efforts to empirically confirm putative links between an NMDA receptor blockage and dysconnectivity of large-scale brain networks, specifically the salience, executive control and default mode networks, suggesting that a glutamatergic imbalance may contribute to dysconnectivity. Development of glutamatergic compounds that alleviate disease burden, possibly through normalizing glutamate excess related increased rCBF, is direly needed.

Epigenetic risk score improves prostate cancer risk assessment.

BACKGROUND: Early detection of aggressive prostate cancer (PCa) remains crucial for effective treatment of patients. However, PCa screening remains controversial due to a high rate of overdiagnosis and overtreatment. To better reconcile both objectives, more effective methods for assessing disease severity at the time of diagnosis are needed. METHODS: The relationship between DNA-methylation and high-grade PCa was examined in a cohort of 102 prospectively enrolled men who received standard 12-core prostate biopsies. EpiScore, an algorithm that quantifies the relative DNA methylation intensities of GSTP1, RASSF1, and APC in prostate biopsy tissue, was evaluated as a method to compensate for biopsy under-sampling and improve risk stratification at the time of diagnosis. RESULTS: DNA-methylation intensities of GSTP1, RASSF1, and APC were higher in biopsy cores from men diagnosed with GS ≥ 7 cancer compared to men with diagnosed GS 6 disease. This was confirmed by EpiScore, which was significantly higher for subjects with high-grade biopsies and higher NCCN risk categories (both P < 0.001). In patients diagnosed with GS ≥ 7, increased levels of DNA-methylation were present, not only in the high-grade biopsy cores, but also in other cores with no or low-grade disease (P < 0.001). By combining EpiScore with traditional clinical risk factors into a logistic regression model, the prediction of high GS reached an AUC of 0.82 (95%CI: 0.73-0.91) with EpiScore, DRE, and atypical histological findings as most important contributors. CONCLUSIONS: In men diagnosed with PCa, DNA-methylation profiling can detect under-sampled high-risk PCa in prostate biopsy specimens through a field effect. Predictive accuracy increased when EpiScore was combined with other clinical risk factors. These results suggest that EpiScore could aid in the detection of occult high-grade disease at the time of diagnosis, thereby improving the selection of candidates for Active Surveillance.

Overview of Clinical Pathology and the Horse.

This article is intended to serve as a reference for clinical pathology in the equine with algorithms and tables provided for anemia diagnosis and leukogram alterations associated with both acute and chronic inflammation. A table of reference is provided for fluid evaluations including joint fluid and effusions into body cavities. Evaluation of newer serum markers, such as cardiac troponin, and a table highlighting test procedures for the evaluation of endocrine disease in the horse are included. A brief overview of quality assurance in the laboratory is provided to stimulate interest in this important aspect of laboratory diagnosis of disease.

Short latency activation of cortex by clinically effective thalamic brain stimulation for tremor.

Deep brain stimulation (DBS) relieves disabling symptoms of neurologic and psychiatric diseases when medical treatments fail, yet its therapeutic mechanism is unknown. We hypothesized that ventral intermediate (VIM) nucleus stimulation for essential tremor activates the cortex at short latencies, and that this potential is related to the suppression of tremor in the contralateral arm. We measured cortical activity with electroencephalography in 5 subjects (seven brain hemispheres) across a range of stimulator settings, and reversal of the anode and cathode electrode contacts minimized the stimulus artifact, allowing visualization of brain activity. Regression quantified the relationship between stimulation parameters and both the peak of the short latency potential and tremor suppression. Stimulation generated a polyphasic event-related potential in the ipsilateral sensorimotor cortex, with peaks at discrete latencies beginning less than 1 ms after stimulus onset (mean latencies 0.9 ± 0.2, 5.6 ± 0.7, and 13.9 ± 1.4 ms, denoted R1, R2, and R3, respectively). R1 showed more fixed timing than the subsequent peaks in the response (P < 0.0001, Levene's test), and R1 amplitude and frequency were both closely associated with tremor suppression (P < 0.0001, respectively). These findings demonstrate that effective VIM thalamic stimulation for essential tremor activates the cerebral cortex at approximately 1 ms after the stimulus pulse. The association between this short latency potential and tremor suppression suggests that DBS may improve tremor by synchronizing the precise timing of discharges in nearby axons and, by extension, the distributed motor network to the stimulation frequency or one of its subharmonics.

Short latency activation of cortex during clinically effective subthalamic deep brain stimulation for Parkinson's disease.

