Throw caution to the wind: is refeeding syndrome really a cause of death in acute care?

BACKGROUND/OBJECTIVES: Refeeding syndrome (RFS), a life-threatening medical condition, is commonly associated with acute or chronic starvation. While the prevalence of patients at risk of RFS in hospital reportedly ranges from 0 to 80%, the prevalence and types of patients who die as a result of RFS is unknown. We aimed to measure the prevalence rate and examine the case histories of patients who passed away with RFS listed as a cause of death. SUBJECTS/METHODS: Patients were eligible for inclusion provided their death occurred within a Queensland hospital. Medical charts were reviewed, for medical, clinical and nutrition histories with results presented using descriptive statistics. RESULTS: Across 18 years (1997-2015) and ~260000 hospital deaths, five individuals (4F, 74 (37-87)yrs) were identified. No patient had a past or present diagnosis, such as anorexia nervosa, that would classify them as at high risk for RFS. RFS was not listed as the primary cause of death for any patient. No individual consumed >3400 kJ per day. Limited consensus was observed in the signs and symptoms used to diagnose RFS, although all patients experienced low levels of potassium, phosphate and/or magnesium. Eighty percent of electrolytes improved before death. CONCLUSIONS: RFS was a rare underlying cause of death, despite reported high prevalence rates of risk. Patient groups usually considered to be at high risk were not identified, suggesting a level of imprecision with the interpretation of criteria used to identify RFS risk. More detailed research is warranted to assist in the identification of those distinctly at risk of RFS.

A multicenter study of primary graft failure after infant heart transplantation: impact of extracorporeal membrane oxygenation on outcomes.

Primary graft failure is the major cause of mortality in infant HTx. The aim of this study was to characterize the indication and outcomes of infants requiring ECMO support due to primary graft failure after HTx. We performed a retrospective review of all infants (<1 yr) who underwent Htx from three institutions. From 1999 to 2008, 92 infants (<1 yr) received Htx. Sixteen children (17%) required ECMO after Htx due to low cardiac output syndrome. Eleven (69%) infants were successfully weaned off ECMO, and 9 (56%) infants were discharged with a mean follow-up of 2.3 ± 2.5 yr. Mean duration of ECMO in survivors was 5.4 days (2-7 days) compared with eight days (2-10 days) in non-survivors (p = NS). The five-yr survival rate for all patients was 75%; however, the five-yr survival rate was 40% in the ECMO cohort vs. 80% in the non-ECMO cohort (p = 0.0001). Graft function within one month post-Htx was similar and normal between ECMO and non-ECMO groups (shortening fraction = 42 ± 3 vs. 40 ± 2, p = NS). For infants, ECMO support for primary graft failure had a lower short-term and long-term survival rate vs. non-ECMO patients. Duration of ECMO did not adversely impact graft function and is an acceptable therapy for infants after HTx for low cardiac output syndrome.

SU-E-T-101: Dosimetry Intercomparison for a Synchrotron-Produced Monochromatic X-Ray Beam.

