Neurocritical care is an evolving subspecialty, integrating clinical expertise in neurology, neurosurgery, and intensive care medicine to diagnose and treat critically ill patients with neurological disease. University Hospitals Cleveland Medical Center (UHCMC) offers a comprehensive Neurocritical Care Fellowship that provides physicians with a unique combination of cognitive, diagnostic and therapeutic skills necessary for the neurocritical care.

The purpose of the training program is to prepare the physician for the independent practice of neurological intensive care. Our approach is based on supervised clinical work, with increasing patient care responsibility over the course of the training program. The UHCMC fellowship program, affiliated with Case Western Reserve University School of Medicine, has a strong foundation of organized instruction in basic elements of both neurological and medical aspects of critical care.

Curriculum

Like all intensivists, the neurointensivist assumes the primary care role for patients in the ICU, coordinating both the neurological and medical management of the patient.

Therefore, the Core Curriculum for the UHCMC Neurocritical Care Fellowship Training is evenly split between neurological diseases and conditions and medical diseases and conditions that commonly complicate acute neurological illnesses.

Clinical Rotations

Our UHCMC program is a two-year fellowship that includes 12 months of ICU time in which the fellow functions as a primary provider of critical care. This includes eight months in the Neurological Intensive Care Unit and four months rotating in the other medical and surgical intensive care units. The remaining 12 months are dedicated to Neurosurgery and Stroke Service, Electives, and protected Research time.

Didactic Components

All fellows regularly attend seminars and conferences in neurology, neurosurgery, critical care, and neuroradiology. This includes a two-year multi-disciplinary critical care course that cover all aspects of intensive care medicine. Additional didactic exposure is available in neuropathology, neuromuscular disease, cerebrovascular disease, epilepsy and neurophysiology, pain management, and rehabilitation. All fellows attend periodic seminars, journal clubs, lectures in basic science, didactic courses, and meetings of local and national neurological societies.

Research

All fellows conduct clinical or basic research during the course of the training. There is tremendous support available at UHCMC and CWRU for developing research projects. Some of the Center's research projects are listed on the research page.

Annual Cleveland Neurocritical Care & Stroke Conference

Each year, we have gathered a distinguished group of world leaders to review advances in the diagnosis and management of acute stroke and neurocritical care in a two-day course. This conference has an innovative, informal, Rock and Roll-themed format so as to create an experience that is both educational and enjoyable. We also host the Annual CWRU Critical Care Bioinformatics Workshop designed to focus on advances in Health Information Technology and informatics. Third, we host our Annual CWRU TCD Ultrasound Workshop designed to provide a complete review of ultrasound principles, techniques, and interpretation. In 2010, we hosted the the 1st Annual Cleveland Music and Medicine Symposium designed to explore the fascinating intersection of music and the brain and music and health.

Trainee Duty Hours and Working Environment

Fellow duty hours are consistent with the ACGME requirements. Neurocritical care fellows do not take in-house calls.

Evaluation and Certification

Clearly defined procedures for regular evaluation of fellows knowledge, skills and overall performance, including the development of professional attitudes consistent with being a physician, are part of the fellowship. Fellows are evaluated on following areas: Patient, Medical Knowledge, Practice-based learning and improvement, Interpersonal and communication skills, Professionalism, Systems-based practice. Upon completion of the program, fellows will be eligible for certification in Neurocritical Care through the United Councils of Neurologic Subspecialties.

Trainee Qualifications

Neurological intensive care fellowship training must be preceded by the completion of residency training in neurology, neurological surgery, internal medicine, anesthesiology, surgery, or emergency medicine, in a program accredited by Accreditation Council for Graduate Medical Education (ACGME) or the Royal College of Physicians (Canada). An Ohio medical license is required.

Related Links

Contact

For more information, please contact:

Michael A. De Georgia, MD, FCCM, FNCS
Director, Center for Neurocritical Care
Email: Michael.DeGeorgia@UHhospitals.org

or

Tarrika Allen
Academic Education Coordinator
University Hospitals Neurological Institute
216.844.3100
Email: Tarrika.Allen@UHhospitals.org

When writing about digital technology, or any topic, is something you do, it takes time to accumulate credibility. Even if you put in the study time up front to know your stuff, building trust takes time.

I’ve been fortunate that, after years expanding my portfolio and the knowledge base under it, people come to me for advice on related subject matter. I’m still not totally comfortable in this position, but I roll with it.

As more professionals put stock in my technical background, I have been exposed to more specialized technical environments and use cases. Friends asking for consumer electronics troubleshooting is worlds apart from professionals looking to overcome a technical hurdle.

This new class of advice I’m prompted to provide has elucidated the challenges that professionals confront. Moreover, when I field the same question multiple times, it hints at a potential gap in computer science training. Naturally, I want to do my part to close it.

To be clear, I’m not putting anyone down. There are plenty of things I don’t know and probably should. I simply want to draw attention to concepts that I’m surprised that competent individuals struggle with. Specifically, what I regard as key Unix principles I’ve found notably missing.

I’m not totally surprised, as a lot of “tech sector” professionals work in levels of abstraction above the OS. But it pays to know these Unix basics considering there is often a Unix/Unix-like OS somewhere in the abstraction hierarchy. If that layer is unsound, the whole edifice risks collapse.

To that end, I want to highlight questions I’ve been asked about Unixy (my substitute for “Unix and Unix-like”) systems, and the fundamentals to grasp to become self-sufficient.

To Run Programs, It’s Best To Stay on the $PATH

While it’s easier than ever for software developers to escape the command line interface, sometimes it’s unavoidable.

