Tapering Off Research Articles

Acceptance of medications for opioid use disorder in recovery housing programs in Missouri

BackgroundRecovery housing plays an important role in supporting individuals in their recovery by building recovery capital and providing stable living environments; however, the extent to which medications for opioid use disorder (MOUD), the gold standard for OUD treatment, are accepted in recovery housing settings is unclear. The purpose of this study, as part of a larger statewide evaluation of Missouri recovery homes, was to identify the extent to which Missouri recovery houses were accepting of methadone, buprenorphine, and naltrexone as well as the extent to which the acceptance of each medication was linked to whether the recovery home encouraged tapering off MOUDs. MethodsSixty-four recovery housing managers and/or staff, out of 66 eligible recovery homes in Missouri completed the survey. ResultsResults indicated that methadone was the least accepted medication for long-term use followed by buprenorphine and then naltrexone. Recovery houses that had significantly lower overall acceptance of methadone encouraged tapering; however, the overall acceptance for buprenorphine and naltrexone was not significantly related to the encouragement of tapering off MOUDs. ConclusionThis work highlights the need to develop reliable instruments to measure and assess MOUD-capable recovery homes and to increase knowledge and acceptance of MOUD within recovery home settings.

Aging clocks & mortality timers, methylation, glycomic, telomeric and more. A window to measuring biological age.

As humans age multiple forms of biological decay ensue, and many aspects of human biology can be measured to determine how far biological machinery has drifted from homeostasis. Research has led to aging clocks being developed that claim to predict biological age as opposed to chronological age. Aging could be regarded as a measured loss of homeostatic biological equilibrium that augments biological decay in fully developed tissues. Measuring aspects of how far various elements of biology have drifted from a youthful state may allow us to make determinations on a subject's health but also make informed predictions on their biological age. As we see across human physiology, many facets that maintain human health taper off such as nicotinamide adenine dinucleotide, glutathione, catalase, super oxide dismutase, and more. Extracellular vesicle density also tapers off during age combined with epigenetic drift, telomere attrition, and stem cell exhaustion, whilst genomic instability and biological insults from environment and lifestyle factors increase. Measuring these types of biomarkers with aging clocks may allow subjects to understand their own health more accurately and enable subjects to better focus on their efforts in the pursuit of longevity and, in addition, allow healthcare practitioners to deliver better health advice.

Yield of surveillance endomyocardial biopsies after heart transplantation: a 10-year experience

Abstract Funding Acknowledgements Type of funding sources: None. Background Endomyocardial biopsy (EMB) is recommended as a surveillance procedure for the detection of allograft rejection in all patients after heart transplant. However, the clinical yield of EMB is reported to be low and there are limited evidence in Asian population. Objective The purpose of this study was to investigate the incidence of allograft rejection in after heart transplantation (HT) and yield of surveillance EMB. Method We conducted a retrospective study of consecutive patients who underwent heart transplantation between 2008 and 2017. Of these patients, EMB were classified into surveillance and clinically indicated EMB and were included for analysis. The study assessed EMB results, allograft rejection episodes, and rejection treatments. All patients received induction immunosuppressant and maintaining immunosuppressant regimen including calcineurin inhibitor, mycophenolate, and 6- month tapering off steroid. T-test, Chi-square were used to analyze. Results A total of 622 EMBs of 67 patients were assess. There were 173, 114, 162, 87 and 86 procedures performed during 0-30 days, 31-90 days, 91-365 days, 1-2 year and more than 2 years after HT, respectively. Of these, 560 (90%) EMBs were performed for surveillance. The common reasons for clinically indicated EMB are post anti-rejection treatment (46.8%) and symptoms and signs of rejection (25.8%). Overall, the 2R and 3R episodes of acute cellular rejection were found in 5.5% of EMB results. The clinically indicated EMBs had higher episodes of abnormal EMB result and rejection requiring treatment (53.2% vs 28.1% and 20.1% vs 3.9%, p <0.001 for both) (Table). Conclusion In this single center study, The EMBs in asymptomatic patients had lower likelihood of abnormal result when compared to clinically indicated EMBs. the clinical yield of EMB is comparable with previously reports in developed countries. This is the largest cohort reported from Southeast Asia. Abstract Figure.

