Chronicity Research Articles

Disease correlation network: a computational package for identifying temporal correlations between disease states from Large-Scale longitudinal medical records.

ObjectiveTo provide an open-source software package for determining temporal correlations between disease states using longitudinal electronic medical records (EMR).Materials and MethodsWe have developed an R-based package, Disease Correlation Network (DCN), which builds retrospective matched cohorts from longitudinal medical records to assess for significant temporal correlations between diseases using two independent methodologies: Cox proportional hazards regression and random forest survival analysis. This optimizable package has the potential to control for relevant confounding factors such as age, gender, and other demographic and medical characteristics. Output is presented as a DCN which may be analyzed using a JavaScript-based interactive visualization tool for users to explore statistically significant correlations between disease states of interest using graph-theory-based network topology.ResultsWe have applied this package to a longitudinal dataset at Loyola University Chicago Medical Center with 654 084 distinct initial diagnoses of 51 conditions in 175 539 patients. Over 90% of disease correlations identified are supported by literature review. DCN is available for download at https://github.com/qunfengdong/DCN.ConclusionsDCN allows screening of EMR data to identify potential relationships between chronic disease states. This data may then be used to formulate novel research hypotheses for further characterization of these relationships.

Importance of Multislice Computed Tomography in Determining the Severity of Chronic Liver Disease State

BackgroundIn the present study, we aimed to put forward the relationship between multidetector computed tomography findings and scores for liver function evaluation. MethodIncluded in the study were 51 patients with liver cirrhosis. Preoperative creatinine levels, international normalized ratio and alpha-fetoprotein values, albumin and sodium levels, the presence of ascites and varices, Model for End-Stage Liver Disease (MELD) scores, MELD-Sodium (MELD-Na) scores, and Child-Turcotte-Pugh Classification, the presence of ascites and varices, the size of liver, the size and diameter of the spleen, portal vein diameter, splenic artery diameter, and proper hepatic and right hepatic artery diameter were all determined. ResultsAlthough the correlation between the spleen diameter and the MELD scores (P <.001) and MELD-Na scores (P = .02) was strong, there was no association with the Child-Turcotte-Pugh Classification (P = .08). Despite the correlations between portal vein diameter (P = .04) and splenic artery diameter (P = .04) and MELD scores, no association was detected with MELD-Na scores and the Child-Pugh scores. Even though a negative correlation between proper hepatic artery diameter (P = .18) and MELD-Na scores was noted, no statistically significant correlation could be identified with any scoring systems. In the multivariate linear regression analyses, the correlation between the portal vein diameter and MELD scores was significant as a radiologic finding. In the multiple linear regression analyses, the negative correlation between the right hepatic artery and MELD-Na scores diameter was statistically significant. In the multiple linear regression analyses, there was no statistically significant correlation between preoperative radiologic findings and Child-Turcotte-Pugh Classification. ConclusionWe believe that preoperative multislice computed tomography imaging in patients with chronic liver disease may contribute to the diagnosis of disease, the determination of vascular anomalies, and the grading of the severity of the disease.

Antidiuretic Hormone and Serum Osmolarity Physiology and Related Outcomes: What Is Old, What Is New, and What Is Unknown?

Although the physiology of sodium, water, and arginine vasopressin (AVP), also known as antidiuretic hormone, has long been known, accumulating data suggest that this system operates as a more complex network than previously thought. English-language basic science and clinical studies of AVP and osmolarity on the development of kidney and cardiovascular disease and overall outcomes. Apart from osmoreceptors and hypovolemia, AVP secretion is modified by novel factors such as tongue acid-sensing taste receptor cells and brain median preoptic nucleus neurons. Moreover, pharyngeal, esophageal, and/or gastric sensors and gut microbiota modulate AVP secretion. Evidence is accumulating that increased osmolarity, AVP, copeptin, and dehydration are all associated with worse outcomes in chronic disease states such as chronic kidney disease (CKD), diabetes, and heart failure. On the basis of these pathophysiological relationships, an AVP receptor 2 blocker is now licensed for CKD related to polycystic kidney disease. From a therapeutic perspective, fluid intake may be associated with increased AVP secretion if it is driven by loss of urine concentration capacity or with suppressed AVP if it is driven by voluntary fluid intake. In the current review, we summarize the literature on the relationship between elevated osmolarity, AVP, copeptin, and dehydration with renal and cardiovascular outcomes and underlying classical and novel pathophysiologic pathways. We also review recent unexpected and contrasting findings regarding AVP physiology in an attempt to explain and understand some of these relationships.