If a program comes preinstalled on a Unixy system or can be installed from an official OS repository, it’s usually easy to invoke. But when the CLI program is some executable downloaded from the internet, this can trip people up.

Running it from within its directory is no big deal. Clicking on it in the file browser might even pop open a terminal emulator and run it. But once some (mainly neophyte) developers leave that directory, they’re not sure why the command is inaccessible without giving the absolute or relative path to it.

This has to do with the shell’s PATH environment variable. When you enter a command into a shell like Bash, the shell has to know where it is. In Unix, everything is a file, and every file is somewhere in the file tree (starting at /). But if the system had to search every file, that would take too long.

Instead, your shell only looks in the directories in the PATH variable. If there is no executable file with the name you entered in one of those directories, a Unixy system doesn’t know where that command is.

To see what directories are in your PATH, open a terminal and run echo $PATH. This outputs the value of the PATH variable as it is currently set in the shell.

If you want to add more places for your system to check for executables, just update PATH. Define the PATH variable explicitly in your shell’s configuration file (e.g. for Bash, ~/.bashrc, ~/.bash_profile or something similar). One common practice is to make a directory in the user’s home directory called “bin” and add $HOME/bin to your PATH (HOME being the current user’s home).

Remember, you don’t want to replace your PATH with just the desired directory. That would make it the only place your shell looks. You just want one more place to search. You could copy the output of echo $PATH as is and paste it into your shell config file. The more conventional method is to add this line:

PATH=”PATH:$HOME/bin”

Just as with many common programming languages, this assignment statement works because the right side of the “=” sign is evaluated first and then assigned to the left side. In other words, your current PATH is returned, your new directory is concatenated to the end, and then PATH is set to that.

Set It So Your Shell Won’t Forget It

There’s another property of environment variables I’ve seen developers overlook: how long they persist.

It’s not uncommon for devs to utilize CLI tools that expect certain environment variables. In Unixy systems, you’re free to define any arbitrary environment variable with any arbitrary value. When they need one, I typically see devs run the same environment variable definition every time they launch their terminal.

This is because every time most terminal emulators (and with them, a shell) start for the first time (from not running anywhere on the system), they start a new session. When the last of the shell processes associated with the terminal emulator terminates, so too does the session. Notably, environment variables set via export command only last for the session.

As you probably intuited, we can set our environment variable in our shell config file just as we did with PATH. Just refer to the PATH definition syntax above to see how. Now enjoy all the time you saved.

Always Know Who’s Listening

While I wouldn’t necessarily consider it a core Unix concept, this next trick is so handy that I’m surprised more devs don’t know it.

In the course of managing some Unixy system, eventually you may need to know what network ports are actively listening. Doing so by checking all running services can be cumbersome because, depending on the system’s available tooling, open ports may not appear in the summarized output. It’s easier to skip the service utility and analyze the ports directly.

My preferred approach is to use lsof. This useful command returns all open files. “Wait,” you might say, “I’m looking for ports, not files.” Ah, but remember, in Unix, everything is a file. That includes ports.

Even better, lsof is tailored for this use case (among many others), as its -i flag limits output to files used as part of Internet Protocol communication. By running lsof -i you can see every open port, including listening ones.

You may want to throw in other flags or pipe it through a regular expression filter via grep to narrow down your search, but the above command alone will get you most of the way there.

Just Your Friendly Neighborhood Penguin-Man

What drew me most to the idea for this article was its direct applicability to a whole class of people who need quick, reliable answers. As I invest more into professional dialog with developers, I hope to uncover more areas where I’m able to light the Unix way I’ve grown so fond of.

Suggest a Topic

Is there a Unix tutorial you’d like to see featured?

Please email your ideas to me and I’ll consider them for a future column.

And use the Reader Comments feature below to provide your input!

JavaScript (JS) is extremely popular in the ecommerce world because it helps create a seamless and user-friendly experience for shoppers.

Take, for instance, loading items on category pages, or dynamically updating products on the site using JS.

While this is great news for ecommerce sites, JavaScript poses several challenges for SEO pros.

Google is consistently working on improving its search engine, and a big part of its effort is dedicated to making sure its crawlers can access JavaScript content.

But, ensuring that Google seamlessly crawls JS sites isn’t easy.

In this post, I’ll share everything you need to know about JS SEO for ecommerce and how you can Improve your organic performance.

Let’s begin!

How JavaScript Works For Ecommerce Sites

When building an ecommerce site, developers use HTML for content and organization, CSS for design, and JavaScript for interaction with backend servers.

JavaScript plays three prominent roles within ecommerce websites.

1. Adding Interactivity To A Web Page

The objective of adding interactivity is to allow users to see changes based on their actions, like scrolling or filling out forms.

For instance: a product image changes when the shopper hovers the mouse over it. Or hovering the mouse makes the image rotate 360 degrees, allowing the shopper to get a better view of the product.

All of this enhances user experience (UX) and helps buyers decide on their purchases.

JavaScript adds such interactivity to sites, allowing marketers to engage visitors and drive sales.

2. Connecting To Backend Servers

JavaScript allows better backend integration using Asynchronous JavaScript (AJAX) and Extensible Markup Language (XML).

It allows web applications to send and retrieve data from the server asynchronously while upholding UX.

In other words, the process doesn’t interfere with the display or behavior of the page.

Otherwise, if visitors wanted to load another page, they would have to wait for the server to respond with a new page. This is annoying and can cause shoppers to leave the site.