General practitioners’ attitudes towards opioids for non-cancer pain: a qualitative systematic review

ObjectivesWorldwide the use of opioids, both doctor-prescribed and illicit, has increased. In most countries, opioids are first prescribed by general practitioners (GPs). Identifying factors that influence GPs’ opioid prescription decision-making...

Taper Off Treatment Can Improve Executive Functions and Regulate Expression of BDNF and 5HTTPLR Genes in Opium Abusers after Six Months Period

Opium is the dried latex obtained from the opium poppy. Opium addiction is the most prevalent addiction in Iranian society. During the last two decades "congress 60" a nongovernmental organization, has been performed a taper off treatment of opium associated with a package of psychological treatment group classes. While the effectiveness of taper off method in opium addiction has been confirmed, molecular mechanisms of this treatment in addicts are not clarified. BDNF gene is a brain-derived neurotrophic factor which is related to several molecular mechanisms of the brain including memory. 5-HTTPLR is a transporter of serotonin that is related to the decision-making process. In present study mRNA level of BDNF and 5-HTTPLR genes in peripheral blood of 20 non-psychiatric persons and 79 opium addicted individuals before and after six months period of taper off treatment was examined by using Real-Time PCR and confirmed by protein level analysis using Western blotting. In addition, executive functions including memory and decision making were analyzed in all participants. Results showed significant down expression of BDNF and 5-HTTPLR in addict persons vs. non psychiatric persons. Also significantly increase detected in BDNF (p<0.01) and5-HTTPLR (p<0.01) expression level in addicts after six months of therapy period. Similar results with gene expression results revealed in protein level analysis. Also, significant improvements in memory and decision making were revealed in addicts after therapy and these improvements were correlated with the expression level of BDNF and 5-HTTPLR. Findings revealed the effect of opium abuse and taper off treatment on the expression of BDNF and 5-HTTPLR. In addition, the association of BDNF mRNA level with psychological states of addict's individuals detected. Results of the present study may help to a better understanding of molecular and neuropsychological mechanisms of opium addiction and taper off treatment. Also, present BDNF and 5-HTTPLR as potential markers for screening the effectiveness of different kinds of addiction treatment.

Association between benzodiazepine receptor agonist use and mortality in patients hospitalised for COVID-19: a multicentre observational study.

To examine the association between benzodiazepine receptor agonist (BZRA) use and mortality in patients hospitalised for coronavirus disease 2019 (COVID-19). A multicentre observational study was performed at Greater Paris University hospitals. The sample involved 14 381 patients hospitalised for COVID-19. A total of 686 (4.8%) inpatients received a BZRA at hospital admission at a mean daily diazepam-equivalent dose of 19.7 mg (standard deviation (s.d.) = 25.4). The study baseline was the date of admission, and the primary endpoint was death. We compared this endpoint between patients who received BZRAs and those who did not in time-to-event analyses adjusted for sociodemographic characteristics, medical comorbidities and other medications. The primary analysis was a Cox regression model with inverse probability weighting (IPW). Over a mean follow-up of 14.5 days (s.d. = 18.1), the primary endpoint occurred in 186 patients (27.1%) who received BZRAs and in 1134 patients (8.3%) who did not. There was a significant association between BZRA use and increased mortality both in the crude analysis (hazard ratio (HR) = 3.20; 95% confidence interval (CI) = 2.74-3.74; p < 0.01) and in the IPW analysis (HR = 1.61; 95% CI = 1.31-1.98, p < 0.01), with a significant dose-dependent relationship (HR = 1.55; 95% CI = 1.08-2.22; p = 0.02). This association remained significant in sensitivity analyses. Exploratory analyses indicate that most BZRAs may be associated with an increased mortality among patients hospitalised for COVID-19, except for diazepam, which may be associated with a reduced mortality compared with any other BZRA treatment. BZRA use may be associated with an increased mortality among patients hospitalised for COVID-19, suggesting the potential benefit of decreasing dose or tapering off gradually these medications when possible.