Quantitative proteomic analyses in blood: A window to human health and disease.

This review discusses how the measurement of proteins in blood and its components via quantitative proteomics analyses can inform health status. Various external and internal factors such as environmental conditions, genetic background, nutrition, diet, and lifestyle, chronic pathological conditions, disease state, or therapeutic intervention will be investigated and their effects on the protein profile will be shown. The resulting changes to ones' health and how this protein expression information can be used in early screening/diagnostic applications, drug discovery, precision treatment, patient management, and monitoring overall health status will also be presented.

Writing therapeutically about chronic pregnancy sickness: women’s perceptions of sufficiency

ABSTRACTThis paper presents findings of the first study to analyse the uses and sufficiency of writing therapy in the context of pregnancy sickness. Ten women, previously hospitalised due to Hyperemesis Gravidarum (HG), a chronic pregnancy related illness, participated in this research study. Participants completed four expressive writing tasks, at home, over a 2-week period, followed by a semi-structured, qualitative telephone interview. The study thematically analysed participants’ experiences of engagement with the writing process, including writing for self rather than audience, and how writing compared to talking about their illness experience. Findings are consistent with the existing research literature on the therapeutic value of reflective writing and contribute new knowledge regarding women’s first-person experiences of this in a new population. Data were analysed through a psychotherapeutic lens by a researcher who lived with HG throughout both of her own pregnancies.

Regulation of Adaptive Immune Cells by Sirtuins

It is now well-established that the pathways that control lymphocyte metabolism and function are intimately linked, and changes in lymphocyte metabolism can influence and direct cellular function. Interestingly, a number of recent advances indicate that lymphocyte identity and metabolism is partially controlled via epigenetic regulation. Epigenetic mechanisms, such as changes in DNA methylation or histone acetylation, have been found to alter immune function and play a role in numerous chronic disease states. There are several enzymes that can mediate epigenetic changes; of particular interest are sirtuins, protein deacetylases that mediate adaptive responses to a variety of stresses (including calorie restriction and metabolic stress) and are now understood to play a significant role in immunity. This review will focus on recent advances in the understanding of how sirtuins affect the adaptive immune system. These pathways are of significant interest as therapeutic targets for the treatment of autoimmunity, cancer, and transplant tolerance.

Direct Visualization of Laryngeal Mucociliary Clearance in Adults.

Mucociliary clearance is a protective mechanism of the respiratory tract that facilitates the removal of foreign particles and microorganisms. There is a paucity of data on the mucociliary clearance in the adult larynx. Our study aims to visualize and describe the mucociliary clearance of the adult larynx in healthy subjects. Subjects were identified from a volunteer database. Exclusion criteria included laryngeal disease, previous laryngeal surgery, recent upper respiratory infection, and current smoking. A high-definition videolaryngoscope was used to visualize the larynx. The larynx was topicalised with local anesthetic. Methylene blue was placed on both false vocal cords and at the petiole of the epiglottis. Dye clearance was recorded and analyzed. In total, 10 participants participated, 7 men and 3 women, with a mean age of 42 ± 15.7 years (range: 25-71). The average reflux symptom index score was 1.4. Clearance of the dye from the false vocal cords followed a uniform lateral flow, up onto the aryepiglottic folds. The dye from the petiole had minimal vertical movement. Swallowing cleared dye from the aryepiglottic folds. The average time for dye clearance to the aryepiglottic fold was 2.21 ± 1.14 minutes. This is the first study visualizing the mucociliary clearance of the larynx. Ciliary directionality was consistent in the participants studied, with dye moving superolateral from the false cords to the aryepiglottic fold. Swallowing was an effective mechanism for clearance from the endolarynx, when the dye had reached the aryepiglottic fold. Future research can study potential alterations in laryngeal mucociliary clearance in chronic disease states.

New horizons in arginine metabolism, ageing and chronic disease states.

