Collections of small urban parks consistently support higher species richness but not higher phylogenetic or functional diversity.

When prioritizing regions for conservation protection, decisions are often based on the principle that a single large reserve should support more species than several small reserves of the same total area (SLOSS). This principle remains a central paradigm in conservation planning despite conflicting empirical evidence and methodological concerns. In urban areas where small parks tend to dominate and policies to promote biodiversity are becoming increasingly popular, determining the most appropriate prioritization method is critical. Here, we document the role of SLOSS in defining the seasonal diversity of birds in 475 parks in 21 US cities. Collections of small parks were consistently associated with higher species richness, spatial turnover and rarity. Collections of both small and large parks were associated with higher phylogenetic and functional diversity whose patterns varied across seasons and cities. Thus, collections of small parks are a reliable source of species richness driven by higher spatial turnover and rarity, whereas collections of both small and large parks contain the potential to support higher phylogenetic and functional diversity. The presence of strong intra-annual and geographical variation emphasizes the need for regional prioritization strategies, where multiple diversity metrics are examined across parks and seasons.

Medication Regimen Complexity in Patients Receiving Consultant Pharmacy Services in Home Health Care.

An interprofessional, team-based approach has become common in a variety of settings. However, consultant pharmacist participation in home health care (HHC) has been limited. To evaluate a potential need for pharmacists in HHC, the objective of this project was to document the medication complexity of patients seen by an established HHC consultant pharmacist service. This retrospective review reports on medication regimen complexity in 79 patients receiving this service using the Patient-Level Medication Regimen Complexity Index (MRCI) tool. The average MRCI score was 30 (± 15 standard deviation), suggesting a high level of medication regimen complexity in this population. High scores have been correlated with increased potential adverse drug events, 30-day hospital readmissions, and reduced adherence. Further research is needed for both the utilization of consultant pharmacists in HHC and the use of MRCI in identifying HHC patients needing pharmacist services.

Analysis of a Long-Standing Consultant Pharmacy Service in Home Health Care.

OBJECTIVE: To analyze the long-term utilization of an on-site consultant pharmacist referral service at a home health care (HHC) agency (HHA) and the medication-related problems in the homebound patients served.
DESIGN: A retrospective, descriptive study reporting the pharmacist's role in providing pharmaceutical care to patients referred by HHC clinicians from 2009 through 2015.
SETTING: A nonprofit HHA in Spokane, Washington, that has utilized a consultant pharmacist service for more than 20 years as part of an academic partnership with Washington State University.
PARTICIPANTS: All patients referred to the pharmacy team were eligible for inclusion in the data analysis.
INTERVENTIONS: Pharmacists provided comprehensive medication management via telephone calls, home visits, and communication with HHA clinicians to resolve clinician-referred problems.
MAIN OUTCOMES: Reason for referral, modality of resolution, number and type of medication-related problems, prescriber response rate.
RESULTS: Of 1,263 referrals, the pharmacy team resolved the case by visiting 421 patients, calling 261 patients, and collaborating with the clinician team for 323 patients; 258 patients declined or were lost to follow-up. The most common problems were the need for education (37%), adverse drug effect (18.8%), and nonadherence (18.4%). The pharmacy team contacted the prescriber 209 times with a 58.4% rate of partial or full acceptance of pharmacy recommendations (nonresponses were counted as not accepted). An additional 265 prescriber contacts were planned to be done by either the patient or HHC clinician.
CONCLUSION: Consultant pharmacists can play an integral role as part of an interdisciplinary HHC team to resolve medication-related problems.

Development of a Tool to Identify Problems Related to Medication Adherence in Home Healthcare Patients.

In the home healthcare setting, clinicians are required to evaluate patient's medication therapy, including adherence. To facilitate this conversation, a pilot question list to help uncover potential medication nonadherence was created after completing a review of the literature and ascertaining the common themes as to why patients were nonadherent to their medication therapies. Pharmacy personnel who provide onsite consultations in a home healthcare setting used the question list to identify medication-related problems that could contribute to nonadherence and to document potential solutions. Through pharmacist-patient interactions, which occurred after admission to the home healthcare agency, pharmacy personnel found on average 2.3 issues per patient, which could affect medication adherence. Side effects were the most common problem identified. After this tool was tested with 65 patient interviews, the questions were analyzed and condensed into a shorter list more specific to the identification of medication-related problems for use by home care clinicians.

