UHSP Collections (University of Health Sciences and Pharmacy)
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Utilization of EKOS in Patients With Pulmonary Embolism
No full textObjective: Current guidelines recommend utilization of catheter-directed thrombolysis systems for management of patients with submassive pulmonary embolism (PE) who have relative contraindications to systemic thrombolysis. Evidence from previous trials have demonstrated the short-term efficacy and safety of one of these systems, the EkoSonic Endovascular System (EKOS). The objective of this study was to evaluate the long-term efficacy and safety of EKOS in submassive PE. Methods: This single-center, retrospective study evaluated subjects ≥18 years old with submassive PE and baseline right ventricular to left ventricular (RV/LV) diameter ratio ≥1. The primary outcome evaluated change in RV/LV diameter ratio from baseline to first follow-up. The secondary outcomes evaluated need for further intervention after EKOS, major bleeding within 72 hours and 6 months, all-cause mortality at 6 months, and all-cause 30-day readmission rate. Results: Overall, 41 subjects received EKOS for submassive PE. Of the 26 subjects evaluated for the primary outcome, the RV/LV diameter ratio decreased by an average of 0.56 (P \u3c 0.05). Of the 41 subjects evaluated for the secondary outcomes, 1 subject required pulmonary embolectomy after EKOS intervention, 1 major bleed occurred within 72 hours, 1 major bleed occurred within 6 months, 1 subject died within 6 months, and 3 subjects were readmitted within 30 days. Conclusions: Intervention with EKOS further reduced right heart strain and resulted in few complications compared with previous trials providing evidence that EKOS is effective and safe long-term for management of submassive PE. Use should be considered in patients with relative contraindications to systemic thrombolytic therapy
Association of low-income subsidy, medicaid dual eligibility, and disability status with high-risk medication use among Medicare Part D beneficiaries
No full textBackground: Low-income subsidy/dual eligibility (LIS/DE) status and disability status may be associated with high-risk medication (HRM) use but are not usually accounted for in medication-use quality measures. Objective: To examine the association of: 1) LIS/DE status and HRM use; and 2) disability status and HRM use, while controlling for both health plan level effects and patient characteristics for Medicare beneficiaries enrolled in Medicare Advantage Prescription Drug Plans (MA-PD) and stand-alone Prescription Drug Plans (PDP). Methods: This retrospective cross-sectional study used 2013 Medicare data to determine if LIS/DE status and disability status were independently associated with HRM use (using the Pharmacy Quality Alliance HRM measure) in MA-PDs and PDPs. Multivariable generalized linear mixed models assessed the association of LIS/DE and HRM use, and disability and HRM use, after adjusting for health plan effect and patient-level confounders for MA-PD and PDP beneficiaries. Results: Of 520,019 MA-PD beneficiaries, 88,693 (17.1%) were LIS/DE and 48,997 (9.4%) were disabled. Of 881,264 PDP beneficiaries, 213,096 (24.2%) were LIS/DE, and 83,593 (9.5%) were disabled. LIS/DE beneficiaries had a higher percent of HRM users compared to non-LIS/DE MA-PD (13.3% vs. 9.7%, p \u3c 0.001) and PDP (17.1% vs. 13.2%, p \u3c 0.001) beneficiaries. Disabled beneficiaries had a higher percent of HRM users compared to non-disabled MA-PD (17.0% vs. 9.6%, p \u3c 0.001) and PDP (22.9% vs. 13.2%, p \u3c 0.001) beneficiaries. Multivariable analyses showed LIS/DE (adjusted odds ratio [AOR] = 1.07; 95% CI = 1.04, 1.10) and disability (AOR = 1.38; 95% CI = 1.34, 1.42) were associated with HRM use among MA-PD and PDP beneficiaries (LIS/DE AOR = 1.14; 95% CI = 1.12, 1.16; disability AOR = 1.37; 95% CI = 1.34, 1.40). Conclusions: The association of LIS/DE and disability with higher HRM use in both MA-PD and PDP beneficiaries, when controlling for health plan effects and patient characteristics, suggests these factors should be considered when comparing health plan performance on HRM measures
Evaluation of a Pharmacist-Driven Protocol for the Treatment of Opioid-Induced Constipation