The elucidation of the metabolic pathways of the amino acid arginine and their role in health and disease have been an intensive focus of basic and clinical research for over a century. The recent advent of robust analytical techniques for biomarker assessment in large population cohorts has allowed the investigation of the pathophysiological role of specific arginine metabolites in key chronic disease states in old age, particularly those characterised by a reduced synthesis of endothelial nitric oxide, with consequent vascular disease and atherosclerosis. Two arginine metabolites have been increasingly studied in regard to their potential role in risk stratification and in the identification of novel therapeutic targets: the methylated arginine asymmetric dimethylarginine (ADMA) and the arginine analogue homoarginine. Higher circulating concentrations of ADMA, a potent inhibitor of nitric oxide synthesis, have been shown to predict adverse cardiovascular outcomes. By contrast, there is emerging evidence that homoarginine might exert cardioprotective effects. This review highlights recent advances in the biological and clinical role of ADMA and homoarginine in cardiovascular disease and other emerging fields, particularly chronic obstructive pulmonary disease, dementia, and depression. It also discusses opportunities for future research directions with the ultimate goal of translating knowledge of arginine metabolism, and its role in health and disease, into the clinical care of older adults.

Impact on an integrated psychiatric pharmacy service in a primary care clinic.

IntroductionTraditionally, clinical pharmacists have been employed in the primary care setting to help manage chronic disease states, such as diabetes and hypertension. Although the benefits of pharmacists managing chronic conditions have been extensively published, published data for clinical pharmacist mental health services in primary care is limited to Veterans Affairs populations. This article describes a practice model in which pharmacists are providing psychiatric medication management and consultation in a federally qualified health center.MethodsA period of 1 year from the psychiatric pharmacy service was analyzed from April 1, 2017, to March 31, 2018. Reports were generated that included information about psychiatric pharmacy consults, 1-on-1 psychiatric pharmacy visits, and psychotropic medication prescribing/dispensing trends. Each consult was further reviewed for additional details, including patient characteristics, medications prescribed, psychiatric diagnoses involved, and actions taken.ResultsA review of this pharmacy service showed significant pharmacist involvement in psychiatric medication consults and 1-on-1 visits. Common disease states consulted on were depressive disorders, anxiety disorders, and neurologic disorders, which reflects psychiatric disease states commonly seen in primary care practice. Provider satisfaction survey results showed that the service was valued and that providers felt their comfort in prescribing psychotropic medications improved due to the service.DiscussionThe service described here exemplifies the potential for pharmacists in the ambulatory care setting to expand beyond the traditional chronic disease state management. It also speaks to a potential role for psychiatric pharmacists in the primary care setting.

Survival After End-Stage Renal Failure: Preventing Cardiac Death in End-Stage Renal Disease Patients

At the 56th European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) Congress, held in June 2019 in Budapest, Hungary, physicians from the USA, UK, and Spain presented an educational symposium entitled ‘Survival After End-Stage Renal Failure: Preventing Cardiac Death in End-Stage Renal Disease Patients.’ During this symposium, physicians discussed concepts underlying dialysis as a chronic cardiovascular disease state; cardiovascular disease challenges with volume overload, hypertension, and heart failure; the challenge of fluid management in intermittent haemodialysis; and the effect of more frequent therapy on volume and symptom control. This review summarises the symposium.

Prevalence and predictors of having no general practitioner - analysis of the German health interview and examination survey for adults (DEGS1)