Post-COVID Neurological Complication; A Case Series and Review of the Literature

Introduction: There are certain post-coronavirus disease (COVID) neurological syndromes which have been reported such as cerebrovascular diseases, cerebral venous thrombosis, peripheral neuropathy, encephalitis, encephalopathy, cerebellar ataxia, facial palsy, and myositis. However, most of these are isolated case reports. In this case series, we discuss the post-COVID neurological complications such as facial palsy, lateral rectus palsy, cerebellar ataxia, peripheral neuropathy, and stroke which occurred within 2 weeks after complete recovery from COVID. Methods: This multicentric case series is from three large tertiary care hospitals in northern and central India. We have reviewed seven patients with recent-onset neurological symptoms who had recovered from COVID infection within 2 weeks. We have retrospectively studied the clinical profile and radiological imaging during COVID infection. Results: Three out of these seven patients had received steroids during COVID treatment. None of our cases had any neurological manifestations during their COVID infection. The likelihood of neurotransmission through the cribriform plate via the olfactory bulb was low, as none of our patients had anosmia. None of the patients in the case series showed features of systemic hyperinflammatory syndrome, making the possibility of macrophage activation syndrome less likely. Conclusion: We hypothesize that antibodies against the coronavirus post recovery from COVID are responsible for these post-COVID neurological complications. Higher likelihood of these complications after rapid tapering off steroids may further corroborate this mechanism, as the antibody levels rise after steroid withdrawal. Titers of antibodies to SARS COV-2 virus in the postinfection period in these cases may have further helped prove our hypotheses which can be considered in future studies on the subject.

"You're Not Supposed to be on it Forever": Medications to Treat Opioid Use Disorder (MOUD) Related Stigma Among Drug Treatment Providers and People who Use Opioids.

Opioid use disorder (OUD) through prescription opioid misuse, heroin, and illicitly manufactured fentanyl use has increased dramatically in the past 20 years. Medications to treat opioid use disorder (MOUD) is considered the gold standard for treating opioid use disorders but uptake remains low. Recently, Madden has argued that in addition to the stigma assigned to substance use and people with SUD, MOUDs also are stigmatized, a process she labels intervention stigma to distinguish it from condition stigma (ie, stigma of SUD) . In this paper, we examine MOUD related stigma from the perspective of people who use opioids (PWUO) and key informants who play some role in providing or referring people to drug treatment. Providers and PWOU often viewed MOUD as one drug replacing another which discouraged providers from recommending and PWUO from accepting MOUD. MOUD stigma was also expressed by providers’ exaggerated fear of MOUD diversion. The extent to which MOUD was accepted as a legitimate treatment varied and influenced treatment providers’ perceptions of the goals of drug treatment and the length of time that MOUD should be used with many feeling that MOUD should only be used as a temporary tool while PWOU work on other treatment goals. This led to tapering off of MOUD after some time in treatment. Some providers also expressed mistrust of MOUD stemming from their previous experiences with the over-prescription of opioids for pain which led to the current crisis. Results from this study suggest that the proportion of PWUO on MOUD is unlikely to increase without addressing MOUD stigma among drug treatment providers and PWUO seeking treatment.

The Confusion between Pustular Psoriasis and Acute Generalized Exanthematous Pustulosis as a Cause of Exfoliative Dermatitis: A Case Report

