A Standardized Training Program in Ultrasound-Guided Intravenous Line Placement: Improving Nurses' Confidence and Success.

BACKGROUND: Ultrasound-guided imagery to obtain peripheral intravenous (USGIV) access is a technique that can be used to increase successful peripheral intravenous catheter insertion rates. Improving rates of USGIV use will subsequently decrease central venous catheter use and thus decrease the time to treatment initiation, reduce costs, and improve patient satisfaction. PURPOSE: Current available programs teach nurses USGIV use for the adult population, mainly with a focus on the emergency department. To address this gap in knowledge, a USGIV program aimed at the specific needs of the neonatal intensive care unit (NICU) nurse was developed and implemented. METHOD: Twelve NICU nurses were trained in USGIV access during a 4-hour combination didactic and simulation-based program. Participants took a pretest survey assessing baseline knowledge and confidence levels related to USGIV access. After didactic lecture, participants worked at stations focused on USGIV access. An 80% benchmark for each participant was set for successful USGIV attempts during simulation. Participants' knowledge and confidence levels were reassessed at the end of the program. RESULTS: Posttest scores increased by an average of 25%, demonstrating increased knowledge. The pre- to posttest confidence scores increased by a minimum of 1.6 points (based on a 5-point Likert scale). All participants (n = 12) successfully demonstrated proficiency by achieving at least 80% of attempted USGIV access on a mannequin. IMPLICATIONS FOR PRACTICE AND RESEARCH: This project demonstrated that USGIV catheter can be employed in neonatal patients by training NICU nurses in USGIV techniques.

Lifestyle Medicine Interventions for Personal and Planetary Health: The Urgent Need for Action.

The deterioration of planetary health-from threats such as climate change, environmental pollution, biodiversity loss, and ocean acidification-are a growing hazard to the foundation of health and the "healthspan." For those with chronic conditions-a large and growing subset of the global population-the health dangers are even greater. Climate change is a threat to the very pillars of lifestyle medicine that we rely on to prevent and manage chronic disease. Already, the planetary crisis is limiting our ability to prescribe healthy nutrition, safe outdoor physical activity, stress management strategies, social connection, restorative sleep, and toxic substance avoidance. In this article, we discuss the proceedings of our workshop at the American College of Lifestyle Medicine (ACLM) annual conference LM2021, "Lifestyle Medicine for Personal and Planetary Health." We examine how lifestyle medicine (LM) interventions are a prescription for individual, community, and planetary health. Our prescriptions work to not only restore the health of individuals and families, but also to bolster health equity while allowing us to mitigate and adapt to the health impacts of the planetary crises.

Incidence of thrombotic complications related to weight-based dosing of activated prothrombin complex concentrate (aPCC) for reversal of apixaban and rivaroxaban in obese patients.

Factor eight inhibitor bypassing activity (aPCC) is recommended as a non-specific reversal agent for direct oral anticoagulants (DOACs) according to the 2017 American College of Cardiology (ACC) guidelines for reversal of anticoagulation. Factor eight inhibitor bypassing activity carries a black box warning for thrombotic events such as stroke, pulmonary embolism, deep vein thrombosis, and myocardial infarction, particularly at high doses. This was a retrospective, single-center, cohort investigation that included patients who received a weight-based dose of aPCC for reversal of apixaban and rivaroxaban between January 1, 2015, and December 31, 2020. Patients were grouped by BMI as obese (BMI ≥ 30 kg/m2) or non-obese (BMI < 30 kg/m2) for analysis. The primary outcome of this investigation was the occurrence of thrombotic complications [venous thromboembolism (VTE), myocardial infarction, stroke] documented in the medical record at any point during hospitalization after administration of aPCC. Secondary outcomes included bleeding complications, in-hospital mortality, ICU and hospital length of stay. Patients in the obese group were younger [76.4 years (SD +/- 11.3 years) vs. 69.6 years (SD +/- 12.4 years); p < 0.0001] and a higher proportion had a diagnosis of diabetes mellitus prior to admission [37 (19.2%) vs. 35 (36.8%); p = 0.0011]. There was no difference in the primary outcome of thrombotic events between non-obese and obese patients [12 (6.2%) vs. 5 (5.3%); p = 0.75], or for any of the secondary outcomes of bleeding, in-hospital mortality or length of stay. This investigation did not reveal a difference in rates of thrombosis or bleeding events between obese and non-obese patients who received aPCC for reversal of apixaban and rivaroxaban.

