Characterization of intentional lurasidone ingestions using the United States National Poison Data System.

Introduction: The ziprasidone analogue lurasidone is approved for the treatment of schizophrenia and bipolar disorder for adults and children older than 10 years. Small studies and case reports suggest lurasidone overdose is not generally associated with major adverse effects, but no large sample has been published.Objective: To describe intentional lurasidone overdoses reported to poison centers.Methods: Retrospective analysis of single-substance intentional lurasidone ingestions from the National Poison Data System (NPDS) from 2011 to 2018.Results: There were 1753 single-substance intentional overdoses. Average age was 28.6 years (SD = 13.3 years) and 1199 (68.4%) of patients were female. Most cases (86.6%) were coded as suspected suicide. Regarding final management site, 1143 (65.2%) were discharged or admitted to psychiatric facilities; 328 (18.8%) were admitted, half of whom were admitted to critical care units (CCUs). Major effect was coded in 12 (0.7%), moderate effect in 259 (14.8%), minor effect in 531 (30%), and no effect in 614 (35%). There were no deaths. For cases for which dose information was available, there was not a statistically significant difference between median doses when analyzed by clinical effect. Most common adverse effects were drowsiness (449, 25.6%), tachycardia (254, 14.5%), vomiting (121, 6.9%), and hypertension (115, 6.6%). Most cases had either no therapy reported, or therapy was recommended by the poison center but confirmed not to have been administered (1010, 57.6%). Of the 164 patients admitted to CCUs, 80 (48.8%) received either no therapy or intravenous fluids alone.Discussion: These data suggest major effects are uncommon from lurasidone overdose. Despite a high rate of admission to CCUs, a substantial proportion received no critical therapies.Conclusions: This report demonstrates intentional lurasidone overdoses reported to poison centers generally have a favorable clinical course.

One-year outcomes after successful chronic total occlusion percutaneous coronary intervention: The impact of dissection re-entry techniques.

We aimed to determine clinical outcomes 1 year after successful chronic total occlusion (CTO) PCI and, in particular, whether use of dissection and re-entry strategies affects clinical outcomes. Hybrid approaches have increased the procedural success of CTO percutaneous coronary intervention (PCI) but longer-term outcomes are unknown, particularly in relation to dissection and re-entry techniques. Data were collected for consecutive CTO PCIs performed by hybrid-trained operators from 7 United Kingdom (UK) centres between 2012 and 2014. The primary endpoint (death, myocardial infarction, unplanned target vessel revascularization) was measured at 12 months along with angina status. One-year follow up data were available for 96% of successful cases (n = 805). In total, 85% of patients had a CCS angina class of 2-4 prior to CTO PCI. Final successful procedural strategy was antegrade wire escalation 48%; antegrade dissection and re-entry (ADR) 21%; retrograde wire escalation 5%; retrograde dissection and re-entry (RDR) 26%. Overall, 47% of CTOs were recanalized using dissection and re-entry strategies. During a mean follow up of 11.5 ± 3.8 months, the primary endpoint occurred in 8.6% (n = 69) of patients (10.3% (n = 39/375) in DART group and 7.0% (n = 30/430) in wire-based cases). The majority of patients (88%) had no or minimal angina (CCS class 0 or 1). ADR and RDR were used more frequently in more complex cases with greater disease burden, however, the only independent predictor of the primary endpoint was lesion length. CTO PCI in complex lesions using the hybrid approach is safe, effective and has a low one-year adverse event rate. The method used to recanalize arteries was not associated with adverse outcomes. © 2017 Wiley Periodicals, Inc.

Taxonomic revision of the South American catfish genus Ageneiosus (Siluriformes: Auchenipteridae) with the description of four new species.