Background: Pustular psoriasis and Acute Generalized Exanthematous Pustulosis (AGEP) are grouped under pustular diseases, in which their clinical manifestations are similar. Those diseases can lead to exfoliative dermatitis. Purpose:To evaluate a specific histopathological examination in differentiating Pustular Psoriasis and AGEP. Case: A 55-year-old woman presented with sudden redness and diffused scaly skin with multiple pustules and also fever. She had taken Cefadroxil 2 days before the scales and pustules appeared. Leukocytosis and histopathological examination results from biopsy supported the diagnosis of AGEP. The patient was then hospitalized and received steroid therapy. Within the first week of tapering off, the scales disappeared but the pustules increased. After such clinical findings, the histopathological examination results were revisited and reassessed. Thus, we considered changing the diagnosis to Pustular Psoriasis, and the therapy was switched to Methotrexate. The patient had a better outcome, and the pustules slowly disappeared entirely. Discussion: It is often difficult to differentiate between the pustules in pustular psoriasis and AGEP unless by thorough history-taking and physical examinations. AGEP is characterized by a widespread of pustules with an acute febrile onset; while pustular psoriasis is an acute variant of psoriasis where pustules are spread over erythematous skin and accompanied by high fever and leukocytosis. Conclusion: Histopathological examination is the gold standard for the establishment of pustular psoriasis diagnosis. The histopathological characteristics of pustular psoriasis and AGEP are difficult to differentiate. Therefore, we need detailed history-taking and physical examination to establish the diagnosis.

And they slept happily ever after: Online interpretive repertoires on the use of benzodiazepines and z-drugs.

Drawing on a critical social-psychological framework for discourse analysis, data from a popular forum for people over 50 were analysed to study how the habitual use of benzodiazepines and Z-drugs (BZD/Z) is discursively negotiated by Flemish older adults. We present five different repertoires (risk and addiction; alternative pathways; suffering; rationalisation; cessation) that illustrate how a pharmaceutical imaginary of these medications is constructed online and how posters act as reflexive users taking on a health role. Most repertoires emerge from a tacit norm on the undesirability of medication use for sleeping problems. In the alternative pathways and cessation repertoires this norm is implicitly accepted by focussing on how to either prevent or overcome chronic use with various alternative solutions or through tapering off, while the risk and addiction repertoire is used to more openly defend and discursively magnify the idea that medication has to be avoided at all cost. We discuss how this reflects a prevailing imperative of health and ethos of healthicisation of sleep. The rationalisation and suffering repertoires on the other hand challenge this norm by defending medication use. We further explore how these repertoires are used to self-position as either 'noble non-user', 'deserving and/or compliant patient' or 'rational user', reflecting previously found moral positions in offline settings. Our data add another position that has thus far not been discussed extensively with regard to prescription medication use, namely that of a 'recovered user'. As such, this study shows how this particular online community is a site for contestation of health promotion and medical/pharmaceuticalised discourses on sleep by users and non-users alike and offers a unique insight into how people in the age group that is known to use most BZD/Z discursively negotiate the use of these medications in pseudonymised online interactions.

Ethnobotanical Study in and around Sirso Natural Forest of Melokoza District, Gamo Goffa Zone, Southern Ethiopia

Background: Melokoza district has many ethnic groups and has a long tradition of using wild plants as a means of livelihood. However, communities’ knowledge associated to plants is not fully studied. Hence, this study was conducted to document plant-based indigenous knowledge of the people in order to preserve the tapering off indigenous plant species and their associated traditional knowledge. Methods: Ethnobotanical data were collected through semi-structured interviews, focus group discussion and guided field walk. A total of 72 informants were selected from four sampled Kebeles (the lowest administrative unit in Ethiopia) using stratified random sampling. Additional 24 key informants were selected purposively for exhaustive discussion. Preference ranking, paired comparison, direct matrix ranking, and informant consensus factor were calculated. Statistical tests were performed to compare the indigenous knowledge of the local communities on plants uses among different informant categories. Results: A total of 135 plant species distributed in 116 genera and 52 families were recorded. Among flowering families Asteraceae was the most dominant family (15 species), followed by Lamiaceae (12 species). Of the total species, 92 plant species were recorded as medicinal to cure 39 human and livestock ailments. Fresh leaves were the most frequently reported plant parts (36), followed by roots (27). The highest ICF value (0.91) was computed for parasite infections disease categories. Vepris dainellii and Embelia schimperi were the most popular medicinal plants with high informant consensus cited by 51 (71%) and 48 (67%) informants respectively. Cordia africana and Croton macrostachyus were shown to be the top multipurpose and the most utilized plant species in the study area. Significant difference at (P =0.003) was observed on the mean number of plant species stated by groups of respondents compared within gender and age on traditional use of plant species for different purposes. Elder people and traditional healers of the area possess vast knowledge on plant use and ethnomedicinal practices in comparison with the young generation and have a positive correlation relationship (r=0.507) between the age and their traditional medicinal knowledge. Vast knowledge on traditional uses of plant species conveyed from one generation to the next one by the word of mouth and the knowledge transfer system is quite restricted within the family members. Conclusions: The study revealed that Sirso natural forest of the district is a home for high diversity of plant species and associated indigenous knowledge. However, preservation efforts of the community are meager to assure survival of plant species and indigenous knowledge in the area. Thus, awareness creation to the youth and training to the healers is highly recommended to prevent the loss of plant species with their associated indigenous knowledge. Keywords: Ethnobotany, Indigenous knowledge, medicinal plants, Sirso natural forest

