An experience of using Clozapine in elderly patients with mental disorders.

BACKGROUND: There is little information on using clozapine in elderly patients with mental disorders from India. AIM: To evaluate the sociodemographic and clinical profile of elderly (age ≥ 60 years) patients started on clozapine. METHODOLOGY: The clozapine registry in the department was screened to identify elderly patients who were started on clozapine. Treatment records of these patients were reviewed to extract sociodemographic and clinical details. RESULTS: Out of the available information of 1058 patients in the registry, 42 (3.96 %) were elderly (≥ 60 years) patients. About two-thirds of the patients had treatment resistance, i.e., their psychotic illness had not responded to two adequate trials of antipsychotics, and the second most common indication for starting clozapine was tardive dystonia or tardive dyskinesia (23.8 %). The mean dose of clozapine was 135.89 (SD: 109.6; Range: 37.5-500; median: 87.5) mg/day. The mean duration of clozapine use at the time of data extraction for the study sample was 3.55 (SD: 2.15; Range 0.3-9; median: 3) years. At the last follow-up, about three-fourths of patients were experiencing at least one side effect, with constipation being the most common side effect, followed by sedation, weight gain, and hypersalivation. In only four patients, clozapine was stopped during the follow-up. In terms of effectiveness, majority of the patients were rated as much improved or very much improved on Clinical Global Impression-Improvement subscale. CONCLUSION: Clozapine can be safely used in elderly patients with mental disorders. Hence, clozapine should not be withheld in elderly patients with mental disorders whenever indicated.

Electrochemical-based approaches for the treatment of forever chemicals: Removal of perfluoroalkyl and polyfluoroalkyl substances (PFAS) from wastewater.

Electrochemical based approaches for the treatment of recalcitrant water borne pollutants are known to exhibit superior function in terms of efficiency and rate of treatment. Considering the stability of Perfluoroalkyl and polyfluoroalkyl substances (PFAS) are designated as forever chemicals, which generating from various industrial activities. PFAS are contaminating the environment in small concentrations, yet exhibit severe environmental and health impacts. Electro-oxidation (EO) is a recent development that treats PFAS, in which different reactive species generates at anode due to oxidative reaction and reductive reactions at the cathode. Compared to water and wastewater treatment methods those being implemented, electrochemical approaches demonstrate superior function against PFAS. EO completely mineralizes (almost 100 %) non-biodegradable organic matter and eliminate some of the inorganic species, which proven as a robust and versatile technology. Electrode materials, electrolyte concentration pH and the current density applying for electrochemical processes determine the treatment efficiency. EO along with electrocoagulation (EC) treats PFAS along with other pollutants from variety of industries showed highest degradation of 7.69 mmol/g of PFAS. Integrated approach with other processes was found to exhibit improved efficiency in treating PFAS using several electrodes boron-doped diamond (BDD), zinc, titanium and lead based with efficiency the range of 64 to 97 %.

Improving Efficiency in Dental School Clinics by Computerizing a Manual Task.

Background: We computerized a formerly manual task of requesting dental faculty to conduct quality checks on student providers during patient encounters. We surveyed student providers who experienced the manual and computerized versions of the faculty request process for one year each. Methods: All surveys were emailed to student providers and there were no reminders or incentives to complete the survey. Simple descriptive data were used to present the results of the study and Institutional Review Board (IRB) approval was provided by the University of Michigan Medical School Committee on Human Research (HUM00131029) on 1 June 2018 Results: The response rate for the survey was 47.1%. A total of 16.1% of student providers reported that the Faculty Request System (FRS) helped them save 1-10 min per clinic session, 22.3% said it saved them 11-20 min, 29.5% said it saved them 21-30 min, 21.4% said it saved 31-40 min, 2.67% said it saved 41-50 min, and 7.14% said it saved more than 50 min per clinic session. Regarding how student providers used the additional time they gained from the FRS, 96.4% said they used some of the time to write up their notes, 88.4% said they used some of the time to discuss treatments with their patients, 83.9% said they engaged in general conversation with their patients, 81.3% said they took care of other patient-related duties, while 1.8% said they had less time available after the implementation of the FRS. Conclusions: The FRS enabled student providers to remain with their patients for almost a full 30 min more (during a 3 h session). This paper describes several benefits experienced by student providers, and the resulting impacts on patient experiences.