PURPOSE: This study performed a dosimetry intercomparison for synchrotron-produced monochromatic x-ray beams. Ion chamber depth-dose measurements in a polymethylmethacrylate (PMMA) phantom were compared with the product of MCNP5 Monte Carlo calculations of dose per fluence and measured incident fluence at 25 and 35 keV. The ion chamber measurements are being used to calibrate dose output for cell irradiations designed to investigate photoactivated Auger electron therapy at the LSU Center for Advanced Microstructures and Devices (CAMD) synchrotron facility. METHODS: Monochromatic beams of 25 and 35 keV were generated on the tomography beamline at CAMD. A cylindrical, air-equivalent ion chamber was used to measure the ionization created in a 10×10×10-cm3 PMMA phantom at depths of 0.6 - 7.7 cm. AAPM TG-61 protocol was applied to convert measured ionization into dose. MCNP5 simulations of the irradiation geometry were performed to determine the dose deposition per photon fluence in the phantom. Photon fluence was determined using a NaI detector to make scattering measurements of the beam from a polyethylene target at angles 15 - 60 degrees. Differential Compton and Rayleigh scattering cross sections were used to derive the incident fluence. RESULTS: At 35 keV dose measurements for equal exposures determined using the MCNP5-fluence results underestimated those of the ion chamber by 1.8 - 4.8% for PMMA depths from 0.6 - 7.7 cm, respectively. At 25 keV there was an overestimate of 6.6 - 1.9%. CONCLUSIONS: These results show that TG-61 ion chamber dosimetry, used to calibrate the dose output for the cell irradiations, is accurate within approximately 7% for beam energies 25-35 keV. This research was supported by contract W81XWH-10-1-0005 awarded by The U.S. Army Research Acquisition Activity, 820 Chandler Street, Fort Detrick, MD 21702-5014. This report does not necessarily reflect the position or policy of the Government, and no official endorsement should be inferred.

SU-E-T-155: Dose Response Curve of EBT2 and EBT3 Radiochromic Films to a Synchrotron-Produced Monochromatic X-Ray Beam.

PURPOSE: This work investigates the dose-response curves of Gafchromic EBT2 and EBT3 radiochromic films using synchrotron-produced monochromatic x-ray beams. These dosimeters are being utilized for dose verification in photoactivated Auger electron therapy at the LSU Center for Advanced Microstructures and Devices (CAMD) synchrotron facility. METHODS: Monochromatic beams of 25, 30 and 35 keV were generated on the tomography beamline at CAMD. Ion chamber depth-dose measurements were used to calculate the dose delivered to films irradiated simultaneously at depths from 0.7 - 8.5 cm in a 10×10×10-cms polymethylmethacrylate phantom. AAPM TG-61 protocol was applied to convert measured ionization into dose. Calibrations of films at 4 MV were obtained for comparison using a Clinac 21 EX radiotherapy accelerator at Mary Bird Perkins Cancer Center. Films were digitized using an Epson 1680 Professional flatbed scanner and analyzed using the optical density (OD) derived from the red channel. RESULTS: For EBT2 film the average sensitivity (OD/dose) at 50, 100, and 200 cGy relative to that for 4-MV x- rays was 1.07, 1.20, and 1.23 for 25, 30, and 35 keV, respectively. For EBT3 film the average sensitivity was within 3 % of unity for all three monochromatic beams. CONCLUSIONS: EBT2 film sensitivity shows strong energy dependence over an energy range of 25 keV - 4 MV. EBT3 film shows weak energy dependence, indicating that it would be the better dosimeter for Auger electron therapy. This research was supported by contract W81XWH-10-1-0005 awarded by The U.S. Army Research Acquisition Activity, 820 Chandler Street, Fort Detrick, MD 21702-5014. This report does not necessarily reflect the position or policy of the Government, and no official endorsement should be inferred.

GSK962040: a small molecule, selective motilin receptor agonist, effective as a stimulant of human and rabbit gastrointestinal motility.