So, JavaScript allows dynamic, backend-supported interactions – like updating an item and seeing it updated in the cart – right away.

Similarly, it powers the ability to drag and drop elements on a web page.

3. Web Tracking And Analytics

JavaScript offers real-time tracking of page views and heatmaps that tell you how far down people are memorizing your content.

For instance, it can tell you where their mouse is or what they clicked (click tracking).

This is how JS powers tracking user behavior and interaction on webpages.

How Do Search Bots Process JS?

Google processes JS in three stages, namely: crawling, rendering, and indexing.

As you can see in this image, Google’s bots put the pages in the queue for crawling and rendering. During this phase, the bots scan the pages to assess new content.

When a URL is retrieved from the crawl queue by sending an HTTP request, it first accesses your robots.txt file to check if you’ve permitted Google to crawl the page.

If it’s disallowed, the bots will ignore it and not send an HTTP request.

In the second stage, rendering, the HTML, CSS, and JavaScript files are processed and transformed into a format that can be easily indexed by Google.

In the final stage, indexing, the rendered content is added to Google’s index, allowing it to appear in the SERPs.

Common JavaScript SEO Challenges With Ecommerce Sites

JavaScript crawling is a lot more complex than traditional HTML sites.

The process is quicker in the case of the latter.

Check out this quick comparison.

Thus, with JS-rich ecommerce sites, Google finds it tough to index content or discover links before the page is rendered.

In fact, in a webinar on how to migrate a website to JavaScript, Sofiia Vatulyak, a renowned JS SEO expert, shared,

“Though JavaScript offers several useful features and saves resources for the web server, not all search engines can process it. Google needs time to render and index JS pages. Thus, implementing JS while upholding SEO is challenging.”

Here are the top JS SEO challenges ecommerce marketers should be aware of.

Limited Crawl Budget

Ecommerce websites often have a massive (and growing!) volume of pages that are poorly organized.

These sites have extensive crawl budget requirements, and in the case of JS websites, the crawling process is lengthy.

Also, outdated content, such as orphan and zombie pages, can cause a huge wastage of the crawl budget.

Limited Render Budget

As mentioned earlier, to be able to see the content loaded by JS in the browser, search bots have to render it. But rendering at scale demands time and computational resources.

In other words, like a crawl budget, each website has a render budget. If that budget is spent, the bot will leave, delaying the discovery of content and consuming extra resources.

Google renders JS content in the second round of indexing.

It’s important to show your content within HTML, allowing Google to access it.

Go to the Inspect element on your page and search for some of the content. If you cannot find it there, search engines will have trouble accessing it.

Troubleshooting Issues For JavaScript Websites Is Tough

Most JS websites face crawlability and obtainability issues.

For instance, JS content limits a bot’s ability to navigate pages. This affects its indexability.

Similarly, bots cannot figure out the context of the content on a JS page, thus limiting their ability to rank the page for specific keywords.

Such issues make it tough for ecommerce marketers to determine the rendering status of their web pages.

In such a case, using an advanced crawler or log analyzer can help.

Tools like Semrush Log File Analyzer, Google Search Console Crawl Stats, and JetOctopus, among others, offer a full-suite log management solution, allowing webmasters to better understand how search bots interact with web pages.

JetOctopus, for instance, has JS rendering functionality.

Check out this GIF that shows how the tool views JS pages as a Google bot.

Similarly, Google Search Console Crawl Stats shares a useful overview of your site’s crawl performance.

The crawl stats are sorted into:

• Kilobytes downloaded per day show the number of kilobytes bots obtain each time they visit the website.
• Pages crawled per day shows the number of pages the bots crawl per day (low, average, or high).
• Time spent downloading a page tells you the amount of time bots take to make an HTTP request for the crawl. Less time taken means faster crawling and indexing.

Client-Side Rendering On Default

Ecommerce sites that are built in JS frameworks like React, Angular, or Vue are, by default, set to client-side rendering (CSR).

With this setting, the bots will not be able to see what’s on the page, thus causing rendering and indexing issues.

Large And Unoptimized JS Files

JS code prevents critical website resources from loading quickly. This negatively affects UX and SEO.

Top Optimization Tactics For JavaScript Ecommerce Sites

1. Check If Your JavaScript Has SEO Issues

Here are three quick tests to run on different page templates of your site, namely the homepage, category or product listing pages, product pages, blog pages, and supplementary pages.

URL Inspection Tool

Access the Inspect URL report in your Google Search Console.

Enter the URL you want to test.

Next, press View Tested Page and move to the screenshot of the page. If you see this section blank (like in this screenshot), Google has issues rendering this page.

Repeat these steps for all of the relevant ecommerce page templates shared earlier.

Run A Google Search

Running a site search will help you determine if the URL is in Google’s index.

First, check the no-index and canonical tags. You want to ensure that your canonicals are self-referencing and there’s no index tag on the page.

Next, go to Google search and enter – Site:yourdomain.com inurl:your url

If there’s some issue with your site’s JS, you’ll either not see this result or get a result that’s similar to this, but Google will not have any meta information or anything readable.

At times, Google may index pages, but the content is unreadable. This final test will help you assess if Google can read your content.

Gather a bunch of content from your page templates and enter it on Google to see the results.

Let’s take some content from Macy’s.

Screenshot from Macy’s, September 2022

But check out what happens with this content on Kroger. It’s a nightmare!

Follow these tests with a detailed JS website audit using an SEO crawler that can help identify if your website failed when executing JS, and if some code isn’t working properly.