The catfish genus Ageneiosus in the exclusively Neotropical family Auchenipteridae is revised. Species of Ageneiosus are widely distributed in all major South American continental drainages except the São Francisco River basin and small rivers along the Brazilian east coast. The taxonomic revision was based on examination of available type specimens, additional museum material and comparisons of original descriptions. A suite of morphometric, meristic and qualitative characters of internal and external anatomy were used to diagnose valid species and determine synonyms. Thirteen valid species are recognized in the genus Ageneiosus, some of which are widely distributed across South America. Ageneiosus pardalis is the only trans-Andean species in the genus. Ageneiosus polystictus and Ageneiosus uranophthalmus are more widely distributed than previously reported. Ageneiosus marmoratus is a junior synonym of Ageneiosus inermis. Ageneiosus dentatus is a valid species and its name is removed from the synonymy of Ageneiosus ucayalensis. Four new species are described: Ageneiosus akamai, Ageneiosus apiaka, Ageneiosus intrusus and Ageneiosus lineatus, all from the Amazon River basin. A dichotomous key for all 13 valid species of Ageneiosus species is provided.

Intracardiac impedance response during acute AF internal cardioversion using novel rectilinear and capacitor-discharge waveforms.

Intracardiac impedance (ICI) is a major determinant of success during internal cardioversion of atrial fibrillation (AF). However, there have been few studies that have examined the dynamic behaviour of atrial impedance during internal cardioversion in relation to clinical outcome. In this study, voltage and current waveforms captured during internal cardioversion of acute AF in ovine models using novel radiofrequency (RF) generated low-tilt rectilinear and conventional capacitor-discharge based shock waveforms were retrospectively analysed using a digital signal processing algorithm to investigate the dynamic behaviour of atrial impedance during cardioversion. The algorithm was specifically designed to facilitate the simultaneous analysis of multiple impedance parameters, including: mean intracardiac impedance (Z M), intracardiac impedance variance (ICIV) and impedance amplitude spectrum area (IAMSA) for each cardioversion event. A significant reduction in ICI was observed when comparing two successive shocks of increasing energy where cardioversion outcome was successful. In addition, ICIV and IAMSA variables were found to inversely correlate to the magnitude of energy delivered; with a stronger correlation found to the former parameter. In conclusion, ICIV and IAMSA have been evidenced as two key dynamic intracardiac impedance variables that may prove useful in better understanding of the cardioversion process and that could potentially act as prognostic markers with respect to clinical outcome.

Hybrid approach improves success of chronic total occlusion angioplasty.

OBJECTIVES: Treatment options for coronary chronic total occlusions (CTO) are limited, with low historical success rates from percutaneous coronary intervention (PCI). We report procedural outcomes of CTO PCI from 7 centres with dedicated CTO operators trained in hybrid approaches comprising antegrade/retrograde wire escalation (AWE/RWE) and dissection re-entry (ADR/RDR) techniques. METHODS: Clinical and procedural data were collected from consecutive unselected patients with CTO between 2012 and 2014. Lesion complexity was graded by the Multicentre CTO Registry of Japan (J-CTO) score, with ≥2 defined as complex. Success was defined as thrombolysis in myocardial infarction 3 flow with <30% residual stenosis, subclassified as at first attempt or overall. Inhospital complications and 30-day major adverse cardiovascular events (MACEs, death/myocardial infarction/unplanned target vessel revascularisation) were recorded. RESULTS: 1156 patients were included. Despite high complexity (mean J-CTO score 2.5±1.3), success rates were 79% (first attempt) and 90% (overall) with 30-day MACE of 1.6%. AWE was highly effective in less complex lesions (J-CTO ≤1 94% success vs 79% in J-CTO score ≥2). ADR/RDR was used more commonly in complex lesions (J-CTO≤1 15% vs J-CTO ≥2 56%). Need for multiple approaches during each attempt increased with lesion complexity (17% J-CTO ≤1 vs 48% J-CTO ≥2). Lesion modification ('investment procedures') at the end of unsuccessful first attempts increased the chance of subsequent success (96% vs 71%). CONCLUSIONS: Hybrid-trained operators can achieve overall success rates of 90% in real world practice with acceptable MACE. Use of dissection re-entry and investment procedures maintains high success rates in complex lesions. The hybrid approach represents a significant advance in CTO treatment.

Impact of proctoring on success rates for percutaneous revascularisation of coronary chronic total occlusions.