There is an urgent clinical need for a safe, efficacious stimulant of gastric emptying; current therapies include erythromycin (an antibiotic with additional properties which preclude chronic use) and metoclopramide (a 5-hydroxytryptamine type 4 receptor agonist and an antagonist at brain D2 receptors, associated with movement disorders). To move away from the complex motilide structure of erythromycin, a small molecule motilin receptor agonist, GSK962040, was identified and characterized. The compound was evaluated using recombinant human receptors, rabbit and human isolated stomach preparations known to respond to motilin and in vivo, by measuring its ability to increase defecation in conscious rabbits. At the human motilin receptor, the pEC50 (the negative logarithm to base 10 of the EC50 value, the concentration of agonist that produces 50% of the maximal response) values for GSK962040 and erythromycin as agonists were, respectively, 7.9 and 7.3; GSK962040 had no significant activity at a range of other receptors (including ghrelin), ion channels and enzymes. In rabbit gastric antrum, GSK962040 300 nmol L(-1)-10 micromol L(-1) caused a prolonged facilitation of the amplitude of cholinergically mediated contractions, to a maximum of 248 +/- 47% at 3 micromol L(-1). In human-isolated stomach, GSK962040 10 micromol L(-1), erythromycin 10 micromol L(-1) and [Nle13]-motilin 100 nmol L(-1), each caused muscle contraction of similar amplitude. In conscious rabbits, intravenous doses of 5 mg kg(-1) GSK962040 or 10 mg kg(-1) erythromycin significantly increased faecal output over a 2-h period. Together, these data show that GSK962040, a non-motilide structure, selectively activates the motilin receptor. Simplification of the structural requirements to activate this receptor greatly facilitates the design of potentially new medicines for gastroparesis.

Activation of nicotinic receptors on GABAergic amacrine cells in the rabbit retina indirectly stimulates dopamine release.

The retina possesses subpopulations of amacrine cells, which utilize different transmitters, including acetylcholine (ACh), GABA, and dopamine. We have examined interactions between these neurones by studying the effects of nicotinic agonists on GABA and dopamine release. Isolated rabbit retinas were incubated with [3H]dopamine and then superfused. Fractions of the superfusate (2 min) were collected and the [3H]dopamine in each sample was measured. Endogenous GABA release was examined by incubating retinas in a small chamber. At 5-min intervals, the medium was changed and the GABA measured by high-pressure liquid chromatography (HPLC). Exposure of the retina to nicotine, epibatidine, and other nicotinic agonists increased the release of both GABA and dopamine. The effects of nicotine and epibatidine were blocked by mecamylamine, confirming an action on nicotinic receptors. The action of epibatidine on dopamine release was unaffected by glutamate antagonists but was blocked by picrotoxin and gabazine. These results suggested that nicotine might increase dopamine release indirectly by stimulating the release of GABA, which in turn inhibited the release of an inhibitory transmitter acting tonically on the dopaminergic amacrines. Exposure of the retina to GABA caused a small increase in dopamine release. This hypothetical inhibitory transmitter was not GABA, an opioid, adenosine, glycine, nociceptin, a cannabinoid, or nitric oxide because appropriate antagonists did not affect the resting release of dopamine. However, metergoline, a 5HT1/5HT2 receptor antagonist, and ketanserin, a 5HT2A receptor antagonist, but not the 5HT1A antagonist WAY100635, increased the resting release of dopamine and blocked the effects of nicotine. The 5HT1A/5HT7 agonist 8-hydroxy DPAT inhibited both the nicotine and GABA-evoked release of dopamine. We conclude that nicotinic agonists directly stimulate the release of GABA, but the evoked release of dopamine is indirect, and arises from GABA inhibiting the input of an inhibitory transmitter, which we tentatively identify as serotonin.

Excellent supervision: the residents' perspective.

Former residents rated their videotaped psychotherapy supervision sessions on how helpful their supervisors were as teachers during the session. Residents' and experts' ratings of the same videotape were compared and found to have no significant correlation. However, male residents were less critical than either female residents or experts. Former residents were also interviewed. Supervisors were rated as excellent when they were accepting and also when they provided guidance about highly charged clinical dilemmas. Discussion of the impact of the residents' personal experiences on the clinical encounter was also rated high and is best understood from an adult developmental perspective. The findings reveal the lasting value of sympathetic supervisors acknowledging personal concerns and are likely mirrored in all clinical settings.

Release of endogenous ascorbic acid preserves extracellular dopamine in the mammalian retina.