For instance, a few SEO crawlers have a list of features that can help you understand this in detail:

• The “JavaScript performance” report offers a list of all the errors.
• The “browser performance events” chart shows the time of lifecycle events when loading JS pages. It helps you identify the page elements that are the slowest to load.
• The  “load time distribution” report shows the pages that are fast or slow. If you click on these data columns, you can further analyze the slow pages in detail.

2. Implement Dynamic Rendering

How your website renders code impacts how Google will index your JS content. Hence, you need to know how JavaScript rendering occurs.

Server-Side Rendering

In this, the rendered page (rendering of pages happens on the server) is sent to the crawler or the browser (client). Crawling and indexing are similar to HTML pages.

But implementing server-side rendering (SSR) is often challenging for developers and can increase server load.

Further, the Time to First Byte (TTFB) is slow because the server renders pages on the go.

One thing developers should remember when implementing SSR is to refrain from using functions operating directly in the DOM.

Client-Side Rendering

Here, the JavaScript is rendered by the client using the DOM. This causes several computing issues when search bots attempt to crawl, render, and index content.

A viable alternative to SSR and CSR is dynamic rendering that switches between client and server-side rendered content for specific user agents.

It allows developers to deliver the site’s content to users who access it using JS code generated in the browser.

However, it presents only a static version to the bots. Google officially supports implementing dynamic rendering.

To deploy dynamic rendering, you can use tools like Prerender.io or Puppeteer.

These can help you serve a static HTML version of your Javascript website to the crawlers without any negative impact on CX.

Dynamic rendering is a great solution for ecommerce websites that usually hold lots of content that change frequently or rely on social media sharing (containing embeddable social media walls or widgets).

3. Route Your URLs Properly

JavaScript frameworks use a router to map clean URLs. Hence, it is critical to update page URLs when updating content.

For instance, JS frameworks like Angular and Vue generate URLs with a hash (#) like www.example.com/#/about-us

Such URLs are ignored by Google bots during the indexing process. So, it is not advisable to use #.

Instead, use static-looking URLs like http://www.example.com/about-us

4. Adhere To The Internal Linking Protocol

Internal links help Google efficiently crawl the site and highlight the important pages.

A poor linking structure can be harmful to SEO, especially for JS-heavy sites.

One common issue we’ve encountered is when ecommerce sites use JS for links that Google cannot crawl, such as onclick or button-type links.

Check this out:

<a href=”/important-link”onclick=”changePage(‘important-link’)”>Crawl this</a>

If you want Google bots to discover and follow your links, ensure they are plain HTML.

Google recommends interlinking pages using HTML anchor tags with href attributes and asks webmasters to avoid JS event handlers.

5. Use Pagination

Pagination is critical for JS-rich ecommerce websites with thousands of products that retailers often opt to spread across several pages for better UX.

Allowing users to scroll infinitely may be good for UX, but isn’t necessarily SEO-friendly. This is because bots don’t interact with such pages and cannot trigger events to load more content.

Eventually, Google will reach a limit (stop scrolling) and leave. So, most of your content gets ignored, resulting in a poor ranking.

Make sure you use <a href> links to allow Google to see the second page of pagination.

For instance, use this:

<a href=”https://example.com/shoes/”>

6. Lazy Load Images

Though Google supports lazy loading, it doesn’t scroll through content when visiting a page.

It resizes the page’s virtual viewport, making it longer during the crawling process. And because the  “scroll” event listener isn’t triggered, this content isn’t rendered.

Thus, if you have images below the fold, like most ecommerce websites, it’s critical to lazy load them, allowing Google to see all your content.

7. Allow Bots To Crawl JS

This may seem obvious, but on several occasions, we’ve seen ecommerce sites accidentally blocking JavaScript (.js) files from being crawled.

This will cause JS SEO issues, as the bots will not be able to render and index that code.

Check your robots.txt file to see if the JS files are open and available for crawling.

8. Audit Your JS Code

Finally, ensure you audit your JavaScript code to optimize it for the search engines.

Use tools like Google Webmaster Tools, Chrome Dev Tools, and Ahrefs and an SEO crawler like JetOctopus to run a successful JS SEO audit.

Google Search Console

This platform can help you optimize your site and monitor your organic performance. Use GSC to monitor Googlebot and WRS activity.

For JS websites, GSC allows you to see problems in rendering. It reports crawl errors and issues notifications for missing JS elements that have been blocked for crawling.

Chrome Dev Tools

These web developer tools are built into Chrome for ease of use.

The platform lets you inspect rendered HTML (or DOM) and the network activity of your web pages.

From its Network tab, you can easily identify the JS and CSS resources loaded before the DOM.

Ahrefs

Ahrefs allows you to effectively manage backlink-building, content audits, keyword research, and more. It can render web pages at scale and allows you to check for JavaScript redirects.

You can also enable JS in Site Audit crawls to unlock more insights.

The Ahrefs Toolbar supports JavaScript and shows a comparison of HTML to rendered versions of tags.

JetOctopus SEO Crawler And Log Analyzer

JetOctopus is an SEO crawler and log analyzer that allows you to effortlessly audit common ecommerce SEO issues.

Since it can view and render JS as a Google bot, ecommerce marketers can solve JavaScript SEO issues at scale.

Its JS Performance tab offers comprehensive insights into JavaScript execution – First Paint, First Contentful Paint, and page load.

It also shares the time needed to complete all JavaScript requests with the JS errors that need immediate attention.

GSC integration with JetOctopus can help you see the complete dynamics of your site performance.