Characteristics of Patients Discontinuing Care.

Objectives: Due to lower fees, dental school clinics (DSCs) may provide dental care for vulnerable populations. This study evaluates factors associated with patients deciding to discontinue care at a DSC. Methods: This is a retrospective analysis of a patient transfer form that was implemented to smooth transition of a patient when their student provider graduated. Forms provided deidentified information about characteristics and unmet dental needs. Descriptive and bivariate statistics were used to identify associations between patient characteristics and deciding to continue treatment in the student practice. Results: Of 1894 patients, 73.4% continued care. Financial limitations were most commonly reported as the reason for discontinuing care (30.1%). Patients speaking a language other than English or who had reported financial barriers were significantly less likely to continue care. Conclusions: Dental school patients from vulnerable groups are more likely to discontinue care. Dental schools should implement programs that will assist patients in maintaining a dental home.

Endocannabinoid-mediated modulation of Gq protein-coupled receptor mediates vascular hyporeactivity to nor-adrenaline during polymicrobial sepsis.

BACKGROUND: Endocannabinoids level are reported to increase in sepsis, however, the role of vascular cannabinoid receptor-1 (CB1R) in sepsis-induced vascular hyporeactivity is yet to be unravelled. METHODS: Polymicrobial sepsis was induced by caecal ligation and puncture in mice. Isometric tension in isolated aortic rings during early (6 h) and late (20 h) phases of sepsis was recorded and expression of mRNA of monoacylglycerol lipase (MAGL) and cannabinoid receptor-1 (CB1R) was investigated. RESULTS: Sepsis significantly (p < 0.001) reduced the mean survival time in mice along with increase in bacterial load in blood and peritoneal lavage. Compared to Sham-operated (SO) mice, vascular reactivity to nor-adrenaline (NA) was significantly (p < 0.05) attenuated in both early and late phases of sepsis. NA-induced vasoconstriction was significantly (p < 0.05) potentiated by inhibition of diacylglycerol lipase (DAGL) and attenuated by inhibition of MAGL in SO mice. Pre-incubation with KT 109, a DAGL inhibitor, significantly (p < 0.05) improved the vascular hypo-reactivity to NA during both the phases of sepsis. mRNA expression of MAGL in aorta was significantly (p < 0.05) attenuated during both the phases of sepsis. But in the presence of AM 251, specific antagonist of CB1R, vascular reactivity to NA was significantly (p < 0.05) restored along with significant (p < 0.05) increase in mRNA expression of CB1R in aortic rings from both early and late phases of septic mice. CONCLUSION: 2-AG regulates vascular response to NA and increased aortic expression of CB1R is responsible for vascular hyporeactivity to NA in sepsis, and in vitro inhibition of this receptor by AM 251 restored the vascular reactivity.

Imaging of the thoracic and lumbar spine in a high volume level 1 trauma center: are reformatted images of the spine essential for screening in blunt trauma?

Reformatted CTs of the thoracic and lumbar spine (CT T/L) from CTs of the chest, abdomen, and pelvis (CT body) may be performed for screening the thoracolumbar spine in patients sustaining blunt trauma. The purpose of this study was to determine whether there was a difference in the rate of detection of spinal fractures on CTs of the body compared to the reformatted T/L spine. A secondary endpoint was to evaluate whether cases dictated by trainees improved fracture detection rate. We reviewed the records of 250 consecutive blunt trauma patients that received CTs of the chest, abdomen, and pelvis (CT body) with concurrent CT T/L reformats. Each report was reviewed to determine if there was a thoracolumbar fracture and whether a trainee had been involved in interpreting the CT body. If a fracture was identified on either report, then the number, type, and location of each fracture was documented. Sixty-nine fractures, from a total of 38 patients, were identified on either the CT of the body or the CT T/L. Sensitivity for CT body interpretations was 94 % (95 % CI: 86-98 %) compared to a 97 % (95 % CI: 89-100 %) sensitivity for the CT T/L (p > 0.5). Although the sensitivity was 97 % (95 % CI: 88-100 %) when a trainee was involved in interpreting the body CT, there was no statistically significant improvement. The results suggest that with careful scrutiny most spine fractures can be diagnosed on body CT images without the addition of spine reformats. The most commonly missed finding is an isolated non-displaced transverse process fracture, which does not require surgical intervention and does not alter clinical management. The results suggest that thin section reformats do not need to be routinely ordered in screening blunt trauma patients, unless a bony abnormality is identified on the thicker section body CT images.

