Individualizing methadone treatment with split dosing: An underutilized tool.

Methadone's long half-life typically allows for once daily dosing. However, a growing body of evidence and clinical experience shows that some patients may benefit from twice-daily ("split") dosing to produce more stable symptoms and minimize side effects, independent of serum peak-to-trough levels. Concerns regarding split dosing typically center on diversion and poor adherence and must be taken seriously. However, policy changes during COVID-19 demonstrate that the rigidity historically applied to methadone may be unnecessarily stringent. Given clinical advances and policy updates, we believe clinicians should weigh the risks and benefits of this underutilized tool for select patients, as we await the evidence-based recommendations our patients deserve.

Predicting Difficult Intubation by using Modified Mallampati (MMT) with or without Thyromental Height Test (TMHT).

Failed Tracheal Intubation with Subsequent inability to maintain an open airway and adequate oxygenation is the most frequent cause of brain damage or death during anesthesia. Recognizing before anesthesia the potential for difficult intubation allows time for optimal preparation. Proper Selection of equipment and techniques is needed to avoid unwanted situation. To find out difficulties associated with endotracheal intubation using Modified Mallampati Test (MMT) combined with Thyromental Height Test (TMHT) and MMT without TMHT. This prospective observational study was conducted at the Department of Anesthesia in Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh from April 2018 to September 2018. Two hundred two patients with different surgical procedures under general anaesthesia in different operation theaters of BSMMU, Dhaka were selected as study population. After taking written consents from each patient or his/her attendant elaborate history of illness, meticulous clinical examinations were performed and relevant laboratory investigations were done. All information was recorded in a preformed data sheet and statistical analysis was done by SPSS-22.0. Mean age ±SD of the study subjects was 42.49±14.29 years in MMT with TMHT group and 43.40±15.39 years in MMT without TMHT group. Females were enrolled more than males in both the groups. BMI was 28.75±3.59kg/m² in MMT with TMHT group and 29.44±8.64kg/m² in MMT without TMHT group. There were no significant differences in age, gender and BMI between the groups. Sensitivity, specificity, PPV, NPV and accuracy were 100.0%, 96.0%, 96.2%, 100.0% and 98.0% respectively of MMT with TMHT in predicting intubation difficulty. Sensitivity, specificity, PPV, NPV and accuracy were 100.0%, 96.0%, 96.2%, 100.0% and 98.0% respectively of MMT only in predicting intubation difficulty. MMT combined with TMHT is a better predictor of intubation difficulty than MMT alone.

HIV Exposure Prophylaxis Delivery in a Low-barrier Substance Use Disorder Bridge Clinic during a Local HIV Outbreak at the Onset of the COVID-19 Pandemic.

OBJECTIVES: People who inject drugs (PWID) may experience high human immunodeficiency virus (HIV) risk and inadequate access to biomedical HIV prevention. Emerging data support integrating HIV post-exposure and pre-exposure prophylaxis (PEP, PrEP) into services already accessed by PWID. We describe PEP/PrEP eligibility and receipt in a low-barrier substance use disorder bridge clinic located in an area experiencing an HIV outbreak among PWID at the onset of the COVID-19 pandemic. METHODS: Retrospective chart review of new patients at a substance use disorder bridge clinic in Boston, MA (January 15, 2020-May 15, 2020) to determine rates of PEP/PrEP eligibility and prescribing. RESULTS: Among 204 unique HIV-negative patients, 85.7% were assessed for injection-related and 23.0% for sexual HIV risk behaviors. Overall, 55/204 (27.0%) met CDC criteria for HIV exposure prophylaxis, including 7/204 (3.4%) for PEP and 48/204 (23.5%) for PrEP. Four of 7 PEP-eligible patients were offered PEP and all 4 were prescribed PEP. Thirty-two of 48 PrEP eligible patients were offered PrEP, and 7/48 (14.6%) were prescribed PrEP. Additionally, 6 PWID were offered PrEP who lacked formal CDC criteria. CONCLUSIONS: Bridge clinics patients have high rates of PEP/PrEP eligibility. The majority of patients with identified eligibility were offered PEP/PrEP, suggesting that upstream interventions that increase HIV risk assessment may support programs in initiating PEP/PrEP care. Additional work is needed to understand why patients declined PEP/PrEP. PrEP offers to PWID who did not meet CDC criteria also suggested provider concern regarding the sensitivity of CDC criteria among PWID. Overall, bridge clinics offer a potential opportunity to increase biomedical HIV prevention service delivery.