Impacts of family and fieldwork on career/family balance among tenure-track and tenured anthropologists.

A common dilemma rarely mentioned during doctoral training is career/family balance-especially the timing of children. This dilemma extends to professional anthropologists and includes questions surrounding the benefits and challenges of taking children to the field. We analyzed survey data from tenure-track and tenured anthropologists to determine if fieldwork in general and fieldwork with or without their children on site impacts career/family balance. We hypothesized that having children and the burden of fieldwork puts more strain on women than on men in anthropology. We compared 297 tenure-track and tenured anthropologists by gender, tenure status, and mean annual time spent conducting fieldwork using survey data collected for the Family and the Field study. Analysis was conducted using a combination of hierarchical multivariate analysis of variance and regression to analyze the differing factors affecting various groups. The primary differences in career/family balance occurred between tenure-track and tenured anthropologists, not women and men, and that fieldwork requirements do not necessarily make achieving personal balance harder for anthropologists than other academics. The need to conduct fieldwork may dissuade some people with or planning to have children from becoming anthropologists. However, upon obtaining tenure-track positions, the burdens impacting "balance" taper off and become less stressful. We offer policy suggestions for buffering stress related to career/family balance that may negatively impact decisions to pursue or continue in anthropology as a career.

Electrically controlled nicotine delivery through Carbon nanotube membranes via electrochemical oxidation and nanofluidically enhanced electroosmotic flow.

A promising tool for nicotine addiction treatment is a programmable nicotine delivery device coupled to smart phone-assisted behavioral therapies. Key metrics for such a device are delivery of adjustable nicotine doses tailored to individual needs, compact size and power efficiency. Reported here is a detailed optimization of carbon nanotube (CNT) membrane fabrication based on electrochemical oxidation, to improve its electrically driven performance for nicotine fluxes and switching ON (-1.5V)-OFF (0V) flux ratio. ON- state nicotine flux of ~ 6 µmoles/cm2/h at -1.5V applied bias was achieved allowing ~ 6-folds decrease in the size of device (4 cm2) to attain flux equivalent to high dose nicotine gum (1.1 µmoles/cm2/h). Application of + 1.5V bias in OFF state reduced diffusional background flux, giving an ON (-1.5V)/OFF (+ 1.5V) flux ratio of 68 that enabled device to deliver between the highest nicotine gum (1.1 µmoles/cm2/h) and lowest nicotine patch (0.08 µmoles/cm2/h) doses, as well as taper off nicotine doses for long term addiction treatment. The nicotine transport mechanism was studied as a function of pH and applied bias, using neutral tracer molecule, showing a mechanism of both electroosmosis and electrophoresis in the atomically smooth nanofluidic pores of CNTs. Optimal power consumption/flux efficiency of 111(µW/cm2)/µmoles/cm2/h was achieved allowing watch-battery lifetimes of 7-62days for conventional treatment dosing regimens. Bluetooth-enabled, remotely controlled CNT membrane system has potential for treatments of nicotine, opioid and alcohol addictions that needs dose adjustment with precise temporal control.