OBJECTIVE: To assess the impact of proctoring for chronic total occlusion (CTO) percutaneous coronary intervention (PCI) in six UK centres. METHODS: We retrospectively analysed 587 CTO procedures from six UK centres and compared success rates of operators who had received proctorship with success rates of the same operators before proctorship (pre-proctored) and operators in the same institutions who had not been proctored (non-proctored). There were 232 patients in the pre-proctored/non-proctored group and 355 patients in the post-proctored group. Complexity was assessed by calculating the Japanese CTO (JCTO) score for each case. RESULTS: CTO PCI success was greater in the post-proctored compared with the pre-proctored/non-proctored group (77.5% vs 62.1%, p<0.0001). In more complex cases where JCTO≥2, the difference in success was greater (70.7% vs 49.5%, p=0.0003). After proctoring, there was an increase in CTO PCI activity in centres from 2.5% to 3.5%, p<0.0001 (as a proportion of total PCI), and the proportion of very difficult cases with JCTO score ≥3 increased from 15.3% (35/229) to 29.7% (105/354), p<0.0001. CONCLUSIONS: Proctoring resulted in an increase in procedural success for CTO PCI, an increase in complex CTO PCI and an increase in total CTO PCI activity. Proctoring may be a valuable way to improve access to CTO PCI and the likelihood of procedural success.

An investigation of the association between omega 3 FA and bone mineral density among older adults: results from the National Health and Nutrition Examination Survey years 2005­2008.

SUMMARY: The relation of omega 3 fatty acids (n-3 FA) with bone mineral density (BMD) was assessed among adults >60 years; NHANES data (2005-2008). The association of dietary n-3 FA with measures of hip BMD was equivocal, but n-3 FA supplement use was significantly associated with higher spine BMD - a finding that deserves further study. INTRODUCTION: Associations between polyunsaturated fatty acids and bone mineral density are not well understood. PURPOSE: To evaluate the cross-sectional relation between dietary omega 3 fatty acid intake (specifically docosahexaenoic acid, eicosapentaenoic acid, and octadecatetraenoic) and BMD at the hip and spine among older adults. METHODS: Omega 3 FA intake (g/day) was assessed from two 24-h recalls using the National Health and Nutrition Examination Survey (NHANES, in 2005-2008); and omega 3 FA supplement use (yes/no) via questionnaire. Multivariable regression models were developed to explain variance in femoral neck, total femur, and lumbar spine BMD among 2,125 men and women over 60 years. RESULTS: Mean age was 70 years. In adjusted models, dietary omega 3 FA were marginally associated with greater femoral neck BMD (p = 0.0505), but not with total femur BMD (p = 0.95) or lumbar spine BMD (p = 0.74). Omega 3 supplement use was significantly positively associated with lumbar spine BMD (p = 0.005) but not with femoral neck or total femur BMD. CONCLUSIONS: Dietary intakes of omega 3 FA were marginally associated with femoral neck BMD; however, omega 3 supplement use was significantly associated with higher lumbar spine BMD in older adults. These results emphasize the need for assessment of total omega 3 intakes (diet and supplements) to provide a greater range of intake and a more accurate picture of the relation between omega 3 FA and BMD.

A low tilt waveform in the transthoracic defibrillation of ventricular arrhythmias during cardiac arrest.

AIM: Most commercially available defibrillators utilise a high tilt waveform. Work in atrial fibrillation has shown improved defibrillation success using low tilt waveforms. We hypothesise that a novel low tilt biphasic waveform will be non-inferior to a standard tilt waveform whilst delivering lower energy for the defibrillation of ventricular arrhythmias. METHODS: Patients in cardiac arrest who experienced ventricular arrhythmias received shocks from a novel low tilt waveform defibrillator at 120J or a standard tilt waveform defibrillator at 150J. Resuscitation guidelines were followed as per Resuscitation Council UK, 2005. A shock was successful when the ventricular arrhythmia was terminated for ≥ 5s following shock delivery. RESULTS: A total of 113 cardiac arrest cases were included. The low tilt device was used for 56 cases and the standard tilt device for 57 cases. The presenting rhythm was ventricular fibrillation (VF) in 71.7% (81/113), pulseless electrical activity (PEA) in 15.9% (18/113), ventricular tachycardia (VT) in 9.7% (11/113), asystole in 1.8% (2/113) and narrow complex rhythm in 0.9% (1/113). The low tilt device resulted in first shock success in 86% (48/56 cases) vs. the standard tilt device first shock success of 77% (44/57 cases). There was no significant difference in first shock success between the two devices (p=0.36). CONCLUSION: The low tilt waveform used in this study demonstrated first shock success rates in keeping with a commercially available high tilt defibrillator which could result in less myocardial damage due to reduced energy requirements.