Hypothyroidism in Bangladesh: Is Autoimmunity the Next Big Threat?

In many low and middle-income countries, iodine-deficient hypothyroidism leads to complex public health consequences. However, increasing evidence from population-based studies has linked thyroid autoimmunity with excess iodine intake. The iodine supplementation program in Bangladesh was a success story. This cross-sectional study aims to assess the pattern and predictors of autoimmunity among Bangladeshi hypothyroid patients. In this study, 154 consecutive, newly detected, biochemically-confirmed patients with primary hypothyroidism were recruited from the Endocrinology outpatient department of Bangabandhu Sheikh Mujib Medical University and tested for anti-thyroid peroxidase and anti-thyroglobulin antibody levels from October 2015 and November 2016. Patterns of thyroid autoimmunity were assessed via descriptive statistics. Predictors of autoimmunity were assessed with multivariable mixed-effect logistic regression. The mean age of participants was 36.1±11.0 years, and 70.1% were female. The frequency of thyroid autoimmunity in the study subjects was very high, 89.0% were positive for either anti-TPO or anti-Tg antibodies and 48.7% were positive for both. More participants were positive for anti-TPO antibodies (82.5%) than anti-Tg antibodies (55.2%). The risk of autoimmunity was associated with the thyroid's structural abnormalities but not with functional status. Weight gain and hypertension were associated with autoimmunity, whereas diabetes was protective against autoimmunity.

Change from transrectal to transperineal ultrasound-guided prostate biopsy under local anaesthetic eliminates sepsis as a complication.

Transrectal ultrasound-guided (TRUS) biopsy of the prostate is associated with increased risk of post-procedural sepsis with associated morbidity, mortality, re-admission to hospital, and increased healthcare costs. In the study institution, active surveillance of post-procedural infection complications is performed by clinical nurse specialists for prostate cancer under the guidance of the infection prevention and control team. To protect hospital services for acute medical admissions related to the coronavirus disease 2019 (COVID-19) pandemic, TRUS biopsy services were reduced nationally, with exceptions only for those patients at high risk of prostate cancer. In the study institution, this change prompted a complete move to transperineal (TP) prostate biopsy performed in outpatients under local anaesthetic. TP biopsies eliminated the risk of post-procedural sepsis and, consequently, sepsis-related admission while maintaining a service for prostate cancer diagnosis during the COVID-19 pandemic.

Towards an Improved Substance Use Disorder Treatment Landscape in Rhode Island - Barriers, Current Progress, and Next Steps.

Expanding addiction treatment services in Rhode Island has never been more urgent. Today, we face colliding syndemics of COVID-19, preventable drug overdoses, and HIV, with another year of record overdoses. While the treatment of substance use disorder (SUD) is an essential component of general medical care, numerous barriers prevent broader treatment access for patients in Rhode Island. Buprenorphine and methadone therapy have restrictions that are not applied to other areas in medicine, including for more dangerous medications. In this piece, we highlight existing barriers to care, applaud current progress being made in our state, and provide recommendations for next steps to turn the tide of this deadly epidemic. We hope that these proposed changes will help develop a robust treatment landscape for all patients with SUD in Rhode Island.

A Case of Brain Tuberculosis With an Unusual Presentation Mimicking Viral Fever During a Dengue Outbreak in Bangladesh.