Emergency radiology fellowship training in the USA: a web-based survey of academic programs.

Interest in emergency radiology as a distinct subspecialty within radiology continues to rise in the USA and globally. While acute care imaging has been performed since the earliest days of the specialty, fellowship training in emergency radiology is a relatively new phenomenon. The purpose of this study was to examine the current status of emergency radiology training in the USA, using data derived from the official websites of US residency training programs. The most current list of radiology residency programs participating in the 2017 match was obtained from the official Electronic Residency Application Service (ERAS) website. The total number of emergency radiology fellowships was recorded after visiting available websites of each academic radiology program. The total number of subspecialty fellowships offered by each academic radiology program was also recorded. There were 12 confirmed emergency radiology fellowships offered in the USA for a combined total of 22 fellowship positions. Eleven programs were 1 year in duration, with one program offering a one- or two-year option. One hundred eight of the 174 (approximately 62 %) surveyed academic radiology programs offered at least one subspecialty fellowship. Emergency radiology fellowships are on the rise, paralleling the growth of emergency radiology as a distinct subspecialty within radiology.

Imaging of the shoulder with arthroscopic correlation.

Shoulder pain with or without trauma is a common complaint. MRI is often the most useful imaging study for evaluating the shoulder. This review provides an overview of various modalities and their role in evaluating various clinical issues in shoulder pathologies. Imaging and arthroscopic correlation of common conditions are provided.

Thoracic myelopathy due to an intramedullary herniated nucleus pulposus: first case report and review of the literature.

BACKGROUND AND IMPORTANCE: Herniation of intervertebral discs is relatively common. Migration usually occurs in the ventral epidural space; very rarely discs migrate in the subdural space. No cases of intradural intramedullary disc have been reported in humans. CLINICAL PRESENTATION: A case of a herniated intervertebral disc directly into the spinal cord parenchyma is presented. The patient presented with 2 weeks of progressive bilateral lower extremity numbness and weakness, saddle hypoesthesia, urinary dysfunction and gait disturbance. Spine magnetic resonance imaging (MRI) with gadolinium revealed a solitary well-defined intramedullary lesion (T7-T8 level) with ring enhancement and focal cord expansion with significant surrounding edema. Metastatic workup and neural axis imaging was negative. A thoracic laminectomy and myelotomy was performed; the lesion was pearlescent and well circumscribed. It was densely adherent to the ventral pia and gross totally removed. Pathology was consistent with nucleus pulposus. CONCLUSION: Intradural intramedullary migration of a herniated intervertebral disc is extremely rare but should be considered in the differential. It may present in a variety of clinical scenarios, including thoracic myelopathy, and mimic intramedullary spinal cord tumor.

Quantomo: validation of a computer-assisted methodology for the volumetric analysis of intracerebral haemorrhage.