Minor Cannabinoids: Biosynthesis, Molecular Pharmacology and Potential Therapeutic Uses.

The medicinal use of Cannabis sativa L. can be traced back thousands of years to ancient China and Egypt. While marijuana has recently shown promise in managing chronic pain and nausea, scientific investigation of cannabis has been restricted due its classification as a schedule 1 controlled substance. A major breakthrough in understanding the pharmacology of cannabis came with the isolation and characterization of the phytocannabinoids trans-Δ9-tetrahydrocannabinol (Δ9-THC) and cannabidiol (CBD). This was followed by the cloning of the cannabinoid CB1 and CB2 receptors in the 1990s and the subsequent discovery of the endocannabinoid system. In addition to the major phytocannabinoids, Δ9-THC and CBD, cannabis produces over 120 other cannabinoids that are referred to as minor and/or rare cannabinoids. These cannabinoids are produced in smaller amounts in the plant and are derived along with Δ9-THC and CBD from the parent cannabinoid cannabigerolic acid (CBGA). While our current knowledge of minor cannabinoid pharmacology is incomplete, studies demonstrate that they act as agonists and antagonists at multiple targets including CB1 and CB2 receptors, transient receptor potential (TRP) channels, peroxisome proliferator-activated receptors (PPARs), serotonin 5-HT1a receptors and others. The resulting activation of multiple cell signaling pathways, combined with their putative synergistic activity, provides a mechanistic basis for their therapeutic actions. Initial clinical reports suggest that these cannabinoids may have potential benefits in the treatment of neuropathic pain, neurodegenerative diseases, epilepsy, cancer and skin disorders. This review focuses on the molecular pharmacology of the minor cannabinoids and highlights some important therapeutic uses of the compounds.

Planetary Health, Climate Change, and Lifestyle Medicine: Threats and Opportunities.

Global environmental degradation and climate change threaten the foundation of human health and well-being. In a confluence of crises, the accelerating pace of climate change and other environmental disruptions pose an additional, preventable danger to a global population that is both aging and carrying a growing burden of noncommunicable diseases (NCDs). Climate change and environmental disruption function as "threat multipliers," especially for those with NCDs, worsening the potential health impacts on those with suboptimal health. At the same time, these environmental factors threaten the basic pillars of health and prevention, increasing the risk of developing chronic disease. In the face of these threats, the core competencies of lifestyle medicine (LM) present crucial opportunities to mitigate climate change and human health impacts while also allowing individuals and communities to build resilience. LM health professionals are uniquely positioned to coach patients toward climate-healthy behavior changes that heal both people and the planet.

Administering DVT Prophylaxis Sooner Than 48 Hours Does Not Increase Failure of Nonoperative Management of High-Grade (Grades III-V) Splenic Injuries.

Splenic injuries are mostly treated with nonoperative management (NOM) with observation to monitor for continued hemorrhage and holding early chemical DVT prophylaxis to reduce the risk of NOM failure. Eberle et al demonstrated chemoprophylaxis prior to 72 hours didn't increase failure rate of NOM. We chose to extrapolate this finding and compare outcomes in high-grade splenic injuries (HGSI) with chemoprophylaxis before and after 48 hours. From January 2013 to December 2017, 104 patients with HGSI received chemoprophylaxis with unfractionated heparin (UH) or low molecular weight heparin (LMWH) within 72 hours of diagnosis. Of these, 8 patients received chemoprophylaxis within 24 hours, 46 between 24 and 48 hours, and 50 patients between 48 and 72 hours. This population consisted of 70 males and 34 females, with an average age of 40.1 years. The average ISS was 23 and the majority (77%) were grade 3 injuries. We observed 6 failures of NOM: 1 in the <24 hour group, 3 in the 24-48 hour group, and 2 in the 48-72 hour group. There was no statistically significant difference between the <24 hour and >24 groups or between the <48 hour and 48-72 hour groups. A linear regression analysis created a model describing the time to initiation of DVT prophylaxis using age, sex, splenic injury grade, and ISS; the failure rate decreased by 0.00002% for each hour prior to giving DVT prophylaxis, with a P value of .111. We conclude a noninferiority statement that DVT prophylaxis prior to 48 hours does not increase the risk of NOM failure.