Spontaneous ARIA-like Events in Cerebral Amyloid Angiopathy-Related Inflammation: A Multicenter Prospective Longitudinal Cohort Study.

Background and ObjectivesThe goal of this work was to investigate the natural history and outcomes after treatment for spontaneous amyloid-related imaging abnormalities (ARIA)-like in cerebral amyloid angiopathy–related inflammation (CAA-ri).MethodsThis was a multicenter, hospital-based, longitudinal, prospective observational study of inpatients meeting CAA-ri diagnostic criteria recruited through the Inflammatory Cerebral Amyloid Angiopathy and Alzheimer's Disease βiomarkers International Network from January 2013 to March 2017. A protocol for systematic data collection at first-ever presentation and at subsequent in-person visits, including T1-weighted, gradient recalled echo–T2*, fluid-suppressed T2-weighted (fluid-attenuated inversion recovery), and T1 postgadolinium contrast-enhanced images acquired on 1.5T MRI, was used at the 3-, 6-, 12-, and 24-month follow-up. Centralized reads of MRIs were performed by investigators blinded to clinical, therapeutic, and time-point information. Main outcomes were survival, clinical and radiologic recovery, intracerebral hemorrhage (ICH), and recurrence of CAA-ri.ResultsThe study enrolled 113 participants (10.6% definite, 71.7% probable, and 17.7% possible CAA-ri). Their mean age was 72.9 years; 43.4% were female; 37.1% were APOEε4 carriers; 36.3% had a history of Alzheimer disease; and 33.6% had a history of ICH. A history of ICH and the occurrence of new ICH at follow-up were more common in patients with cortical superficial siderosis at baseline (52.6% vs 14.3%, p < 0.0001 and 19.3% vs 3.6%, p < 0.009, respectively). After the first-ever presentation of CAA-ri, 70.3% (95% confidence interval [CI] 61.6%–78.5%) and 84.1% (95% CI 76.2%–90.6%) clinically recovered within 3 and 12 months, followed by radiologic recovery in 45.1% (95% CI 36.4%–54.8%) and 77.4% (95% CI 67.7%–85.9%), respectively. After clinicoradiologic resolution of the first-ever episode, 38.3% (95% CI 22.9%–59.2%) had at least 1 recurrence within the following 24 months. Recurrence was more likely if IV high-dose corticosteroid pulse therapy was suddenly stopped compared to slow oral tapering off (hazard ratio 4.68, 95% CI 1.57–13.93; p = 0.006).DiscussionThese results from the largest longitudinal cohort registry of patients with CAA-ri support the transient and potentially relapsing inflammatory nature of the clinical-radiologic acute manifestations of the disease and the effectiveness of slow oral tapering off after IV corticosteroid pulse therapy in preventing recurrences. Our results highlight the importance of differential diagnosis for spontaneous ARIA-like events in β-amyloid–driven diseases, including treatment-related ARIA in patients with Alzheimer disease exposed to immunotherapy drugs.

A Case Report :Alprazolam Therapy in A Dextra Fronto-Parietal Meningioma Patient With Anxiety Disorders

Meningiomas in the frontoparietal lobe may cause anxiety disorders and panic attacks. While alprazolam is one of the most widely used medications for anxiety disorders, long-term use may result in adverse side effects (withdrawal and rebound effects). This case study aims to describe the efficacy of long-term alprazolam administration in patients with meningiomas for regulating anxiety disorders. Case report :The asymmetrical face is the primary concern of a 65-year-old female when she is anxious. The results of the physical assessment and laboratory tests are within normal ranges. However, The HARS procedure showed moderate anxiety, and the CT scan revealed a meningioma in the right frontoparietal lobe. To regulate patient anxiety disorders, doctors give alprazolam 0.5 mg per day single dose for 4 months and tapering off for 3 months. Conclusion: Long-term administration of alprazolam in these patients can reduce the patient's anxiety disorder without causing withdrawal or rebound effects. A low dosage of alprazolam, a mild level of anxiety illness, and a slow tapering off phase were factors that contributed to the effectiveness of alprazolam treatment to suppress anxiety symptoms in this situation.