BACKGROUND: Volume measurements of intracerebral haemorrhage are prognostically important and are increasingly used in clinical trials to measure the effects of potential interventions. The purpose of this work is to establish the reliability of haematoma volume measurements obtained using a computer-assisted method called Quantomo (for quantitative tomography) and the ABC/2 method. Hypothesis Quantomo reliably detects smaller changes in intracerebral haemorrhage volume as compared with the ABC/2 method because computer-assisted volume measurements are tailored to measure the geometry of individual haematoma volumes whereas the ABC/2 method approximates all haematoma volumes as ellipsoids. METHODS: Thirty randomly selected computed tomography scans with intracerebral haemorrhage were measured by four raters a total of four times each (two sessions using Quantomo and two using the ABC/2 method). Interrater and intrarater reliability for both techniques were calculated simultaneously using a two-way random-effects analysis of variance model. The precision of intracerebral haemorrhage volume measurement was quantified as the minimum detectable difference with 95% confidence intervals. RESULTS: The median (first quartile and third quartile) intracerebral haemorrhage volume measurements of all rater and sessions for Quantomo were 32.7 ml (6.2 and 54.4 ml) and for ABC/2 40.7 ml (8.6 and 76.0 ml). Quantomo intracerebral haemorrhage volume measurements were more precise, having an inter- and intrarater minimum detectable difference of 8.1 and 5.3 ml, while the inter- and intrarater minimum detectable difference for ABC/2 were 37.0 and 15.7 ml. CONCLUSIONS: Quantomo is a computer-assisted methodology that is more reliable for quantifying intracerebral haemorrhage volume as compared with the ABC/2 method.

A smartphone client-server teleradiology system for primary diagnosis of acute stroke.

BACKGROUND: Recent advances in the treatment of acute ischemic stroke have made rapid acquisition, visualization, and interpretation of images a key factor for positive patient outcomes. We have developed a new teleradiology system based on a client-server architecture that enables rapid access to interactive advanced 2-D and 3-D visualization on a current generation smartphone device (Apple iPhone or iPod Touch, or an Android phone) without requiring patient image data to be stored on the device. Instead, a server loads and renders the patient images, then transmits a rendered frame to the remote device. OBJECTIVE: Our objective was to determine if a new smartphone client-server teleradiology system is capable of providing accuracies and interpretation times sufficient for diagnosis of acute stroke. METHODS: This was a retrospective study. We obtained 120 recent consecutive noncontrast computed tomography (NCCT) brain scans and 70 computed tomography angiogram (CTA) head scans from the Calgary Stroke Program database. Scans were read by two neuroradiologists, one on a medical diagnostic workstation and an iPod or iPhone (hereafter referred to as an iOS device) and the other only on an iOS device. NCCT brain scans were evaluated for early signs of infarction, which includes early parenchymal ischemic changes and dense vessel sign, and to exclude acute intraparenchymal hemorrhage and stroke mimics. CTA brain scans were evaluated for any intracranial vessel occlusion. The interpretations made on an iOS device were compared with those made at a workstation. The total interpretation times were recorded for both platforms. Interrater agreement was assessed. True positives, true negatives, false positives, and false negatives were obtained, and sensitivity, specificity, and accuracy of detecting the abnormalities on the iOS device were computed. RESULTS: The sensitivity, specificity, and accuracy of detecting intraparenchymal hemorrhage were 100% using the iOS device with a perfect interrater agreement (kappa=1). The sensitivity, specificity, and accuracy of detecting acute parenchymal ischemic change were 94.1%, 100%, and 98.09% respectively for reader 1 and 97.05%, 100%, and 99.04% for reader 2 with nearly perfect interrater agreement (kappa=.8). The sensitivity, specificity, and accuracy of detecting dense vessel sign were 100%, 95.4%, and 96.19% respectively for reader 1 and 72.2%, 100%, and 95.23% for reader 2 using the iOS device with a good interrater agreement (kappa=.69). The sensitivity, specificity, and accuracy of detecting vessel occlusion on CT angiography scans were 94.4%, 100%, and 98.46% respectively for both readers using the iOS device, with perfect interrater agreement (kappa=1). No significant difference (P<.05) was noted in the interpretation time between the workstation and iOS device. CONCLUSION: The smartphone client-server teleradiology system appears promising and may have the potential to allow urgent management decisions in acute stroke. However, this study was retrospective, involved relatively few patient studies, and only two readers. Generalizing conclusions about its clinical utility, especially in other diagnostic use cases, should not be made until additional studies are performed.

iPhone-based teleradiology for the diagnosis of acute cervico-dorsal spine trauma.