Both dengue and tuberculosis are endemic in South Asian countries, including Bangladesh. Here we report an interesting case presenting as suspected dengue fever and eventually diagnosed as a case of brain tuberculosis. A 27-year-old immunocompetent male presented to us with fever, headache, retro-orbital pain, and photophobia for five days. He had no other complaints, and clinical examination findings were normal. Full blood count revealed neutrophilic leukocytosis; dengue antigen test and anti-dengue antibody test were negative. Magnetic resonance imaging (MRI) of the brain showed both supra and infra-tentorial multiple small (2-4 mm) gadolinium-enhancing lesions suggestive of tuberculomas. A cerebrospinal fluid study revealed lymphocytic pleocytosis with raised protein, low sugar level, and positive Gene Xpert MTB/RIF (Cepheid, California, US) assay test. Investigations did not reveal the involvement of other organs except for the brain. We started standard anti-tuberculosis therapy (HRZE) along with steroids and pyridoxine, and the patient became symptom-free within one week. The patient was discharged with the advice of follow-up after one month. The clinical course and all investigation findings of this case are presented. Central nervous system tuberculosis may present with non-specific signs and symptoms and may be misdiagnosed as other infections, including dengue, particularly during an ongoing epidemic. It may cause significant morbidity and mortality when the diagnosis is delayed due to its vague clinical presentation.

International Foot and Ankle Osteoarthritis Consortium review and research agenda for diagnosis, epidemiology, burden, outcome assessment and treatment.

OBJECTIVE: To summarise the available evidence relating to the diagnosis, epidemiology, burden, outcome assessment and treatment of foot and ankle osteoarthritis (OA) and to develop an agenda to guide future research. METHOD: Members of the International Foot and Ankle Osteoarthritis Consortium compiled a narrative summary of the literature which formed the basis of an interactive discussion at the Osteoarthritis Research Society International World Congress in 2021, during which a list of 24 research agenda items were generated. Following the meeting, delegates were asked to rank the research agenda items on a 0 to 100 visual analogue rating scale (0 = not at all important to 100 = extremely important). Items scoring a mean of 70 or above were selected for inclusion. RESULTS: Of the 45 delegates who attended the meeting, 31 contributed to the agenda item scoring. Nineteen research agenda items met the required threshold: three related to diagnosis, four to epidemiology, four to burden, three to outcome assessment and five to treatment. CONCLUSIONS: Key knowledge gaps related to foot and ankle OA were identified, and a comprehensive agenda to guide future research planning was developed. Implementation of this agenda will assist in improving the understanding and clinical management of this common and disabling, yet relatively overlooked condition.

Characterizing Substance Use Disorders Among Transgender Adults Receiving Care at a Large Urban Safety Net Hospital.

OBJECTIVES: In the midst of the opioid crisis, increasing attention has been given to assessing and addressing substance use disorders (SUDs) among transgender and gender diverse (TGD) populations. As electronic health records begin to more uniformly collect gender identity data, clinicians and public health professionals are better able to examine the prevalence of SUDs and the receipt of SUD treatment services in these populations. METHODS: We utilized cross-sectional electronic health records data from January 2005 to December 2019 from a large safety-net hospital in Massachusetts. A cohort of TGD patients was identified using self-reported gender identity data as well as diagnostic and procedures codes associated with receipt of gender-affirming care (n = 2000). We calculated odds of SUD diagnosis and receipt of medications for SUD among TGD patients. RESULTS: Among a cohort of 2000 TGD patients, 8.8% had a SUD diagnosis. SUD diagnoses were more common among older, Black, and transmasculine patients, as well as those holding public health insurance. SUD diagnoses were less likely among those reporting college-level education. Of those with an opioid use disorder (OUD), 46% were prescribed an FDA-approved medication for OUD. CONCLUSIONS: SUD diagnoses among TGD patients were associated with demographic, socioeconomic, and gender-related factors. We found a modestly lower prevalence of non-tobacco SUD among our cohort of TGD patients than the national average of 7.4%. Despite a relatively better receipt of prescription treatment services than the national average, the low rate of treatment overall represents a missed opportunity to address SUDs in these vulnerable populations.