BackgroundAlthough patients in Germany are generally free to choose their primary healthcare provider, this role should mainly be assumed by general practitioners (GPs). While some predictors of the frequency of use of GP services have been reported in international studies, there is still a lack in knowledge what could deter people from contacting a GP in Germany. To improve healthcare, it is important to identify characteristics of people without a GP.MethodsThis cross-sectional analysis was based on the first wave of the “German Health Interview and Examination Survey for Adults” (DEGS1) conducted by the Robert Koch Institute in 2008–2011. Descriptive analyses and multiple logistic regression by gender were performed to analyze the association between having no GP and age, gender, residential area, socioeconomic status (SES), marital status, working hours per week, general state of health, chronic diseases and health insurance.ResultsOverall, 9.5% (95% confidence interval (CI): 8.4–10.7) of the 7755 participants stated to have no GP, more often men (11.4%) than women (7.6%). Life in urban areas (big cities vs. rural: adjusted odds ratio (aOR): 2.9, 95% CI: 2.1–3.9), younger age (18–29 years vs. 65–79 years: aOR: 4.4, 95% CI: 2.5–7.7) and the presence of chronic diseases (yes vs. no: aOR: 0.4, 95% CI: 0.3–0.6) showed significant associations of not having a GP. For men, the type of health insurance (private vs. statutory: aOR: 2.1, 95% CI: 1.5–3.0; other vs. statutory: aOR: 2.1, 95% CI: 1.4–3.1) and for women, SES (low vs. medium: aOR: 1.8, 95% CI: 1.2–2.7; high vs. medium: aOR: 2.1, 95% CI: 1.4–3.0) increased the risk of having no GP.ConclusionsOur analysis offers new insights into the use of GPs in Germany and revealed differences between men and women. Public health strategies regarding access to a GP have to focus on men and on women with a low SES. Further analyses are needed to determine whether men with private health insurance prefer to consult a specialist rather than a GP. For young adults, improving the transition process from a pediatrician to a GP could fill a gap in health care.

Ohio Community Pharmacist Interest and Participation in Community-Clinical Linkages.

Community-clinical linkages have been promoted as a means to improve population health. The community pharmacy is an ideal location for these partnerships to occur due to the expertise of the community pharmacist. While the need for these partnerships exists, there are limited data regarding community pharmacists' current participation in such programs. The purpose of this analysis was to assess Ohio community pharmacists' involvement and interest in community-clinical linkages. An electronic survey tool containing 26 questions was developed to assess Ohio community pharmacists' participation in community-clinical linkages and interest to develop such partnerships. The tool was sent via email to a random sample of 500 pharmacists registered in Ohio and practicing in a community setting. Chi-square or Fisher exact nonparametric statistical tests were used as appropriate to identify whether there were any significant differences in current partnership or interest to partner with a prescriber who refers patients to their community pharmacy based on education (Bachelor of Science or Doctor of Pharmacy degree) or pharmacy location (urban, suburban, or rural). Nine emails were undeliverable, leaving a sample of 491 pharmacists. Ninety-three (19%) responded to the survey. Sixteen respondents (17%) indicated that they currently partner with a prescriber who refers patients to their pharmacy for assistance with medications or chronic disease state management; this practice was more often reported in urban settings (p=0.022). Of those not currently participating in such a partnership, 53 (57%) were interested in developing one. Thirty-two respondents (34%) reported providing referrals for at least 1 type of screening or counseling service. For some types of services, pharmacists reported that they provide the service in the pharmacy and/or were interested to develop the service in the pharmacy rather than provide a referral. However, for any given service there were a number of pharmacists who expressed interest in providing referrals although they were not currently doing so. This sample of Ohio community pharmacists reported limited participation in community-clinical linkages but interest to develop them. Further studies should explore the pharmacists' role and impact in such programs.

Clinical pharmacy specialists’ impact in patient aligned care teams for type 2 diabetes management

ObjectivesClinical pharmacy specialists (CPSs) are a core member of the primary care team, and they have been shown to improve outcomes, decrease overall cost, and increase the availability of primary care providers (PCPs) by assisting with the management of chronic disease states. CPSs have the opportunity to increase access to care if they are used at their full scope of practice. The objective of this study was to compare the reduction in HbA1c between CPSs and PCPs. MethodsThis retrospective, chart review study assessed the impact of CPSs on patients with uncontrolled type 2 diabetes who saw a CPS in addition to a PCP compared to those who saw a PCP alone from January 1, 2011, to October 1, 2016. The CPS held prescriptive authority and ordered, interpreted, and monitored laboratory results. Secondary outcomes included the reduction of blood pressure, appropriate statin intensity, weight loss, initiation of insulin, and access to care. ResultsSeventy-five patients were included in both the CPS and PCP groups. There was a statistically significant decrease in HbA1c in the CPS group (3.02% vs. 0.93%; P < 0.0001), with most patients reaching their HbA1c goal in 6 months or less with an average of 7 clinic visits in that timeframe. In addition, significantly more patients were taking the appropriate intensity statin in the CPS group (90.7% vs. 73.3%; P = 0.006). ConclusionThe use of CPSs in the management of type 2 diabetes led to similar achievements in HbA1c goal, but over a shorter duration. CPSs provided effective patient care while increasing access to health care.