Assessed Value of Consultant Pharmacist Services in a Home Health Care Agency.

OBJECTIVE: To report results of a survey administered to clinicians in a home health care agency regarding reasons for them to initiate consultation with a pharmacist working onsite at the agency and the perceived value of the interaction. DESIGN: The survey listed 16 reasons why an agency clinician commonly makes referrals and 9 questions assessing the perceived value of these services provided by the onsite consultant pharmacist. Responses were reported on a five-point Likert scale where 1 = Almost always/strongly agree and 5 = Almost never/strongly disagree. SETTING: Home health care agency in Spokane, Washington, with onsite and in-home consultant pharmacy services for 20 years via a partnership with Washington State University. PARTICIPANTS: All clinicians employed by the home health care agency. RESULTS: Twenty-eight of 101 part-time and full-time clinicians responded to the survey. Eighty-nine percent of respondents strongly agreed that it is valuable to have a consultant pharmacist onsite and pharmacy personnel serve as a helpful source of information. The most common reasons for referral were pain management, drug side effects, and drug interactions. CONCLUSION: Clinicians indicated consultant pharmacist services are beneficial and they used the consultant pharmacist primarily for pain management, drug side effects, and drug interactions, but made referrals for a wide range of reasons. This indicates that an onsite consultant pharmacist is valuable to home care providers. Further research regarding the benefit of an onsite consultant pharmacist in the home care setting is warranted.

Serotonin syndrome after cardiopulmonary bypass: a case demonstrating the interaction between methylene blue and selective serotonin reuptake inhibitors.

Methylene blue, a drug used to treat vasoplegia and methemoglobinemia, also inhibits monoamine oxidase-A. When given in combination with serotonergic medications, methylene blue can lead to serotonin excess syndrome. Given the widespread use of serotonergic medication to treat depression, anesthesia providers should be aware of this potentially lethal interaction. Patients undergoing cardiopulmonary bypass for cardiac surgery are a specific population at risk for postbypass vasoplegic shock. The use of methylene blue to treat vasoplegia in this group of patients should be weighed in light of their current medications and potential drug interactions.

Intraoperative ketamine reduces perioperative opiate consumption in opiate-dependent patients with chronic back pain undergoing back surgery.

BACKGROUND: Ketamine is an N-methyl-d-aspartate receptor antagonist that has been shown to be useful in the reduction of acute postoperative pain and analgesic consumption in a variety of surgical interventions with variable routes of administration. Little is known regarding its efficacy in opiate-dependent patients with a history of chronic pain. We hypothesized that ketamine would reduce postoperative opiate consumption in this patient population. METHODS: This was a randomized, prospective, double-blinded, and placebo-controlled trial involving opiate-dependent patients undergoing major lumbar spine surgery. Fifty-two patients in the treatment group were administered 0.5 mg/kg intravenous ketamine on induction of anesthesia, and a continuous infusion at 10 microg kg(-1) min(-1) was begun on induction and terminated at wound closure. Fifty patients in the placebo group received saline of equivalent volume. Patients were observed for 48 h postoperatively and followed up at 6 weeks. The primary outcome was 48-h morphine consumption. RESULTS: Total morphine consumption (morphine equivalents) was significantly reduced in the treatment group 48 h after the procedure. It was also reduced at 24 h and at 6 weeks. The average reported pain intensity was significantly reduced in the postanesthesia care unit and at 6 weeks. The groups had no differences in known ketamine- or opiate-related side effects. CONCLUSIONS: Intraoperative ketamine reduces opiate consumption in the 48-h postoperative period in opiate-dependent patients with chronic pain. Ketamine may also reduce opioid consumption and pain intensity throughout the postoperative period in this patient population. This benefit is without an increase in side effects.

A novel method for selective delivery of drugs to the pulmonary arteries.

Drug treatment of pulmonary hypertension may be limited by systemic hypotension. Selective action of a vasodilator drug in pulmonary arteries could be achieved by administering a vasodilator gas into systemic venous blood so that it dilates pulmonary arteries before immediate first-pass elimination via exhalation. This article presents in vivo data to show that a pharmacologically active gas can be delivered safely into systemic venous blood where it has a distribution pattern and physiologic effects similar to those observed when the gas is inhaled into pulmonary venous (systemic arterial) blood. This is a first step toward development of first-pass pulmonary clearance as a mechanism to concentrate drugs in pulmonary arteries.