Impact of Obesity on Warfarin Reversal With Fixed-Dose Factor VIII Inhibitor Bypassing Activity (aPCC).

BACKGROUND: Data are limited addressing anticoagulant reversal in obese patients using activated prothrombin complex concentrate (aPCC). OBJECTIVE: Assess the impact of obesity on INR reversal with fixed aPCC dosing. METHODS: Institutional review board-approved, retrospective cohort conducted in a large academic medical center. Patients 18 years or older who received fixed-dose aPCC for warfarin-associated hemorrhage were included. Patients who received aPCC for any other indications or who had no follow-up INR after aPCC administration were excluded. Patients with an INR of 5 or greater received 1000 units aPCC, whereas those with INR less than 5 received 500 units aPCC, per institutional protocol. Patients were stratified into obese and nonobese based on body mass index. Primary end point was INR reversal, defined as repeat INR of 1.4 or less within 4 hours following aPCC treatment, without a repeated dose. Secondary end points included percentage change in INR, proportion of patients requiring an additional dose of aPCC, bleeding complications, thrombotic complications, hospital length of stay, and in-hospital mortality. RESULTS: 259 patients were included, of whom 83 were obese (32%). A significantly higher proportion of nonobese patients achieved an INR of 1.4 or less within 4 hours of treatment (169 [96.02%] vs 69 [83.13%]; P = 0.0004). There were no differences in any secondary end points. CONCLUSION AND RELEVANCE: When fixed-dose aPCC is used for warfarin reversal, obesity is associated with a significantly lower rate of INR reversal, without increased bleeding. This study adds to the limited amount of literature on aPCC dosing in obesity.

Shifting the Paradigm.

Current medical education lacks significant training in the principles and practices of lifestyle medicine. In this column, I describe my journey to lifestyle medicine, lifestyle medicine education, and what it is going to take to shift the educational paradigm away from the current model to one that is focused on nutrition and lifestyle behaviors and that is both accessible and effective.

Organocatalyzed Intramolecular Carbonyl-Ene Reactions.

An organocatalyzed intramolecular carbonyl-ene reaction was developed to produce carbocyclic and heterocyclic 5- and 6-membered rings from a citronellal-derived trifluoroketone and a variety of aldehydes. A phosphoramide derivative was found to promote the cyclization of the trifluoroketone, whereas a less acidic phosphoric acid proved to be a superior catalyst for the aldehyde substrates.

Effects of the incontinence dish pessary on urethral support and urodynamic parameters.

OBJECTIVE: To evaluate the effects of the incontinence dish pessary (IDP) on urethral mobility and urodynamics. STUDY DESIGN: Prospective study of women with symptoms of stress incontinence. Q-tip test was performed recording the resting and straining angles with and without an IDP. Changes in resting and straining angles were calculated. Those with evidence of urodynamic stress incontinence had urodynamics with the IDP. Paired t-test was used to compare the difference in Q-tip angles with and without the pessary. RESULTS: Mean Q-tip straining angle without and with the pessary, respectively, was 57.8 (+19.5) and 34.4 (+29.7). Mean change was 23.5 (+18.5) P < .00001. Maximum urethral closure pressure (MUCP) was significantly increased by 19.7 cm H(2)0 P < .001. Overall, 60% of the subjects did not leak with the IDP. CONCLUSION: The IDP eliminates >60% of USI. The mechanism of action may be a combination of improved UVJ support and increased MUCP.

Sheared epidural catheter during an elective procedure.

BACKGROUND: Epidural catheter fracture and retention is uncommon. Imaging techniques identifying catheter location are limited, and clear management guidelines are lacking. Radiculopathy and lumbar stenosis are recognized complications. CASE: During epidural placement in an elderly woman undergoing gynecologic surgery, a portion of the catheter was shorn off in the epidural space. Imaging, including plain X-ray and computed tomography scan had limited ability to identify the catheter. The initial neurosurgical consultation recommended leaving the catheter in place. However, the patient became symptomatic with radicular pain; 16.5 cm of the catheter were subsequently surgically removed. CONCLUSION: Retained epidural catheter fragments can be associated with long-term sequelae. Immediate removal is facilitated by a blood-clot tract and may present the best time for removal. Current imaging techniques have limited use in these situations.