Ultrasonographic examination of equine fetal growth parameters throughout gestation in pony for Equine-Assisted Therapy.

Equine-Assisted Therapy (EAT) is gaining popularity. Ultrasound examination is used to decrease the abortion rate in horses. In this study, to monitor fetal well-being throughout the gestation for EAT, we measured fetal heart rate (FHR), fetal eye orbit (FEO), fetal gonad length (FGL), fetal kidney length (FKL), and the combined thickness of the uterus and placenta (CTUP) by ultrasonography in pony mares. Additionally, we measured the plasma progesterone (P4) and estradiol (E2) concentrations in pregnant horses using enzyme immunoassay. The FGL peaked at week 32 and then decreased to term, and a strong correlation (r=0.72, P<0.001) between the FGL and E2 concentration was observed. A strong correlation with gestational age was detected among the FEO (r=0.96, P<0.001), FKL (r=0.85, P<0.001), and CTUP (r=0.96, P<0.001). The P4 concentration peaked at week 10, decreased to low levels (below 5 ng/ml), and peaked before parturition. In conclusion, this study provides information on fetal growth throughout gestation in pony mares for EAT. In addition, it revealed the relationship between ultrasonographic profile and plasma hormone concentrations during gestation.

An improved model and performance analysis for grid-connected photovoltaic system in Oman.

The PV systems' sources are environmentally friendly, but at the same time, they are constantly changing with time. When evaluating solar energy resources, it is necessary to consider the variability and effects of different environmental operation parameters like solar irradiances, ambient temperature, and module temperature. The study introduces a method to simulate an existing photovoltaic system using a mathematical model that permits intelligent strategies to optimise the efficiency and adjust the most effective operational parameters for the solar energy systems. A mathematical analysis for the data framework, including correlation and regression coefficients, was calculated to identify and chart the relationships between the system's most influential parameters and the generated power from the PV system. An improved mathematical model was built with the most influential parameters. The improved model was simple, accurate, and based on the loss ratio by eliminating the unknown parameters. The system's efficiency was analysed using an existing data framework-recorded hourly from 1st January 2017 to December 2018 for a grid-connected photovoltaic system installed in the south of Oman. The results showed that the most influential parameters on the efficiency were the module's solar irradiance and surface temperature. The operating parameters such as ambient temperature, wind speed, and air humidity had a negligible effect on the generated power compared to the cell temperatures and solar radiation. The dissipation factor was used in the new output current and voltage equations to stimulate the output power of the PV model. The improved model was validated in a MATLAB Simulink and showed a more promising output with a lower RMSE of 5 %.

Deep learning approach towards accurate state of charge estimation for lithium-ion batteries using self-supervised transformer model.

Accurate state of charge (SOC) estimation of lithium-ion (Li-ion) batteries is crucial in prolonging cell lifespan and ensuring its safe operation for electric vehicle applications. In this article, we propose the deep learning-based transformer model trained with self-supervised learning (SSL) for end-to-end SOC estimation without the requirements of feature engineering or adaptive filtering. We demonstrate that with the SSL framework, the proposed deep learning transformer model achieves the lowest root-mean-square-error (RMSE) of 0.90% and a mean-absolute-error (MAE) of 0.44% at constant ambient temperature, and RMSE of 1.19% and a MAE of 0.7% at varying ambient temperature. With SSL, the proposed model can be trained with as few as 5 epochs using only 20% of the total training data and still achieves less than 1.9% RMSE on the test data. Finally, we also demonstrate that the learning weights during the SSL training can be transferred to a new Li-ion cell with different chemistry and still achieve on-par performance compared to the models trained from scratch on the new cell.

Correction: Particle swarm optimization algorithm-based PI inverter controller for a grid-connected PV system.

[This corrects the article DOI: 10.1371/journal.pone.0243581.].

Multi-dimensional optimization of In0.53Ga0.47As thermophotovoltaic cell using real coded genetic algorithm.