Ryte UX Tool

Ryte is another tool that’s capable of crawling and checking your javascript pages. It will render the pages and check for errors, helping you troubleshoot issues and check the usability of your dynamic pages.

seoClarity

seoClarity is an enterprise platform with many features. Like the other tools, it features dynamic rendering, letting you check how the javascript on your website performs.

Summing Up

Ecommerce sites are real-world examples of dynamic content injected using JS.

Hence, ecommerce developers rave about how JS lets them create highly interactive ecommerce pages.

On the other hand, many SEO pros dread JS because they’ve experienced declining organic traffic after their site started relying on client-side rendering.

Though both are right, the fact is that JS-reliant websites too can perform well in the SERP.

Follow the tips shared in this guide to get one step closer to leveraging JavaScript in the most effective way possible while upholding your site’s ranking in the SERP.

More resources:

Featured Image: Visual Generation/Shutterstock

The appointment of a new Registration, Recognition and Certification Board (RRCB) is high on the agenda and the process is expected to be completed in short order, according to Natalie Willis, the acting permanent secretary in the Ministry of Labour.

The Board has not been operational since May 30, 2022 following the expiry of the term of the chairman and eight members.

This Board is responsible for matters relating to the certification of trade unions as recognised majority unions in accordance with Part II, Section 21 (1) of the Industrial Relations Act, Chapter 88:01 (IRA).

The work of the Board also facilitates workers’ right to freedom of association and the effective recognition of the right to collective bargaining by joining a trade union of their choice.

Speaking at the Board’s 50th anniversary, at Crews Inn ballroom, Chaguaramas last Friday, Willis said the Ministry of Labour is working assiduously to complete the process of filling the positions of members needed to constitute the new RRCB.

She noted that under the function of labour administration, the Conciliation Advisory and Advocacy Division of the Ministry and the RRCB have been able to fulfil their obligations to the Industrial Court.

“It has been noted that there was a sharp increase in the number of requests made to the RRCB through the Minister of Labour to ascertain membership in good standing and to also ascertain workers within the meaning of the Act.

“For 2020, there were 27 requests to the RRCB whereas for 2021, there were 96 requests sent for investigation,” Willis highlighted.

She added that it is noteworthy to mention that there has been an increase in the RRCB’s response rate to its stakeholders’ requests, which is attributed to your improved internal processes.

Board secretary and secretariat, Brendon Taitt, who said the Board has determined bargaining units for large organisations thereby giving full benefit to the right to organise and the right to collective bargaining.

Taitt said it must be noted that the Trinidad and Tobago Unified Teachers’ Association (TTUTA) is the only public service association that has a certificate of recognition from the Board.

He explained that the Board, as the first port of call, has put to rest the burning issue of the recognition of unions, which gives full effect to the right to organise and the right to collective bargaining.

In spite of its challenges, Taitt outlined that the Board continues to fulfil its mandate and the stakeholders must be cognisant of the fact that delays only hurt the worker.

“Therefore, it is my humble view that the powers that be in the new legislation that in order for the Board to be expeditious there is need to remove it from being subjected to judicial review. Any appeal should be to the Industrial Court on points of law,” Taitt stressed.

Abstract and Introduction

Abstract

Study Objective. To determine the effects of mild-to-moderate induced hypothermia—a neuroprotectant and/or therapeutic strategy for the management of intracranial hypertension in neurologically injured patients—on the pharmacokinetics of aminoglycoside therapy.
Design. Pharmacokinetic analysis.
Setting. Critical care unit at a university-affiliated hospital.
Patients. Three patients, aged 22, 24, and 47 years, who received tobramycin and had documented tobramycin levels while undergoing induced hypothermia for more than 24 hours for intracranial hypertension.
Measurements and Main Results. For each of the three patients, predicted pharmacokinetic parameters (volume of distribution, first-order elimination rate constant, half-life, and renal drug clearance) based on population data were compared with their real pharmacokinetic parameters that were calculated based on observed tobramycin serum levels. All three patients had a normal creatinine clearance, estimated according to established methods. When pharmacokinetic parameters were calculated after the first tobramycin dose using a one-compartment method, all patients had a slower first-order elimination rate and a larger volume of distribution compared with predicted population estimates.
Conclusion. These findings suggest that induced hypothermia may result in impaired elimination of aminoglycosides. Caution should be exercised when attempting to use predicted pharmacokinetic parameters to dose aminoglycosides in this patient population, and first-dose pharmacokinetics should be considered to optimize the dose and dosing interval early in the course of therapy. Further investigation of this phenomenon with greater numbers of patients are needed to confirm these findings and to determine optimal dosing strategies of aminoglycosides in patients undergoing induced hypothermia.

Introduction

Mild-to-moderate induced hypothermia may be used as a neuroprotectant and/or therapeutic strategy during the management of intracranial hypertension. Strong evidence supports its consideration for the management of patients after cardiac arrest, with more limited data for the management of traumatic brain injury, malignant ischemic stroke, acute liver failure, spinal cord injury, and refractory status epilepticus.^[1] In induced hypothermia, the core body temperature is lowered to 32–34°C to decrease cerebral metabolic demand, mitigate excitatory neurotransmitter overstimulation, and attenuate the inflammatory response, thereby modulating secondary brain insults.^[2]

Physiologic effects occur with nearly every organ system during mild-to-moderate induced hypothermia. Activity of temperature-dependent enzymatic systems slow, thus decreasing the metabolism of some hepatically metabolized drugs; however, the effect on the pharmacokinetics of renally eliminated drugs is yet to be determined in humans.^[3–5] The reabsorption of renal solute may be impaired secondary to a cold diuresis. However, renal function, as measured by creatinine clearance, is often impaired as renal vascular resistance increases with a subsequent reduction in renal blood flow.^[5,6] In addition, cardiac output may be decreased 25–40% secondary to bradycardia and increased systemic vascular resistance.^[3] These physiologic alterations may affect renal perfusion and, subsequently, the glomerular filtration rate and clearance of renally eliminated drugs.