No full textBackground: Opioid-induced constipation (OIC) treatment guidelines recommend over-the-counter laxatives as first-line therapy, followed by treatment with a peripherally-acting mu-opioid receptor antagonist (PAMORA) in refractory patients. Objective: To evaluate the ability of a pharmacist-driven OIC protocol to promote increased scheduled laxative use prior to escalation to PAMORA therapy. Methods: This retrospective, single-center cohort study evaluated patients 2 years pre- and post-protocol implementation. The primary outcome was the difference in the percentage of patients receiving 2 scheduled laxatives for ≥ 2 days prior to PAMORA therapy pre- and post-protocol. Secondary outcomes included difference in time to first bowel movement after PAMORA initiation, difference in total number of laxative/PAMORA doses administered, and difference in overall estimated total cost. Data was analyzed using chi-squared tests and Student’s t tests. Results: Three-hundred patients were included (150 patients in the pre and post-protocol groups). In the pre-protocol group, 53 patients (35%) received 2 scheduled laxatives for 2 days prior to naloxegol/methylnaltrexone compared to 96 patients (64%) in the postprotocol group (p \u3c 0.0001). One-thousand twenty-one scheduled laxative doses were given pre-protocol versus 1625 doses post-protocol. Average time to first bowel movement was similar between groups (17.7 hours vs 16.0 hours p = 0.441). Estimated total cost of OIC reversal therapy decreased from 13,405.47. Conclusion: A pharmacist-driven OIC protocol is associated with an increase in the use of scheduled laxatives prior to PAMORA administration and decreased overall estimated total cost. A larger, prospective study is necessary to assess if this promotes more efficacious OIC
Lack of pathogen identification influencing antibiotic de-escalation in hospital-Acquired pneumonia
No full textCharacterization of Oligomer Formation of Surfactant Protein-D (SP-D) Using AF4-MALLS
No full textBackground: Surfactant protein-S (SP-D) is a naturally occurring lung protein with the potential to treat pulmonary infections. A recombinant surfactant protein-D (SP-D) has been produced and was previously found to exist in multiple oligomeric states. Introduction: Separation and characterization of interconverting oligomeric states of a protein can be difficult using chromatographic methods, so an alternative separation technique was employed for SPD to characterize the different association states that exist. Methods: Samples of SP-D were analyzed using asymmetrical flow field-flow fractionation (AF4) using UV and multi-angle laser light scattering (MALLS) detection. The AF4 method appears to be able to separate species as small as the monomer up to the dodecamer (the dominant species) to much larger species with a molar mass greater than 5 MDa. Results: Consistent elution of four distinct peaks was observed after repeated injections. The largest species observed under the last peak (labeled as Peak 4) were termed “unstructured multimers” and were resolved fairly well from the other species. The AF4-MALLS data suggest that only a small fraction of Peak 4 truly corresponds to high molar mass unstructured multimers. All other peaks demonstrated significant molar mass homogeneity consistent with AFM results. Conclusion: AF4-MALLS technology appears to be a powerful analytical approach to characterize the complex and dynamic interplay among different protein oligomeric species of SP-D in an aqueous solution
Ceftriaxone resistance and adequacy of initial antibiotic therapy in community onset bacterial pneumonia
No full textMuch remains unknown about the impact of initial antibiotic adequacy on mortality in community onset bacterial pneumonia (COBP). Therefore, we performed a study to determine how the adequacy of initial antibiotic therapy affects in-hospital mortality for patients with COBP. We carried out a retrospective cohort study among the 11 BJC Healthcare community and academic hospitals in Missouri and Illinois. The electronic medical records for BJC Healthcare were queried to obtain a set of patient admissions with culture positive (respiratory or blood) COBP admitted from January 1, 2016 through December 31, 2019. Patients with COBP required an International Classification of Diseases (ICD)-10 diagnostic code for pneumonia, admission to the hospital through an emergency department, a chest radiograph with an infiltrate, an abnormal white blood cell count or temperature, an order for 1 or more new antibiotics, and a positive