ST elevation on the exercise ECG in patients presenting with chest pain and no prior history of myocardial infarction.

OBJECTIVE: To assess the aetiology, and prognosis of ST-segment elevation (STE) on the exercise electrocardiogram in patients with chest pain without a prior history of myocardial infarction (MI). METHODS: Between January 1998 and December 2005, 14 941 exercise stress tests were performed to assess chest pain in patients without a prior history of MI. Those who developed STE were identified. RESULTS: STE occurred in 0.78% (116/14 941). Coronary angiography was performed in 108 patients. All patients had at least one severe coronary artery stenosis (>70%). The site of STE on exercise ECG was shown to be 95.4% predictive of a severe stenosis in the coronary artery supplying that area. Lateral STE was rare (1/116). Ninety-eight patients underwent revascularisation; 67 patients had percutaneous coronary intervention (PCI) and 31 underwent coronary artery bypass grafting (CABG). Follow-up included recording of death, MI, cerebrovascular event, heart failure and target vessel revascularisation. The projected 7-year event-free survival probability was 62.1% for those undergoing CABG, 77.1% for those who had PCI and 68.6% for those not undergoing revascularisation (no difference between these three groups, log rank p = 0.802). CONCLUSIONS: STE on the exercise ECG is rare but specific for ischaemic heart disease and is predictive of a severe stenosis in the corresponding coronary artery. Prognosis is favourable following revascularisation.

Biphasic energy selection for transthoracic cardioversion of atrial fibrillation. The BEST AF Trial.

AIMS: To compare the efficacy and safety of an escalating energy protocol with a non-escalating energy protocol using an impedance compensated biphasic defibrillator for direct current cardioversion of atrial fibrillation (AF). METHODS AND RESULTS: This prospective multicentre randomised trial enrolled 380 patients (248 male, mean (SD) age 67 (10) years) with AF. Patients were randomised to either an escalating energy protocol (protocol A: 100 J, 150 J, 200 J, 200 J), or a non-escalating energy protocol (protocol B: 200 J, 200 J, 200 J). Cardioversion was performed using an impedance compensated biphasic waveform. First-shock success was significantly higher for those randomised to 200 J than 100 J (71% vs 48%; p<0.01) and for patients with a body mass index (BMI) >25 kg/m(2) (75% vs 44%; p = 0.01). In patients with a normal BMI there was no significant difference in first-shock success. There was also no significant difference between subsequent shocks or overall success. The use of a non-escalating protocol (protocol B) resulted in fewer shocks but with a higher cumulative energy. There was no difference in duration of procedure, amount of sedation administered or post-shock erythema between the groups. CONCLUSION: First-shock success was significantly higher, particularly in patients with a BMI >25 kg/m(2), when a non-escalating initial 200 J energy was selected. The overall success, duration of procedure and amount of sedation administered, however, did not differ significantly between the two protocols.

Geographical clustering of mortality from systemic lupus erythematosus in the United States: contributions of poverty, Hispanic ethnicity and solar radiation.

The objective was to investigate whether spatial variation in poverty, Hispanic ethnicity, and solar radiation explains the strong pattern of geographical clustering of mortality from systemic lupus erythematosus (SLE) in the United States. SLE mortality counts for women and men of black and white race in US counties, 1979-1998, were obtained from the National Center for Health Statistics. County-level poverty rates and proportions of Hispanic residents were drawn from the 1990 national census. The annual cumulative level of ambient ultraviolet 'B' radiation (UVB) was estimated for each county according to latitude, longitude, and elevation. Maps for the full study population and for sex - and race-specific subpopulations showed that the national pattern of geographical variation in SLE mortality primarily reflected the experience of white women. Formal spatial analysis of the data for white women identified 10 statistically significant, multi-county clusters--four with elevated and six with reduced SLE mortality rates. Multivariate regression modeling established that higher levels of poverty, Hispanic ethnicity, and UVB were each associated with elevated local rates of SLE mortality among white women. Statistical adjustment via the regression model was used to remove effects of these factors on local rates. In a re-application of spatial analysis to the adjusted rates, four clusters 'disappeared'. In those clusters, poverty, Hispanic ethnicity and UVB had explained an average of 58.2% of the deviations between local and national SLE mortality rates. In six clusters (including three that disappeared with adjustment), Hispanic ethnicity explained a larger percentage of the deviations between local and national rates than either poverty or UVB. In multivariate models based on data for black women and for men of both races, poverty and UVB had similar effects on SLE mortality rates to those observed among white women. However, Hispanic ethnicity was not a significant predictor of SLE mortality in any of these other groups. The contributions of poverty, Hispanic ethnicity and solar radiation to geographical variation of SLE mortality in the United States are substantial, but these factors do not fully account for the clustering phenomenon.