Aminoglycosides represent one class of drugs that are heavily dependent on glomerular filtration rate, display a narrow therapeutic index, and require therapeutic drug monitoring to optimize effectiveness and minimize known toxicities. In the setting of induced hypothermia, alterations in normal physiology may lead to reduced renal clearance of aminoglycosides and, ultimately, to deleterious effects due to errors in dosage estimation.

Thus, to better understand the effects of induced hypothermia on the pharmacokinetics of aminoglycosides, we analyzed the data of patients who had undergone induced hypothermia for more than 24 hours and had documented aminoglycoside concentrations in their medical records. Patients were identified by cross-referencing all patients who received induced hypothermia for more than 24 hours with those who had aminoglycoside levels. Three patients were identified; all had traumatic brain injury, managed in accordance with the Brain Trauma Foundation Guidelines,^[7] with interventions directed at minimizing secondary insults, and all had received tobramycin. Patients with refractory intracranial hypertension often require progressive treatment with decompressive craniectomy, chemical paralysis, barbiturate coma, and mild-tomoderate induced hypothermia.^[7] According to our institution's protocol for induced hypothermia, the patients were cooled to a goal temperature of 32–34°C and rewarmed when deemed appropriate by the treating neurointensivist.

New board seat brings independent community pharmacist perspective to the table

WASHINGTON, Sept. 27, 2022 /PRNewswire/ -- The Pharmacy Technician Certification Board (PTCB), the nation's first and only nonprofit credentialing organization for pharmacy technicians, today announced the addition of B. Douglas Hoey, RPh, MBA, CEO of the National Community Pharmacists Association (NCPA) to its Board of Governors. As the first new board member since 2001, NCPA joins PTCB's five founding governing organizations to collaborate on guidance to best support and advance the pharmacy technician profession in all settings.

PTCB gains new independent community pharmacy board seat with the addition of NCPA

"We're excited to welcome NCPA to PTCB's Board of Governors," said William Schimmel, PTCB Executive Director and CEO. "Independent community pharmacies are critical lifelines for so many Americans and settings where pharmacy technicians can build their careers and serve their communities. Bringing the voice for independent pharmacy to the table is invaluable for helping to empower technicians and advance patient safety."

Founded in 1898, NCPA represents 19,400 pharmacies employing more than 215,000 individuals nationwide. Pharmacy technicians working in independent community pharmacies represent more than 10 percent of PTCB's 2022 Workforce Survey respondents. They are essential to advancing medication safety, supporting efficient workplace operations, and ensuring consistent care. NCPA's perspective will help shape the offerings of PTCB credentials based on what pharmacy technicians need to be successful and provide safe patient care in the community pharmacy setting.

"For community pharmacies to be as successful as possible, they must be made up of a strong team. Empowering technicians to develop specialized skills and support business operations that assist the pharmacist's work benefits independent pharmacy owners, their pharmacy teams, and the patients they serve," said NCPA's CEO, B. Douglas Hoey. "We're pleased to join the PTCB board to give a voice to independent owners' interests in preparing technicians for roles in local, small business-pharmacies."

Story continues

PTCB is a uniquely pharmacy-driven organization founded by and for the pharmacy profession to continuously Improve and support patient care. PTCB's Board is comprised of leaders from the American Pharmacists Association, American Society of Health-System Pharmacists, Illinois Council of Health-System Pharmacists, Michigan Pharmacists Association, National Association of Boards of Pharmacy, and now the National Community Pharmacists Association.

For more information, please visit PTCB.org.

About PTCB

The Pharmacy Technician Certification Board (PTCB) is the nation's first, most trusted, and only nonprofit pharmacy technician credentialing organization. Founded on the guiding principle that pharmacy technicians play a critical role in advancing medication and patient safety, PTCB has established the universal standard of excellence for those supporting patient care teams through offering the industry's most-recognized credentials, including the PTCB certification for Certified Pharmacy Technicians (CPhT).

About NCPA

Founded in 1898, the National Community Pharmacists Association is the voice for the community pharmacist, representing nearly 19,400 pharmacies that employ approximately 215,000 individuals nationwide. Community pharmacies are rooted in the communities where they are located and are among America's most accessible health care providers. To learn more, visit www.ncpa.org.

View original content to obtain multimedia:https://www.prnewswire.com/news-releases/the-pharmacy-technician-certification-board-welcomes-national-community-pharmacists-association-to-board-of-governors-301634250.html

SOURCE Pharmacy Technician Certification Board

A PCB is a basic component of modern electronic devices and appliances that has revolutionised the electronics manufacturing industry. The first usage of a PCB dates back to 1936 when its inventor, Paul Eisler applied it to his radio system, however, PCBs started gaining their popularity only in the 1950s gradually domineering point-to-point electronic constructions.

PCB vs PCB assembly: essential terminology

The PCB acronym stays for a printed circuit board and is sometimes called a printed wiring card or a printed wiring board. It is also common to see PCBs referred to as PCBAs, albeit this is not accurate.