The Importance of Goal Setting: Why Every Pharmacist Should Make Goal Setting a Habit

When speaking with pharmacists and students at pharmacy meetings, we often ask these two questions: Did they discover or learn anything new or interesting at the meeting, and;What do they hope to do with the knowledge and experiences they have encountered.At this year's Western Pharmacy Exchange meeting, many pharmacists voiced their desire to implement more clinical services, or see if the innovations showcased at the meeting could work in their practice. Students attended the meeting to find opportunities to network and explore other areas of pharmacy practice. When we go back to our busy lives and schedules, do we get a chance to follow through on these ideas that could advance us personally or professionally?As pharmacists, we often counsel our patients on medications and lifestyle changes. We encourage them to set goals to improve their diet, increase their exercise, manage their chronic disease state, and improve medication compliance. We utilize the teach-back method and employ motivational interviewing techniques. We realize that it is important for our patients to set clear goals and have a plan to achieve success.But how many of us actually practice what we preach? We have pledged to apply our knowledge, experience, and skills to the best of our ability to assure optimal outcomes for our patients.(1) As the pharmacy profession evolves, and as we train future generations of pharmacists, we have increased opportunities to expand our role and impact as a pharmacist. Goal setting is an important and valuable tool to support us in our personal and professional growth.The first step toward this growth is to establish S.M.A.R.T. goals. S.M.A.R.T. goals are Specific, Measurable, Achievable, Relevant, and Time-bound.(2) Be specific about what you want to accomplish and what steps you are going to take to accomplish your goal. Establish a measurable outcome to define success. Ensure that your goal is achievable. Set relevant goals that support your big picture. Keep yourself accountable and on track by setting a realistic time frame.Setting short- and long-term S.M.A.R.T. goals lays the groundwork for creating and implementing a plan of action. Think about where you want to go and work backward. What skills and experiences are necessary to achieve your goals? How can your short-term goals build toward accomplishing a longer-term goal? What is a realistic time frame to encourage success and promote accountability?Goals should be periodically evaluated and modified as well. Honest self-reflection and identification of strengths and weaknesses is a must. If a certain trait, characteristic, or practice is impeding success, it should be identified and addressed. As goals are accomplished, and we move closer to our end goal, we may need to modify the steps we take to get there. Goal setting is a valuable tool, and one that can and should be applied at every stage in our personal and professional development to promote success.

Identifying Malnutrition in PALTC Communities

Identifying Malnutrition in PALTC Communities

Opioids: A Review of Pharmacokinetics and Pharmacodynamics in Neonates, Infants, and Children.

Pain management in the pediatric population is complex for many reasons. Mild pain is usually managed quite well with oral acetaminophen or ibuprofen. Situations involving more severe pain often require the use of an opioid, which may be administered by many different routes, depending on clinical necessity. Acute and chronic disease states, as well as the constantly changing maturational process, produce unique challenges at every level of pediatrics in dosing and management of all medications, especially with regard to high-risk opioids. Although there has been significant progress in the understanding of opioid pharmacokinetics and pharmacodynamics in neonates, infants, children, and adolescents, somewhat limited data existfrom which necessary information, concerning the safe and effective use of these agents, may be drawn. The evidence here provided is intended to be helpful in directing the practitioner to patient-specific reasons for preferring one opioid over another. As our knowledge of opioids and their effects has grown, it has become clear that older medications like codeine and meperidine (pethidine) have very limited use in pediatrics. This review provides pharmacokinetic and pharmacodynamic evidence on the currently available opioids: morphine, fentanyl (and derivatives), codeine, meperidine, oxycodone, hydrocodone, hydromorphone, methadone, buprenorphine, butorphanol, nalbuphine, pentazocin, ketobemidone, tramadol, piritramide, naloxone and naltrexone. Morphine, being the most studied opioid analgesic, is the standard against which all others are compared. Pharmacokinetic parameters of morphine that have been found in neonates, i.e., higher volume of distribution, immature metabolic processes that develop at various rates, elimination that is variable based on age and weight, as well as treated and untreated disease processes, are an example of all opioids in the population discussed in this review. Outside the premature and neonatal population, the use of opioids in infants, children, and adolescents quickly begins to resemble the established values found in adults. As such, the concerns (risks) of these medications become comparable to those seen in adults.