The optimization of thermophotovoltaic (TPV) cell efficiency is essential since it leads to a significant increase in the output power. Typically, the optimization of In0.53Ga0.47As TPV cell has been limited to single variable such as the emitter thickness, while the effects of the variation in other design variables are assumed to be negligible. The reported efficiencies of In0.53Ga0.47As TPV cell mostly remain < 15%. Therefore, this work develops a multi-variable or multi-dimensional optimization of In0.53Ga0.47As TPV cell using the real coded genetic algorithm (RCGA) at various radiation temperatures. RCGA was developed using Visual Basic and it was hybridized with Silvaco TCAD for the electrical characteristics simulation. Under radiation temperatures from 800 to 2000 K, the optimized In0.53Ga0.47As TPV cell efficiency increases by an average percentage of 11.86% (from 8.5 to 20.35%) as compared to the non-optimized structure. It was found that the incorporation of a thicker base layer with the back-barrier layers enhances the separation of charge carriers and increases the collection of photo-generated carriers near the band-edge, producing an optimum output power of 0.55 W/cm2 (cell efficiency of 22.06%, without antireflection coating) at 1400 K radiation spectrum. The results of this work demonstrate the great potential to generate electricity sustainably from industrial waste heat and the multi-dimensional optimization methodology can be adopted to optimize semiconductor devices, such as solar cell, TPV cell and photodetectors.

It's Time to Expand Chlamydia Treatment for Gay and Bisexual Men.

Expedited partner therapy involves prescribing sexually transmitted infection (STI) treatment for a patient's partner(s) without seeing the partner. It is approved for heterosexual partners of patients with chlamydia in most states. However, the Centers for Disease Control and Prevention recommends against expedited partner therapy in men-who-have-sex-with-men (MSM), citing limited data in this population and concerns that expedited partner therapy could discourage comprehensive STI testing, thereby driving increased HIV transmission. In this piece, we describe the case of a 33-year-old gay man on HIV pre-exposure prophylaxis (PrEP) whose cycle of chlamydia reinfection might have been prevented by expedited partner therapy. His case highlights how new HIV prevention strategies-including PrEP and Treatment as Prevention-challenge the assumption that all MSM with chlamydia are at risk for HIV. Until more data on expedited partner therapy in MSM are available, clinicians should incorporate characteristics of patients' sexual networks in weighing the risks and benefits of expedited partner therapy.

Proximal Myopathy With Hypercalcemic Crisis and Papillary Thyroid Carcinoma in a 38-Year-Old Female.

Although proximal myopathy is a well-known manifestation of primary hyperparathyroidism (PHP), it is usually not the first one. Here, we present the case of a 38-year-old female who presented to the neurology outpatient department with proximal myopathy as the presenting feature of PHP along with a hypercalcemic crisis. Her serum calcium and intact parathyroid hormone levels were very high. Her symptoms and calcium levels improved with adequate hydration and bisphosphonate therapy. Ultrasonography of the thyroid and parathyroid glands and Tc99m sestamibi single-photon emission computed tomography-computed tomography of the parathyroid glands suggested adenoma or carcinoma of the parathyroid gland on the right side with another irregular right-sided thyroid nodule. Electromyography showed low-amplitude polyphasic potentials suggestive of myopathy. Subsequently, the patient underwent surgical resection of both the right parathyroid glands and the thyroid nodule. Histopathology report was suggestive of parathyroid adenoma and papillary thyroid carcinoma. Hypercalcemic crisis is a rare clinical scenario, which needs prompt diagnosis and treatment. Otherwise, the condition may have a fatal outcome. Due to its diverse presentation, physicians should be aware of this condition. Moreover, we need to be cautious in treating a patient having hyperparathyroidism with thyroid nodule due to possible concomitant thyroid malignancy.

Particle swarm optimization algorithm-based PI inverter controller for a grid-connected PV system.