A PCB is a blank board, which has a printed circuit map on its surface. Yet, there are no electronic elements attached to it and it cannot be used directly in electronic devices. It first has to undergo one of the PCB assembly (PCBA) processes to turn into an assemblage of electronic components to be able to power other electronic goods.

PCB composition

All PCBs consist of several layers of materials depending on the complexity and price of the final product. Still, regardless of these factors, any PCB has its basic substrate layer used for holding layers of copper and soldermask. These two layers can be located either on a single side of the substrate layer or both of its sides.

Traditionally, one of the best materials used as a substrate is fiberglass, which gives PCBs the necessary rigidity, however, some products require flexible PCBs. These are made of high-temperature polymer materials.

The next layer is made of a copper foil attached to the board with heat and an adhesive substance. As a rule, the layers of a PCB are calculated by the layers of copper. One-layered boards are the most basic, but there can be tens of copper layers. Copper is insulated to avoid contact with conductive bits or metals with a layer of soldermask.

A layer of silkscreen allows labelling certain parts of a PCB.

PCB assembly technologies

Turning a blank PCB into a fully-functioning device component requires attaching electronic elements to its surface. This can be done with an older THT or through-hole technology, which inserts electronics into drilled holes in the board or with a more modern surface-mount technology commonly referred to as SMT. The latter one is more popular today due to the possibility of automating the manufacturing processes.

SMT includes mapping the PCB surface with a soldering material. Then, a pick-and-place machine locates all of the pieces in their right places and the boards are moved to a reflow oven for solidifying the soldermask creating adhesion between a PCB and electronic components.

Conclusions

Differentiating a PCB from a PCB assembly is crucial for understanding the PCB assembly basics since these are two separate terms in electronic manufacturing. A PCB is a blank multi-layered board maintaining the connections between electronic components attached to its surface with either SMT or through-hole PCB assembly technology.

To learn more visit: asselems.com

Events in a neurological intensive care unit are not always predictable and patients can often be unstable. This practical manual is a clear and concise guide for recognising and managing neurological emergencies. Each chapter covers a crucial subject in neurocritical care, from understanding the pathophysiology of various neurological diseases, to neuroradiology used in diagnosis, and best practice for difficult decision making in the ICU. A variety of conditions are described such as haemorrhage (intracerebral, subdural, and subarachnoid), seizures, trauma and temperature dysregulation. An international team of experts have contributed chapters, providing a breadth of experience and knowledge for readers. This is an invaluable guide for clinicians on the front line of caring for patients with neurological emergencies who need life-saving answers quickly.

New board seat brings independent community pharmacist perspective to the table

WASHINGTON, Sept. 27, 2022 /PRNewswire/ -- The Pharmacy Technician Certification Board (PTCB), the nation's first and only nonprofit credentialing organization for pharmacy technicians, today announced the addition of B. Douglas Hoey, RPh, MBA, CEO of the National Community Pharmacists Association (NCPA) to its Board of Governors. As the first new board member since 2001, NCPA joins PTCB's five founding governing organizations to collaborate on guidance to best support and advance the pharmacy technician profession in all settings.

"We're excited to welcome NCPA to PTCB's Board of Governors," said William Schimmel, PTCB Executive Director and CEO. "Independent community pharmacies are critical lifelines for so many Americans and settings where pharmacy technicians can build their careers and serve their communities. Bringing the voice for independent pharmacy to the table is invaluable for helping to empower technicians and advance patient safety."

Founded in 1898, NCPA represents 19,400 pharmacies employing more than 215,000 individuals nationwide. Pharmacy technicians working in independent community pharmacies represent more than 10 percent of PTCB's 2022 Workforce Survey respondents. They are essential to advancing medication safety, supporting efficient workplace operations, and ensuring consistent care. NCPA's perspective will help shape the offerings of PTCB credentials based on what pharmacy technicians need to be successful and provide safe patient care in the community pharmacy setting.

"For community pharmacies to be as successful as possible, they must be made up of a strong team. Empowering technicians to develop specialized skills and support business operations that assist the pharmacist's work benefits independent pharmacy owners, their pharmacy teams, and the patients they serve," said NCPA's CEO, B. Douglas Hoey. "We're pleased to join the PTCB board to give a voice to independent owners' interests in preparing technicians for roles in local, small business-pharmacies."

PTCB is a uniquely pharmacy-driven organization founded by and for the pharmacy profession to continuously Improve and support patient care. PTCB's Board is comprised of leaders from the American Pharmacists Association, American Society of Health-System Pharmacists, Illinois Council of Health-System Pharmacists, Michigan Pharmacists Association, National Association of Boards of Pharmacy, and now the National Community Pharmacists Association.

For more information, please visit PTCB.org.

The Pharmacy Technician Certification Board (PTCB) is the nation's first, most trusted, and only nonprofit pharmacy technician credentialing organization. Founded on the guiding principle that pharmacy technicians play a critical role in advancing medication and patient safety, PTCB has established the universal standard of excellence for those supporting patient care teams through offering the industry's most-recognized credentials, including the PTCB certification for Certified Pharmacy Technicians (CPhT).

Founded in 1898, the National Community Pharmacists Association is the voice for the community pharmacist, representing nearly 19,400 pharmacies that employ approximately 215,000 individuals nationwide. Community pharmacies are rooted in the communities where they are located and are among America's most accessible health care providers. To learn more, visit www.ncpa.org.