Implementation of a medication therapy management program in a primary care clinic

ObjectiveThis study examined the use of a medication therapy management (MTM) program by clinic-embedded pharmacists within a primary care clinic primarily by evaluating the impact on patient identification for pharmacy services. Secondary outcomes included characterizing intervention type, targeted drugs and disease states, and barriers to successful interventions, SettingPrimary care clinic. Practice descriptionCoxHealth Center Steeplechase is a primary care clinic of 13 providers with a clinic-embedded pharmacist, pharmacy residents, and student pharmacists providing chronic disease state management under collaborative practice agreements. Practice innovationCommunity pharmacists have an established history of providing services through MTM programs. Clinic-embedded pharmacists have the potential to participate in these programs as well, and many barriers to providing patient care services reported by community pharmacists can be overcome by clinic-embedded pharmacists, potentially allowing for greater success of MTM interventions. EvaluationA 4-week pilot, in which clinic-embedded pharmacists dedicated 4 hours per week of effort to MTM services, examined the effectiveness of the program at identifying patients not otherwise receiving clinical pharmacy services, types of identified interventions, intervention success rates, barriers to intervention success, and revenue generation. ResultsThe clinical pharmacy team attempted 46 interventions in 34 unique patients in this 4-week pilot. Of the identified patients, 67.7% (n = 23) had no contact with the clinical pharmacy team in the previous year. Targeted interventions were more frequently attempted (targeted interventions n = 42; comprehensive reviews n = 4) and more successful than comprehensive medication reviews (88% vs. 25% success rate). Barriers to success included patient refusal of services, inability to contact the patient, and inapplicability of targeted interventions. ConclusionImplementation of an MTM program in one clinic required coordinated interdepartmental efforts to implement, but it effectively expanded pharmacy services by identifying patients not otherwise referred to the clinical pharmacy team for chronic disease management.

Effects of Two‐Hit Lipopolysaccharide (LPS) Administration on Acute Intermittent Hypoxia (AIH)‐Induced Inspiratory Motor Behaviors in Urethane‐anesthetized Spontaneously Breathing Adult Male Sprague‐Dawley Rat

Ongoing studies designed to induce peripheral inflammation, and its accompanying neuroinflammation, have begun to examine various aspects of neural control of breathing. While most studies typically administer the bacterial endotoxin lipopolysaccharide (LPS) systemically or in an airway/lung targeted manner in order to produce models of systemic inflammatory response syndrome (SIRS)/sepsis and acute lung injury (ALI), a ‘two‐hit’ LPS administration protocol in which systemic LPS (ip, 3 mg/kg) is administered ~24 hr prior to an airway/lung targeted (intratracheal (IT); 0.5 mg/kg) LPS injection has been used to better reflect chronic (lung/airway) disease states. One of the most studied respiratory behaviors in which inflammation has been shown to negatively impact breathing is AIH‐induced inspiratory motor (phrenic) long‐term facilitation (pLTF), where in anesthetized, vagotomized, ventilated adult male rats, single‐hit systemic LPS administration attenuates AIH‐induced serotonin2‐dependent pLTF. Here, we examined the impact of two‐hit LPS administration in urethane‐anesthetized vagal intact spontaneously breathing adult male Sprague‐Dawley rats on AIH‐induced inspiratory motor behaviors using AIH composed of five 3‐min episodes of hypoxia (11% O2) separated by 3‐min exposures to hyperoxia (40% O2) with all rats being continuously supplied with 2% CO2. Similar experiments were performed in control rats that were either untreated or received two‐hit saline injections. We found that in control rats, exposure to the repetitive bouts of hypoxia elicited increases in both diaphragm EMG burst frequency (~18% increase) and amplitude (IH1, ~22% to IH5, ~31%) that resulted in progressive augmentation (PA) and LTF inspiratory burst amplitude that persisted for ~75 min post‐AIH (sustained ~12–18% increase above baseline levels); no frequency LTF and a robust post hypoxic frequency decline (PHFD) after each hypoxic exposure and for up to 25 min post‐AIH were also observed. In contrast, in LPS‐treated rats, exposure to the repetitive bouts of hypoxia elicited a more robust increase in diaphragm EMG burst frequency (~25–30% increase) and a blunted or absent amplitude response (IH1, ≤8%). Moreover, in these rats, PA of burst amplitude was absent, inspiratory burst amplitude LTF was highly variable with an overall amplitude increase of ~10% above baseline levels that subsided by 20 min post‐AIH, and PHFD after each hypoxic exposure slightly increased in magnitude and persisted for up to 50 min post‐AIH. These preliminary observations suggest that (compared to control rats) two‐hit LPS administration affects mechanisms underlying multiple components responsible for inspiratory burst frequency and amplitude plasticity in response to hypoxic exposure(s) and following AIH exposure. Additional experiments, including those using other AIH protocols, will be needed to confirm these observations and identify specific mechanisms underlying these differences.Support or Funding InformationNIH NS101737; Thomas Hartman Center for Parkinson's Disease Research at Stony Brook UniversityThis abstract is from the Experimental Biology 2019 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