Implications of dopaminergic medication withdrawal in Parkinson's disease.

The trajectory of the use of dopamine replacement therapy (DRT) in Parkinson’s disease (PD) is variable and doses may need to be increased, but also tapered. The plan for dose adjustment is usually done as per drug information recommendations from the licensing bodies, but there are no clear guidelines with regards to the best practice regarding the tapering off schedule given sudden dose reductions of drugs such as dopamine agonists may have serious adverse consequences. A systematic literature search was, therefore, performed to derive recommendations and the data show that there are no controlled studies or evidence-based recommendations how to taper or discontinue PD medication in a systematic manner. Most of the data were available on the dopamine agonist withdrawal syndrome (DAWS) and we found only two instructions on how to reduce pramipexole and rotigotine published by the EMA. We suggest that based on the available data, levodopa, dopamine agonists (DA), and amantadine should not be discontinued abruptly. Abrupt or sudden reduction of DA or amantadine in particular can lead to severe life-threatening withdrawal symptoms. Tapering off levodopa, COMT inhibitors, and MAO-B inhibitors may worsen motor and non-motor symptoms. Based on our clinical experience, we have proposed how to reduce PD medication and this work will form the basis of a future Delphi panel to define the recommendations in a consensus.

Psychofarmaca: pleidooi voor een voorzichtig beleid bij vroege psychose

Psychopharmaceuticals: a plea for cautious management in early psychosis. From the holistic approach in VRINT (Early psychosis intervention team), a psychotic episode is regarded as an existential crisis in which both biological and psychosocial factors play a role and interact with each other. Non-pharmacological treatments are indispensable and preferred. However, antipsychotics can have an important role and be even lifesaving in certain circumstances. Therefore, in this article 3 questions are explored: How long before prescribing antipsychotics? How long should they be prescribed and is medication tapering possible? Are antipsychotics neuroprotective or rather harmful? Based on the scientific literature regarding antipsychotics as well as their own experience, the authors conclude that they do have their place in treating early psychosis, but they should be prescribed with the necessary caution, since antipsychotics are not harmless products. Treatment with antipsychotics should always consist of administering the lowest possible dose with a minimum of side effects. The decision to start treatment with antipsychotics and the correct adjustment of dosage should always be done in consultation with the person in crisis and his or her family. After a first psychotic episode, medication tapering can be considered, but the tapering off must be properly supervised over a sufficiently long period of time. After all, a full long-term recovery is pursued, whereby the person with psychosis can take control of his or her own life.

Frequency of computed tomography abnormalities in patients with chronic thromboembolic pulmonary hypertension: a comparative study between lung perfusion scan and computed tomography pulmonary angiography.

IntroductionChronic thromboembolic pulmonary hypertension (CTEPH) is one of the leading causes of pulmonary hypertension. Diagnosis of CTEPH can be established using various imaging techniques, including ventilation-perfusion scintigraphy (VQ) and multidetector computed tomography pulmonary angiography (CTPA). The aim of this study was to determine the frequency of direct pulmonary vascular, parenchymal lung, and cardiac abnormalities on CTPA in patients with CTEPH and to compare the diagnostic accuracy of both VQ scan CTPA in detecting CTEPH.MethodsWe retrospectively included 54 patients who had been referred for pulmonary hypertension service (20 males, 34 females). All patients had VQ scan and CTPA within 15 days and underwent pulmonary artery endarterectomy (PEA) thereafter. VQ scans were reported according to modified PIOPED (Prospective Investigation of Pulmonary Embolism Diagnosis) criteria. CTPA was considered as diagnostic for CTEPH if it showed presence of thrombus, webs, stenosis, or perfusion lung abnormalities.ResultsThe mean age of the study population was 41±10 years. The mean pulmonary artery pressure was 53±13 mmHg. Fifty-three out of 54 patients in the study population had high probability VQ scan and one patient had intermediate probability. CTPA was suggestive of CTEPH in all patients. The most frequent CTPA findings in the central pulmonary arteries and peripheral arteries were presence of thrombotic materials, abnormal vessel tapering and abrupt vessels-cut off (76% vs 65%, 67% vs 48%, and 48% vs 22%), respectively. The mosaic lung perfusion was present in 78% of the patients, and various cardiac morphology abnormalities were present and most common was abnormal right to left ventricle ratio (69%).ConclusionOur findings indicate that both VQ scan and CTPA are highly sensitive for the detection of CTEPH confirmed by PEA. Most CTEPH patients had several pulmonary vascular, parenchymal lung and cardiac abnormalities. There was no sign with 100% sensitivity on CTPA for CTEPH detection.