View original content to obtain multimedia:https://www.prnewswire.com/news-releases/the-pharmacy-technician-certification-board-welcomes-national-community-pharmacists-association-to-board-of-governors-301634250.html

SOURCE Pharmacy Technician Certification Board

UAB is proud to offer a UCNS-accredited fellowship in Neurocritical Care. UAB houses a 36-bed, dedicated Neurosciences Intensive Care Unit, which is staffed continuously by 2 neurointensivist-led multidisciplinary teams. Patients are managed collaboratively by the critical care teams as well as the admitting service, which may be either general neurology, vascular neurology, or neurosurgery. Fellows will interact closely with a broad range of specialists and subspecialists, as well as critical care pharmacists, advanced practice providers, neuroscience nurses, and a full range of allied health professionals. As an institution, UAB offers several advantages for prospective fellows seeking advanced training:

• Rich and diverse patient population, due in part to our large cachement area
• Designated as a Level 1 Trauma Center
• Currently the only Joint Commission-certified Comprehensive Stroke Center in the state of Alabama
• NAEC-Certified Level 4 Epilepsy Center

Program Structure

The UAB Neurocritical Care Program offers 3 different training pathways, suitable for fellows from a variety of different backgrounds. These include:

1.  A 24-month program, designed for applicants without prior training in neurosurgery or critical care. In order to be eligible, applicants must be on track to complete an ACGME- or RCPSC- accredited training program in neurology, anesthesiology, emergency medicine, or internal medicine prior to beginning fellowship training.
2.  A 12-month program, intended for applicants who have previously completed an ACGME- or RCPSC-accredited critical care fellowship. This pathway allows an experienced intensivist to gain additional expertise in patients with neurological disease.
3.  A 12-month program, structured for applicants from ACGME- or RCPSC-accredited neurosurgical programs.

Fellows will have the opportunity to rotate through the medical ICU, the trauma-burn ICU, the surgical ICU, and the cardiac surgery ICU in addition to their NICU rotations. Additional clinical experiences include vascular neurology and the OR. A variety of elective opportunities including epilepsy, neuroradiology, neurosurgery and cerebrovascular ultrasound are available to supplement the curriculum.

Didactics

As part of a large academic medical center, fellows benefit from a variety of educational opportunities. The Critical Care Medicine lecture series provides a comprehensive overview of critical care principles, and is attended by critical care fellows from the Departments of Anesthesiology and Internal Medicine as well. Neurocritical care fellows are integrated closely with the Anesthesiology Critical Care program, which sponsors daily noon lectures as well as a journal club and case conference. Fellows also attend the neurosurgery morning report and the weekly cerebrovascular conference, which includes faculty from neurosurgery, vascular neurology, neurocritical care and neuroradiology. Through one-on-one meetings, bedside teaching rounds, case conferences and directed reading, fellows will have ample exposure to core principles of neurocritical care.

Core Faculty

The program is directed by Dr. Angela Hays Shapshak, a neurologist with more than 10 years of experience as a practicing neurointensivist and medical educator. Dr. Hays Shapshak completed her neurology residency at Washington University in Saint Louis before going on to a fellowship in Neurocritical Care and Cerebrovascular Diseases at the University of California at San Francisco. She is board certified in neurology (ABPN), vascular neurology (ABPN), and neurocritical care (UCNS).

Dr. David Miller, an associate professor of anesthesiology, serves as both the medical director of the NICU and the Director of the Division of Critical Care Medicine, and Vice Chair of the Department of Anesthesiology. Dr. Miller completed a residency in anesthesiology and a fellowship in critical care medicine, both at UAB. He is board-certified in anesthesiology and critical care medicine by the ABA, and in Neurocritical Care by UCNS.

Dr. Kenneth Smithson completed his clinical training in anesthesiology and critical care medicine at the Mayo Clinic in Rochester, MN. He holds a PhD in Physiology and Neuroscience, and has more than 20 years of experience in neurocritical care and neuroanesthesiology. His research interests include the effect of anesthetic agents on tumorigenesis, postoperative delirium and cognitive dysfunction postoperatively and delirium in the ICU.

Dr. Vinod Singh completed his medical education and residency training in internal medicine in India, before moving to the UK to pursue additional residency training in anesthesiology. He went on to complete fellowships in critical care medicine and neurocritical care at Addenbrooke’s Hospital in Cambridge, UK. Dr. Singh joined the faculty at UAB in 2013, and has been active in both research and graduate medical education.

Dr. Mali Mathru is a professor of anesthesiology, who has been practicing critical care medicine for more than 30 years. He has authored more than 100 publications on subjects such as ARDS, ischemic preconditioning, physiological effects of hypertonic fluids, and genetic factors associated with outcome in subarachnoid hemorrhage. He attends frequently in the NICU, and is a valuable mentor for residents and fellows.

Dr. Sangha completed his neurology training at SUNY Upstate Medical University, followed by fellowships in Neurocritical Care and Vascular Neurology at Northwestern School of Medicine. He will be attending in the NICU and on the Acute Stroke Service as of July, 2017.

Dr. Bush completed her anesthesiology residency at the University of Louisville before going on to a critical care fellowship at the University of Kentucky, followed by a neurocritical care fellowship at Northwestern. She joined the faculty as a neurointensivist and neuroanesthesiologist in September of 2017.

To Apply

Applications will be accepted via the San Francisco Match program (https://www.sfmatch.org).

For additional information, please contact:

Program Director

Angela Hays Shapshak, MD
Associate Professor, Departments of Neurology and Anesthesiology
Program Director, Neurocritical Care Fellowship
Associate Director, Neurology Residency Program
P: 205.934.2401 | ashapshak@uabmc.edu