PURPOSE: To investigate whether the inhibitory effect of nitric oxide (NO) on dopamine release from the retina is due to chemical oxidation of dopamine in the extracellular medium rather than to an inhibitory effect on dopamine release from retinal neurons. METHODS: Dopamine was incubated in Krebs bicarbonate medium and its rate of chemical degradation measured by high-performance liquid chromatography (HPLC). The effects of NO donors and antioxidants on dopamine were assessed by comparing dopamine degradation in the presence and absence of drug. The effects of NO donors on the K-evoked release of [3H]dopamine were measured from isolated superfused rabbit retinas. The release of ascorbic acid from the isolated rat retina and from an eyecup preparation in anesthetized rabbits was measured by HPLC. RESULTS: After 10 minutes' incubation in Krebs bicarbonate medium, the dopamine concentration decreased by 20%. This decline increased to 80% in the presence of S-nitroso-N-acetyl-DL-penicillamine (SNAP) or sodium nitroprusside (SNP). The increased rate of dopamine degradation was abolished if retina was incubated in the medium and then removed before the incubation of dopamine. The protective effect of preincubation with tissue was lost in the presence of ascorbate oxidase suggesting the release of ascorbic acid. HPLC analysis confirmed a substantial release of ascorbic acid from both rabbit and rat retinas. The K-evoked release of [3H]dopamine from the rabbit retina was inhibited by SNP. CONCLUSIONS: NO can rapidly, oxidize dopamine in physiological medium, but in the presence of retina, sufficient endogenous antioxidants (mainly ascorbate) are released to prevent this chemical reaction. Thus, the inhibitory action of NO on dopamine release results from an action on retinal neurons. Ascorbate release in the retina may have an important physiological role in prolonging the life of dopamine, which often has to diffuse long distances from axons in the inner plexiform layer to receptors in other retinal layers.

Pharmaceutical therapies for sealing of permeabilized cell membranes in electrical injuries.

Several years ago, we proposed that loss of cell membrane structural integrity by electroporation is a substantial cause of tissue necrosis in victims of electrical trauma. Specifically, this involves the permeabilization of the lipid bilayer by thermal and electrical forces. We further suggested that certain mild surfactants in low concentration could induce sealing of permeabilized lipid bilayers and salvage of cells that had not been extensively heat-damaged. Successful restoration of membrane transport properties using the surfactant poloxamer 188 was reported in 1992. The purpose of this study is to further examine the response of electroporated rat skeletal muscle membranes to poloxamer 188 (P188) therapy by direct assay of membrane transport properties. Experimental evidence accumulated to date suggests that P188 is effective in sealing permeabilized cell membranes both in vitro and in vivo.

Transformation of tooth type induced by inhibition of BMP signaling.

Mammalian dentitions are highly patterned, with different types of teeth positioned in different regions of the jaws. BMP4 is an early oral epithelial protein signal that directs odontogenic gene expression in mesenchyme cells of the developing mandibular arch. BMP4 was shown to inhibit expression of the homeobox gene Barx-1 and to restrict expression to the proximal, presumptive molar mesenchyme of mouse embryos at embryonic day 10. The inhibition of BMP signaling early in mandible development by the action of exogenous Noggin protein resulted in ectopic Barx-1 expression in the distal, presumptive incisor mesenchyme and a transformation of tooth identity from incisor to molar.

Moonlighting by psychiatric residents.

Much of the literature on resident moonlighting has been editorial in nature. Very little information on psychiatric residents' moonlighting practices and attitudes exists. The authors developed an instrument that was mailed to survey the chief residents of all 203 Accreditation Council for Graduate Medical Education-approved psychiatry residencies, with 137 (67.5%) programs responding. According to the responses, the percentage of residents moonlighting increased with each successive year of training, with an average of 31 hours per resident per month. The two major reasons given for moonlighting were payment of living expenses (58%) and repayment of student loans (24%). No supervision was provided to 22% of the moonlighting residents. Only 10% of the programs proscribed moonlighting by their residents. To better assess the positive and negative effects of moonlighting, it is time to truly monitor and guide the moonlighting experience for both residents and their programs.