Nonlinear association of nurse staffing and readmissions uncovered in machine learning analysis.

Several studies of nurse staffing and patient outcomes found a curvilinear or U-shaped relationship, with benefits from additional nurse staffing diminishing or reversing at high staffing levels. This study examined potential diminishing returns to nurse staffing and the existence of a "tipping point" or the level of staffing after which higher nurse staffing no longer improves and may worsen readmissions. The Readiness Evaluation And Discharge Interventions (READI) study database of over 130,000 adult (18+) inpatient discharges from 62 medical, surgical, and medical-surgical (noncritical care) units from 31 United States (US) hospitals during October 2014-March 2017. Observational cross-sectional study using a fully nonparametric random forest machine learning method. Primary exposure was nurse hours per patient day (HPPD) broken down by registered nurses (nonovertime and overtime) and nonlicensed nursing personnel. The outcome was 30-day all-cause same-hospital readmission. Partial dependence plots were used to visualize the pattern of predicted patient readmission risk along a range of unit staffing levels, holding all other patient characteristics and hospital and unit structural variables constant. Secondary analysis of the READI data. Missing values were imputed using the missing forest algorithm in R. Partial dependence plots were U-shaped, showing the readmission risk first declining and then rising with additional nurse staffing. The tipping points were at 6.95 and 0.21 HPPD for registered nurse staffing (nonovertime and overtime, respectively) and 2.91 HPPD of nonlicensed nursing personnel. The U-shaped association was consistent with diminishing returns to nurse staffing suggesting that incremental gains in readmission reduction from additional nurse staffing taper off and could reverse at high staffing levels. If confirmed in future causal analyses across multiple outcomes, accompanying investments in infrastructure and human resources may be needed to maximize nursing performance outcomes at higher levels of nurse staffing.

Transitioning From Thrombopoietin Agonists to the Novel SYK Inhibitor Fostamatinib: A Multicenter, Real-World Case Series.

Fostamatinib is an oral spleen tyrosine kinase (SYK) inhibitor used for the treatment of adult patients with chronic immune thrombocytopenia (ITP) who have had an insufficient response to a previous treatment. Clinical and operational barriers may exist that warrant bridging or switching from thrombopoietin receptor agonists (TPO-RAs), such as volatility or unpredictability of platelets, adverse events, and quality of life or patient preference. While fostamatinib demonstrated durable platelet responses, the safety and efficacy in combination, bridging, and/or switching with TPO-RAs is not well documented. The objective of this article is to provide guidance from real-world case studies for a safe and effective strategy for the transitioning of patients from TPO-RAs to fostamatinib, with some degree of overlap between the two agents. Currently, the evidence does not exist to guide the safe and effective use of combination therapy or transition between therapies in ITP. This case series highlights the importance to further understand the complexities of managing this disease, as well as successfully combining, bridging, and/or switching patients over to fostamatinib without the need for rescue therapy or increase in adverse events. The need for real-world evidence that guides providers on the safety and efficacy of short- and long-term combination therapy of fostamatinib and TPO-RAs is crucial. The rationale for combination therapy is to target different pathways, platelet destruction, and production without added toxicities. Additionally, gradual tapering off of TPO-RAs may provide a more favorable clinical outcome when switching to fostamatinib. The need for additional data is necessary to provide clinicians with guidance when managing patients with ITP.