The lack of control in voltage overshoot, transient response, and steady state error are major issues that are frequently encountered in a grid-connected photovoltaic (PV) system, resulting in poor power quality performance and damages to the overall power system. This paper presents the performance of a control strategy for an inverter in a three-phase grid-connected PV system. The system consists of a PV panel, a boost converter, a DC link, an inverter, and a resistor-inductor (RL) filter and is connected to the utility grid through a voltage source inverter. The main objective of the proposed strategy is to improve the power quality performance of the three-phase grid-connected inverter system by optimising the proportional-integral (PI) controller. Such a strategy aims to reduce the DC link input voltage fluctuation, decrease the harmonics, and stabilise the output current, voltage, frequency, and power flow. The particle swarm optimisation (PSO) technique was implemented to tune the PI controller parameters by minimising the error of the voltage regulator and current controller schemes in the inverter system. The system model and control strategies were implemented using MATLAB/Simulink environment (Version 2020A) Simscape-Power system toolbox. Results show that the proposed strategy outperformed other reported research works with total harmonic distortion (THD) at a grid voltage and current of 0.29% and 2.72%, respectively, and a transient response time of 0.1853s. Compared to conventional systems, the PI controller with PSO-based optimization provides less voltage overshoot by 11.1% while reducing the time to reach equilibrium state by 32.6%. The consideration of additional input parameters and the optimization of input parameters were identified to be the two main factors that contribute to the significant improvements in power quality control. Therefore, the proposed strategy effectively enhances the power quality of the utility grid, and such an enhancement contributes to the efficient and smooth integration of the PV system.

Effect of increased serum 25(OH)D and calcium on structure and function of post-menopausal women: a pilot study.

The purpose was to determine if increasing serum 25(OH)D and calcium in postmenopausal women increased skeletal muscle size, strength, balance, and functional task performance while decreasing muscle fatigue. PCSA of the vastus lateralis increased and ascent of stairs time decreased after 6 months of increased serum 25(OH)D. PURPOSE: The Institute of Medicine recommends ≥ 20 ng/ml of serum 25-hydroxyvitamin D [25(OH)D] for bone and overall health. Serum 25(OH)D levels have been associated with physical performance, postural sway, and falls. The purpose of this study was to determine if increasing postmenopausal women's serum 25(OH)D levels from 20-30 ng/ml to 40-50 ng/ml improved skeletal muscle size, strength, balance, and functional performance while decreasing skeletal muscle fatigue. METHODS: Twenty-six post-menopausal women (60-85 years old) with baseline serum 25(OH)D levels between 20 and 30 ng/ml were recruited. Oral over-the-counter (OTC) vitamin D3 and calcium citrate were prescribed to increase subjects' serum 25(OH)D to levels between 40 and 50 ng/ml, serum calcium levels above 9.2 mg/dl, and PTH levels below 60 pg/ml, which were confirmed at 6 and 12 weeks. Outcome measures assessed at baseline and 6 months included muscle physiological cross-sectional area (PCSA), muscle strength, postural balance, time to perform functional tasks, and muscle fatigue. Repeated measures comparisons between baseline and follow-up were performed. RESULTS: Nineteen subjects completed the study. One individual could not afford the time commitment for the repeated measures. Three individuals did not take their vitamin D as recommended. Two subjects were lost to follow-up (lack of interest), and one did not achieve targeted serum 25(OH)D. Vastus lateralis PCSA increased (p = 0.007) and ascent of stair time decreased (p = 0.042) after 6 months of increasing serum 25(OH)D levels from 20-30 ng/ml to 40-50 ng/ml. Isometric strength was unchanged. Anterior-posterior center of pressure (COP) excursion and COP path length decreased (p < 0.1) albeit non-significantly, suggesting balance may improve from increased serum 25(OH)D and calcium citrate levels. CONCLUSIONS: Several measures of muscle structure and function were sensitive to elevated serum 25(OH)D and calcium levels indicating that further investigation of this phenomenon in post-menopausal women is warranted.