Collaboration with the nonphysician therapist : a seminar for postgraduate third-year psychiatry residents.

The integration of psychotherapy and pharmacotherapy becomes more complex when two clinicians collaborate in providing patient treatment. A course for postgraduate third-year psychiatry residents was developed to review the literature, discuss various treatment models, and delineate the technical skills and treatment issues involved in the collaborative model. This article describes the course content, design, and evaluation at one institution.

The 1995 Lindberg Award. Nonthermally mediated muscle injury and necrosis in electrical trauma.

Joule heating has long been considered the principal component of tissue damage in electrical injury. Recent studies suggest electroporation, a nonthermally mediated mechanism of cell membrane damage, is also a factor. We investigated whether electroporation-mediated muscle necrosis can occur in vivo without significant Joule heating. Pulsed electric fields approximately 150 V/cm were produced in the hind limbs of anesthetized rats. In shocked limbs core muscle temperature rose less than 1.8 degrees C, yet significant damage occurred as determined by technetium-99m pyrophosphate uptake, elevated serum creatine phosphokinase, and prominent hypercontraction band degeneration of myofibers on histopathologic examination. This study is significant because it directly addresses whether nonthermal mechanisms of cell damage can cause tissue necrosis. These results indicate that electroporation effects can mediate skeletal muscle necrosis without visible thermal changes. Thus the phenomenon of "progressive recognition" may be characteristically largely explained by the occurrence of nonthermally mediated tissue damage.

A miniature gamma camera.

We have described a mobile miniature-gamma-camera system for use in electrical trauma units and have presented images and imaging characteristics of a prototype system. The system has as its principal component a miniature gamma camera based on a PSPMT. The camera is 92 mm x 92 mm x 190 mm in size, weighs 5 kg, has a 48 mm x 48 mm field of view, and has an intrinsic resolution of approximately 3 mm FWHM and 6 mm FWTM. It is expected that devices of this type will be useful as imaging tools in electrical trauma units and laboratories where imaging studies regarding uptake mechanisms of radiopharmaceuticals for assessing tissue viability are carried out.

Qualities of adolescent mothers' parenting.

PURPOSE: This study examined the interrelations among adolescent mothers' parenting attitudes, parenting confidence, and parenting stress and the potential differences in these dimensions by mothers' age, race and parity, and age and sex of child. METHODS: Subjects were 119 former adolescent mothers (M age = 20.2 years) from predominantly poor, minority backgrounds (50% Hispanic, 27% African-American, 17% non-Hispanic white). All subjects completed questionnaires about their parenting qualities twice an average of 10 weeks apart. All children were at least one year of age (M age = 37.2 months; range 12-50 months). RESULTS: Results indicated that for some mothers there exists a triple jeopardy of low parenting confidence, high parenting stress, and inappropriate parenting values. Young maternal age at delivery and young maternal age at the time of this study were associated with low child acceptance. Non-Hispanic white mothers had significantly more favorable parenting values than did African-American and Hispanic mothers, and African-American mothers reported significantly greater caretaking confidence than did Hispanic mothers. No parity or sex of child effects were found. CONCLUSIONS: These results suggest the presence of meaningful patterns of convergence and within-group variation for the psychological qualities of adolescent mothers' parenting.