Postoperative hyperthermia following off-pump versus on-pump coronary artery bypass surgery.

OBJECTIVE: Hyperthermia is common in the first 24 hours following coronary artery bypass graft surgery (CABG) with cardiopulmonary bypass (CPB). An inflammatory response to CPB is often implicated in the pathophysiology of this fever. Unlike CABG with CPB, the temperature pattern after off-pump CABG (OPCAB), where CPB is avoided, has not yet been described. The purpose of this study was to describe the postoperative temperature pattern following OPCAB and to compare it with that following on-pump cardiac surgery. DESIGN: Retrospective, observational study. SETTING: Tertiary care university hospital. PARTICIPANTS: Consenting patients undergoing CABG or OPCAB procedures. INTERVENTIONS: Observational. MEASUREMENTS AND MAIN RESULTS: Of the CABG patients, 89% had temperature elevations above 38 degrees C, versus 44% of the OPCAB patients (P = 0.04). Peak body temperature was higher in the on-pump patients (CABG 38.5 degrees C +/- 0.4 degrees C versus OPCAB 37.9 degrees C +/- 0.5 degrees C; P = 0.002), as was the area under the curve for temperatures greater than 38 degrees C (CABG 1.6 +/- 1.7 degrees C/hr versus OPCAB 0.4 +/- 1.2 degrees C/hr; P = 0.02). CONCLUSIONS: Off-pump CABG surgery patients experience less hyperthermia compared with on-pump CABG patients. The reasons for a lower incidence and severity of hyperthermia after OPCAB surgery are not known, but may be related to a reduced inflammatory response.

Xenon and the inflammatory response to cardiopulmonary bypass in the rat.

OBJECTIVE: The purpose of this study was to investigate the effect of xenon on the inflammatory response to cardiopulmonary bypass. DESIGN: Prospective, randomized experimental study. SETTING: University research laboratory. PARTICIPANTS: Sprague-Dawley rats. INTERVENTIONS: After surgical preparation, rats were randomly divided into 4 groups: (1) SHAM rats were cannulated but did not undergo cardiopulmonary bypass; (2) cardiopulmonary bypass rats were subjected to 60 minutes of cardiopulmonary bypass using an oxygenator receiving a 30% O(2), 65% N(2), and 5% CO(2) gas mixture; (3) MK801 rats received MK801 (0.15 mg/kg intravenous) 15 minutes before 60 minutes of cardiopulmonary bypass with the same gas mixture; and (4) xenon rats underwent 60 minutes of cardiopulmonary bypass receiving a 30% O(2), 60% xenon, 5% N(2), and 5% CO(2) gas mixture. MEASUREMENTS AND MAIN RESULTS: All bypass groups showed elevations in both cytokines compared with the SHAM-operated group. However, the inflammatory response to cardiopulmonary bypass in the group receiving xenon was no different from the other bypass groups. CONCLUSIONS: Xenon appears to have no effect on the inflammatory response to cardiopulmonary bypass, making its previously described neuroprotective effect during cardiopulmonary bypass likely independent of any inflammation modulation.

Pathophysiology and management of one-lung ventilation.

The ability to manage OLV effectively in patients with significant pulmonary disease is increasing. Knowledge of pulmonary ventilation and perfusion physiology, improvements in the ability to prevent and treat hypoxia, and a thorough grasp of traditional and novel ventilatory techniques may promote improved perioperative outcomes.

"Other" neurologic complications after cardiac surgery.

Compared to the neurologic morbidity of stroke and cognitive dysfunction, "other" neurologic complications involving injuries to the brachial plexus, phrenic nerve, cranial nerves, other peripheral nerves, as well as the visual pathways, have been disproportionately underrepresented in the cardiac surgery and anesthesiology literature. These injuries are often missed in the early postoperative period when attention is focused principally on recovery from the acute trespass of cardiac surgery and cardiopulmonary bypass. However, when these problems do become apparent, they can cause considerable discomfort and morbidity. An overview of the current concepts of injury mechanisms/etiology, diagnosis, prognosis, and when possible, prevention of these injuries is presented.

Fatal warfarin-induced skin necrosis after total hip arthroplasty.

Skin necrosis associated with warfarin anticoagulation is a rare but serious complication. Few cases of warfarin-induced skin necrosis are found in the orthopaedic literature. We report a fatal case of warfarin-induced skin necrosis after total hip arthroplasty.