Subthalamic deep brain stimulation (DBS) is superior to medical therapy for the motor symptoms of advanced Parkinson's disease (PD), and additional evidence suggests that it improves refractory symptoms of essential tremor, primary generalized dystonia, and obsessive-compulsive disorder. Despite this, its therapeutic mechanism is unknown. We hypothesized that subthalamic stimulation activates the cerebral cortex at short latencies after stimulus onset during clinically effective stimulation for PD. In 5 subjects (six hemispheres), EEG measured the response of cortex to subthalamic stimulation across a range of stimulation voltages and frequencies. Novel analytical techniques reversed the anode and cathode electrode contacts and summed the resulting pair of event-related potentials to suppress the stimulation artifact. We found that subthalamic brain stimulation at 20 Hz activates the somatosensory cortex at discrete latencies (mean latencies: 1.0 ± 0.4, 5.7 ± 1.1, and 22.2 ± 1.8 ms, denoted as R1, R2, and R3, respectively). The amplitude of the short latency peak (R1) during clinically effective high-frequency stimulation is nonlinearly dependent on stimulation voltage (P < 0.001; repeated-measures analysis of variance), and its latency is less variable than that of R3 (1.02 versus 19.46 ms; P < 0.001, Levene's test). We conclude that clinically effective subthalamic brain stimulation in humans with PD activates the cerebral cortex at 1 ms after stimulus onset, most likely by antidromic activation. These findings suggest that alteration of the precise timing of action potentials in cortical neurons with axonal projections to the subthalamic region may be an important component of the therapeutic mechanism of subthalamic brain stimulation.

Predictive factors for percutaneous nephrolithotomy outcomes in neurogenic bladder population.

PURPOSE: To review experience performing percutaneous nephrolithotomy (PCNL) on patients with neurogenic bladder, evaluating predictors for increased length of stay (LOS), intensive care unit (ICU) stay, stone-free rate, and number of procedures and outcomes measures between spinal cord injury (SCI) and spina bifida (SB) patients. PATIENTS AND METHODS: We retrospectively reviewed our PCNLs from January 1, 2002 to December 31, 2009 and identified 47 patients. Data collected included LOS, ICU stay, stone-free rate, complications, and total procedures. RESULTS: A total of 66 PCNLs were performed on 47 patients. The mean LOS was 5.3 days, and nine patients needed ICU stay (mean 13.9 d). Initial stone-free rate was 60.6%, and final stone-free rate was 69.7%. Multiple access was associated with increased LOS (P=0.01), ICU stay (P<0.01), transfusion (P<0.01), and pulmonary complications (P=0.03). Upper-pole access was associated with decreased initial stone-free rate (P=0.04). Midpolar access predicted increased final stone-free rate (P=0.04). Mean stone size was 3.31 cm and was predictive of an increased number of procedures (P=0.04). Larger stone size was also predictive of decreased initial stone-free rate (P=0.03) and final stone-free rate (P=0.05). There were no statistically significant differences between SCI and SB patients in terms of outcomes. CONCLUSIONS: Increasing stone size and multiple access were predictors of adverse outcomes, and location of access affected stone-free status. We found no differences in outcomes between SB and SCI patients. To our knowledge, this is the largest series reported regarding PCNLs in this patient population.

The ARID family transcription factor bright is required for both hematopoietic stem cell and B lineage development.

Bright/Arid3a has been characterized both as an activator of immunoglobulin heavy-chain transcription and as a proto-oncogene. Although Bright expression is highly B lineage stage restricted in adult mice, its expression in the earliest identifiable hematopoietic stem cell (HSC) population suggests that Bright might have additional functions. We showed that >99% of Bright(-/-) embryos die at midgestation from failed hematopoiesis. Bright(-/-) embryonic day 12.5 (E12.5) fetal livers showed an increase in the expression of immature markers. Colony-forming assays indicated that the hematopoietic potential of Bright(-/-) mice is markedly reduced. Rare survivors of lethality, which were not compensated by the closely related paralogue Bright-derived protein (Bdp)/Arid3b, suffered HSC deficits in their bone marrow as well as B lineage-intrinsic developmental and functional deficiencies in their peripheries. These include a reduction in a natural antibody, B-1 responses to phosphocholine, and selective T-dependent impairment of IgG1 class switching. Our results place Bright/Arid3a on a select list of transcriptional regulators required to program both HSC and lineage-specific differentiation.

Loss of Bright/ARID3a function promotes developmental plasticity.