Clopidogrel in non-ST segment elevation acute coronary syndromes: an overview of the submission by the British Cardiac Society and the Royal College of Physicians of London to the National Institute for Clinical Excellence, and beyond.

A comprehensive appraisal was undertaken on behalf of the British Cardiac Society and the Royal College of Physicians of London to assess the use of clopidogrel in acute coronary syndromes. The appraisal was submitted to the National Institute for Clinical Excellence (NICE) in August 2003 and contributed to the development of the recently published guidelines for the use of clopidogrel in acute coronary syndromes. The submission to NICE and more recent publications evaluating the use of clopidogrel are reviewed.

Condition, prolonged swimming performance and muscle metabolic capacities of cod Gadus morhua.

This study evaluated the link between swimming endurance and condition of Atlantic cod Gadus morhua that had been fed or starved during the 16 weeks preceding the tests, and assessed whether muscle metabolic capacities explain such links. The condition factor [(somatic mass x fork length(-3))x100] of starved cod was 0.54+/-0.1 whereas that of fed cod was 0.81+/-0.1. In white and red muscle, we measured four glycolytic enzymes: phosphofructokinase (PFK), pyruvate kinase (PK), creatine kinase (CK) and lactate dehydrogenase (LDH), two mitochondrial enzymes: cytochrome c oxidase (CCO) and citrate synthase (CS), a biosynthetic enzyme, nucleoside diphosphate kinase (NDPK), glycogen and protein levels and water content. Muscle samples were taken at three positions along the length of the fish; starvation affected the metabolic capacities of white muscle more than those of red muscle. The levels of glycolytic enzymes and glycogen changed more in white than red muscle during starvation. Both in fed and starved cod, muscle metabolic capacities varied with position along the fish; starvation reduced this longitudinal variation more in white than red muscle. In white muscle of fed cod, the glycolytic enzyme levels increased from head to tail, while in starved cod this longitudinal variation disappeared. In red muscle mitochondrial enzyme levels were highest in the caudal sample, but fewer differences were found for glycolytic enzymes. Swimming endurance was markedly affected by fish condition, with starved fish swimming only 30% of the time (and distance) of fed fish. This endurance was closely linked with the number of burst-coast movements during the test and the activity of CCO and LDH in white muscle. The number of burst-coast movements was significantly linked with condition factor and PFK activity in caudal red muscle and gill arch mass. Our data indicated that cod use both glycolytic and oxidative capacities to support endurance swimming. Furthermore, swimming endurance is linked with the metabolic capacities of red and white muscle.

The collation of forensic DNA case data into a multi-dimensional intelligence database.

The primary aim of any DNA Database is to link individuals to unsolved offenses and unsolved offenses to each other via DNA profiling. This aim has been successfully realised during the operation of the New Zealand (NZ) DNA Databank over the past five years. The DNA Intelligence Project (DIP), a collaborative project involving NZ forensic and law enforcement agencies, interrogated the forensic case data held on the NZ DNA databank and collated it into a functional intelligence database. This database has been used to identify significant trends which direct Police and forensic personnel towards the most appropriate use of DNA technology. Intelligence is being provided in areas such as the level of usage of DNA techniques in criminal investigation, the relative success of crime scene samples and the geographical distribution of crimes. The DIP has broadened the dimensions of the information offered through the NZ DNA Databank and has furthered the understanding and investigative capability of both Police and forensic scientists. The outcomes of this research fit soundly with the current policies of 'intelligence led policing', which are being adopted by Police jurisdictions locally and overseas.