PIP: This study examined the interrelations among adolescent mothers' parenting attitudes, parenting confidence, and parenting stress and the potential differences in these dimensions by mothers' age, race, and parity, and age and sex of child. Subjects were 119 former adolescent mothers (mean age = 20.2 years) from predominantly poor, minority backgrounds (50% Hispanic, 27% African American, 17% non-Hispanic White). All subjects completed questionnaires about their parenting qualities twice an average of 10 weeks apart. All children were at least 1 year of age (mean age = 37.2 months; range 12-50 months). Subjects' parenting attitudes were assessed by the Adult-Adolescent Parenting Inventory, a 32-item questionnaire. The Maternal Self-Report inventory was used to assess the mothers' self-esteem or their confidence in the mothering role. To assess the stress experienced with parenting, the Parenting Daily Hassles scale was used. Results indicated that for some mothers there exists a triple jeopardy of low parenting confidence, high parenting stress, and inappropriate parenting values. Mothers who reported feeling high parenting stress had low confidence in themselves as mothers, low empathy to their children's needs, and low acceptance of their children. Mothers who were older at the time of the study placed greater value on physical punishment and had less confidence in their caretaking abilities. Young maternal age at delivery and young maternal age at the time of this study were associated with low child acceptance. Non-Hispanic White mothers had significantly more favorable parenting values (greater empathy to child's needs and less value of physical punishment) than did African-American and Hispanic mothers, and African-American mothers reported significantly greater caretaking confidence than did Hispanic mothers. No parity or sex of child effects were found. These results suggest the presence of meaningful patterns of convergence and within-group variation for the psychological qualities of adolescent mothers' parenting.

What do excellent psychotherapy supervisors do?

OBJECTIVE: The author's goal was to discover strategies used by psychotherapy supervisors judged to be excellent teachers. METHOD: In an earlier study, experienced teachers of psychotherapy rated the level of excellence of 34 different supervisors in 53 videotaped supervision sessions. In this study, the authors examined the transcripts of the nine videotapes assigned the highest ratings as well as three videotapes assigned mid-level ratings and three videotapes assigned low ratings in the previous study. In analyzing these transcripts, the authors drew from their experience with the complete set of videotapes. RESULTS: Supervisors with high ratings allowed the resident's story about the encounter with the patient to develop. They consistently tracked the most immediate aspects of the resident's affectively charged concerns. Most of their comments were directed toward helping the resident further understand the patient and were specific to the material presented in the session. The resident was invited to speculate about the material, and technical words were used sparsely. Discussions about the relationships between resident and patient and between supervisor and resident were in the context of the resident's concerns. Supervisors with mid-level ratings were less disciplined in tracking the resident's concerns and inhibited the development of the resident's story. Supervisors with low ratings paid little or no attention to the resident's issues. CONCLUSIONS: The ability to track residents' concerns is at the center of supervisory activities rated as excellent. The resident provides data about what occurred, and new knowledge is constructed in the supervisory interaction. These findings provide an empirical basis for orienting supervisors to supervision.

Quantitative assessment of the behavior of psychotherapy supervisors.

OBJECTIVE: The aim of this study was to explore the behavior of psychotherapy supervisors by using the Psychotherapy Supervision Inventory. METHOD: The authors used the Psychotherapy Supervision Inventory to rate 53 videotaped supervision sessions of 34 different supervisors. They also used the variable of the rater's perception of the excellence of the supervisor as a teacher. The data were subjected to a cluster analysis and a K-means analysis. Discriminant function analyses were applied to the comparison of the behavior of 19 supervisors with two different residents and the behavior of all 34 supervisors with residents in three different years of training. The relationship between rater-perceived excellence and Psychotherapy Supervision Inventory scores was analyzed by using stepwise multiple regression. RESULTS: There was a high level of agreement among the four raters' judgments of supervisors' excellence. Empathy accounted for 72% of the variance in rater-perceived excellence and focus on the therapist accounted for an additional 5%. When empathy was dropped from the equation, experiential orientation accounted for 60% of the variance in ratings of excellence, clarification and interpretation accounted for an additional 16%, and depth accounted for another 3%. CONCLUSIONS: In the context of established relationships, supervisors have stable behavior patterns. Rater-perceived excellence is related to the supervisor's focusing on the resident's immediate experiences and making many synthesizing comments in depth. The Psychotherapy Supervision Inventory can be used to orient supervisors to supervision and provide feedback about their behavior.