B-cell regulator of immunoglobulin heavy chain transcription (Bright)/ARID3a, an A+T-rich interaction domain protein, was originally discovered in B lymphocyte lineage cells. However, expression patterns and high lethality levels in knockout mice suggested that it had additional functions. Three independent lines of evidence show that functional inhibition of Bright results in increased developmental plasticity. Bright-deficient cells from two mouse models expressed a number of pluripotency-associated gene products, expanded indefinitely, and spontaneously differentiated into cells of multiple lineages. Furthermore, direct knockdown of human Bright resulted in colonies capable of expressing multiple lineage markers. These data suggest that repression of this single molecule confers adult somatic cells with new developmental options.

Vascular development in embryoid bodies: quantification of transgenic intervention and antiangiogenic treatment.

It has become increasingly clear that the investigation of vascular development is best considered in the context of a whole tissue environment since in vivo endothelial cells interact closely with other cell types. Murine embryoid bodies have been used as a model for the early development of a vascular network and are amenable to genetic manipulation and treatment with soluble modulators. However, quantifying morphological changes in these complex three-dimensional structures is challenging. In this paper we describe protocols to culture embryoid bodies on a large scale to study vascular development together with methods to quantify changes seen when antiangiogenic agents or endothelial cell-specific transgenes are introduced.

Bright/ARID3A contributes to chromatin accessibility of the immunoglobulin heavy chain enhancer.

Bright/ARID3A is a nuclear matrix-associated transcription factor that stimulates immunoglobulin heavy chain (IgH) expression and Cyclin E1/E2F-dependent cell cycle progression. Bright positively activates IgH transcriptional initiation by binding to ATC-rich P sites within nuclear matrix attachment regions (MARs) flanking the IgH intronic enhancer (Emu). Over-expression of Bright in cultured B cells was shown to correlate with DNase hypersensitivity of Emu. We report here further efforts to analyze Bright-mediated Emu enhancer activation within the physiological constraints of chromatin. A system was established in which VH promoter-driven in vitro transcription on chromatin- reconstituted templates was responsive to Emu. Bright assisted in blocking the general repression caused by nucleosome assembly but was incapable of stimulating transcription from prebound nucleosome arrays. In vitro transcriptional derepression by Bright was enhanced on templates in which Emu is flanked by MARs and was inhibited by competition with high affinity Bright binding (P2) sites. DNase hypersensitivity of chromatin-reconstituted Emu was increased when prepackaged with B cell nuclear extract supplemented with Bright. These results identify Bright as a contributor to accessibility of the IgH enhancer.

Abdominal surgery in neonatal foals.

Abdominal surgery in foals under 30 days old has become more common with improved neonatal care. Early recognition of a foal at risk and better nursing care have increased the survival rates of foals that require neonatal care. The success of improved neonatal care also has increased the need for accurate diagnosis and treatment of gastrointestinal, umbilical, and bladder disorders in these foals. This chapter focuses on the early and accurate diagnosis of specific disorders that require abdominal exploratory surgery and the specific treatment considerations and prognosis for these disorders.

Segmental ostectomy of the second and fourth metacarpal and metatarsal bones in horses: 17 cases (1993-2002).

OBJECTIVE: To determine clinical findings in and outcome of horses with fractures of the second or fourth metacarpal or metatarsal bone that underwent segmental ostectomy, leaving the proximal and distal portions of the bone undisturbed. DESIGN: Retrospective case series. ANIMALS: 17 horses. PROCEDURES: Medical records were reviewed, and information on signalment, affected bone, lesion type, surgical procedure, amount of bone removed, and surgical and postsurgical complications was obtained. Follow-up information was obtained through telephone conversations with owners, trainers, and referring veterinarians. RESULTS: One horse had a fracture involving the distal third of the second metacarpal bone; 13 had fractures involving the middle third of the second metacarpal bone (n = 4), fourth metacarpal bone (5), or fourth metatarsal bone (4); and 3 had fractures involving the proximal third of the second (2) or fourth (1) metacarpal bone. Affected portions of the bones were surgically resected, leaving the proximal and distal portions undisturbed. All horses returned to previous performance levels without evidence of lameness. Cosmetic results were good to excellent. CONCLUSIONS AND CLINICAL RELEVANCE: Results suggest that horses with a complicated injury of the proximal, middle, or distal portion of the second or fourth metacarpal or metatarsal bone may be successfully treated by means of segmental ostectomy of the abnormal portion of the bone.