RADIOLOGICAL AND NUCLEAR TERRORISM - MEDICAL-BIOLOGICAL AND HYGIENIC PROBLEMS

The main aspects of radiological and nuclear terrorism have been considered in the paper. The nuclear terrorism scenario, i.e. the usage of nuclear weapons by terrorists has been emphasized to look unlikely. While the threat of radiological terrorism related to the usage of radioactive materials with the purpose of malicious exposure to the public, for example, by detonating of a “dirty bomb” with further radioactive contamination of the environment where people live, or by a hidden usage of radioactive materials appears to be rather realistic. The character and consequences of the usage of various types and sources of ionizing radiation from alpha-emitting radionuclides to gamma-, gamma-beta or beta-emitting radionuclides under external, internal or contact exposure have been discussed. The criteria of radiation impact to a person are emphasized to include both the absorbed dose and absorbed dose rate. In the case of external exposure it is necessary to consider the character of the exposure: total (whole body exposure) or local (some parts of a body) to a person; in the case of the internal exposure - features of distribution and metabolic characteristics of a specific radionuclide. Deterministic effects (acute radiation sickness, local radiation injury, chronic radiation sickness) and stochastic effects (malignant tumors, hereditary diseases) are considered as effects of the radiation exposure. Under the comparison of a radiation threat due to different pathways as a result of an act of radiological terrorism usually the first place is taken by the external exposure, followed by the internal exposure by inhalation intake of radionuclides, in the case of dispersed radioactive materials due to detonation - through wounds and burned skin surfaces; the lesser important pathway is oral intake of radionuclides. The analysis of various scenarios of the radiological terrorism shows the number of casualties with deterministic effects will be small, while the number of people with stochastic effects will not be discernible from spontaneous variation of levels of the prevalence rate of malignant tumors and hereditary diseases. The main negative factor of radiological terrorism is psychological impact of the terrorism associated with a radiation threat

Role of the Ambulatory Care Clinical Pharmacist in Management of a Refugee Patient Population at a University-Based Refugee Healthcare Clinic.

The International Family Medicine Clinic (IFMC) at University of Virginia Health System serves refugees and special immigrants in Virginia. The IFMC comprises an interprofessional team including a clinical pharmacist. A retrospective chart review of electronic medical records was performed. Adult refugee patients who attended a scheduled clinical pharmacist visit between October 6, 2015 and December 31, 2016 were included. The primary outcome was to characterize interventions made by a clinical pharmacist. Secondary outcomes included describing chronic disease states experienced by certain refugee populations and the clinical impact of pharmacist interventions in diabetes management. 80 refugee patients attended 275 clinical pharmacist visits. On average, visits lasted 30min. Numerous patient interventions were made, including initiation of 68 new medications, discontinuation of 49 medications, and 66 medication dose changes. An average A1c reduction of 1.8% (p < 0.001) was noted. The clinical pharmacist can play an important role in refugee healthcare.