OBJECTIVE: To assess the feasibility of iPhone-based teleradiology as a potential solution for the diagnosis of acute cervico-dorsal spine trauma. MATERIALS AND METHODS: We have developed a solution that allows visualization of images on the iPhone. Our system allows rapid, remote, secure, visualization of medical images without storing patient data on the iPhone. This retrospective study is comprised of cervico-dorsal computed tomogram (CT) scan examination of 75 consecutive patients having clinically suspected cervico-dorsal spine fracture. Two radiologists reviewed CT scan images on the iPhone. Computed tomogram spine scans were analyzed for vertebral body fracture and posterior elements fractures, any associated subluxation-dislocation and cord lesion. The total time taken from the launch of viewing application on the iPhone until interpretation was recorded. The results were compared with that of a diagnostic workstation monitor. Inter-rater agreement was assessed. RESULTS: The sensitivity and accuracy of detecting vertebral body fractures was 80% and 97% by both readers using the iPhone system with a perfect inter-rater agreement (kappa:1). The sensitivity and accuracy of detecting posterior elements fracture was 75% and 98% for Reader 1 and 50% and 97% for Reader 2 using the iPhone. There was good inter-rater agreement (kappa: 0.66) between both readers. No statistically significant difference was noted between time on the workstation and the iPhone system. CONCLUSION: iPhone-based teleradiology system is accurate in the diagnosis of acute cervicodorsal spinal trauma. It allows rapid, remote, secure, visualization of medical images without storing patient data on the iPhone.

Extravasating contrast material on angiography following carotid angioplasty and stenting: not necessarily subarachnoid hemorrhage.

We describe a case of asymptomatic extravasation of iodinated contrast material into the sulci on digital subtraction angiography following carotid angioplasty and stenting resulting in sulcal hyperdensity on computed tomography (CT). We believe the mechanism for this observation is hyperperfusion injury and that in the absence of any associated clinical signs, it should not be considered alarming for subarachnoid hemorrhage.

Toxic and acquired metabolic encephalopathies: MRI appearance.

OBJECTIVE: The differential diagnosis of patients presenting with acute encephalopathy is broad. Imaging can help in narrowing the differential in many cases. We pictorially review the more classic MRI features of several acute toxic and acquired metabolic encephalopathies. CONCLUSION: After completing this article, the reader will have knowledge of the more common imaging appearances of toxic and acquired metabolic encephalopathies, which will help in correctly identifying the cause of encephalopathy in some patients.

Multifocal complex glioneuronal tumor in an elderly man: an autopsy study: case report.

OBJECTIVE: The clinicopathological spectra of a dysembryoplastic neuroepithelial tumor (DNT) and a rosette-forming glioneuronal tumor (RGNT) are expanding. We report here the autopsy findings of a case of complex glioneuronal tumor with combined histological features of both a DNT and an RGNT. CLINICAL PRESENTATION: A 79-year-old man presented with a 1-month history of confusion and gait difficulties. A magnetic resonance imaging scan revealed obstructive hydrocephalus attributed to a mass in the posterior third ventricle. INTERVENTION: A third ventriculostomy was performed. Postoperatively, the mass remained unchanged in size for more than 14 months. Thirty-eight months after his initial manifestations, he experienced minor head trauma and was then hospitalized. Despite placement of an external ventricular drain and other supportive treatment, he deteriorated and died. A full autopsy was performed, with emphasis on the brain. The mass lesion and a few independent microfoci situated primarily around the third ventricle showed histological features of pilocytic astrocytoma with recurrent hemorrhage. Far more numerous were microfoci with histological features of a DNT, including floating neurons, as well as typical RGNT-associated, synaptophysin-positive rosettes and perivascular pseudorosettes. CONCLUSION: The advanced age of the patient, the coexisting histological features of the DNT and RGNT, and the distinctive anatomic distribution of the lesions, being centered on the third ventricle, may lend insight into the histogenetic relationship of a DNT, an RGNT, and mixed glioneuronal tumors.