respiratory or blood culture. Antibiotic selection was deemed adequate if the patient had organisms susceptible to at least one of the antibiotics received according to in vitro testing using standard laboratory breakpoints. Among 36,645 screened pneumonia admissions, 1843 met criteria for culture positive COBP. Eight hundred nineteen (44.4%) had ceftriaxone-resistant (CTX-R) organisms and 1024 had ceftriaxone-sensitive (CTX-S) organisms. The most common CTX-R pathogens were methicillin resistant Staphylococcus aureus (46.9%), Pseudomonas species (38.4%), and Escherichia coli (4.5%). On the day of admission 71% of all patients were given adequate antibiotic treatment (62.2% of CTX-R and 77.9% of CTX-S). Unnecessarily broad initial treatment was administered to 57.1% of CTX-S patients. In a logistic regression model accounting for comorbidities and severity of illness, inadequate therapy on the day of admission was associated with higher in-hospital mortality (P=.005). Among CTX-S patients who were adequately treated, initial use of unnecessarily broad antibiotics was associated with increased in-hospital mortality (P=.003). Ceftriaxone resistance was common in this cohort of culture positive COBP patients. Inappropriate coverage on day of admission was associated with greater likelihood of in-hospital mortality
Evaluation of Thrombocytopenia in Patients Receiving Percutaneous Mechanical Circulatory Support with an Impella Device
No full textOBJECTIVES: Evaluate the time course of thrombocytopenia in patients with Impella devices (Abiomed, Danvers, MA). DESIGN: This was a retrospective, multicenter review of electronic medical records at a large hospital system from April 2018 to August 2020. SETTING: Electronic medical records of patients at SSM Health hospitals were reviewed. PATIENTS: Patients 18-89 years old admitted to an SSM Health hospital from April 2018 to August 2020 who received greater than or equal to 24 hours of percutaneous mechanical circulatory support (pMCS) with an Impella device were included. Exclusion criteria were use of other pMCS devices, history of heparin-induced thrombocytopenia (HIT), and presence of device upon transfer from an outside hospital. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Ninety-three patients were included. The median duration of pMCS was 63.5 hours. Thrombocytopenia occurred in 86% of patients and was evident 24 hours after device placement. The platelet nadir occurred 84 hours after device placement. Platelet recovery occurred 86.5 hours after device removal. The duration of thrombocytopenia was 156 hours. Signs of hemolysis were present in 44.09% of patients, were evident 12-24 hours after device placement, and resolved after device removal. CONCLUSIONS: Thrombocytopenia occurred in the majority of patients and was evident 24 hours after device placement. The time course of thrombocytopenia mirrored that of hemolysis
Improving and validating a rating scale to assess student pharmacists’ perception of professional identity
No full textBackground: There are limited data on the psychometric properties of instruments evaluating professional identity (PI) among student pharmacists. Objectives: This study analyzed the psychometric properties of an instrument to assess student pharmacists’ perception of their PI. Methods: Data from a cross-sectional survey were used to establish validity and reliability evidence of student pharmacists’ perception of PI using Rasch analysis. Linear regression was conducted to evaluate the association of students’ characteristics with their perceived PI. Analyses were conducted in WINSTEPS (SWREG, Minnetonka, MN) and SAS (SAS, Cary, NC). Results: The analysis included 118 student pharmacists. Primary analysis suggested inadequate scale functionality; thus, some response categories were merged. With modified item anchors and the removal of the most misfitting item, the data fit the model as measured by student and item infit and outfit mean-squared values. The item-person map showed appropriate distribution of item difficulty, identifying medicine adviser and entrepreneur being the easiest and hardest items to agree with, respectively. Students’ abilities initially mismatched with item difficulty and exhibited a ceiling effect, requiring addition of items reflecting students’ higher perceptions of PIs. Although students’ reliability coefficient (RC) and separation index were 0.98 and 1.73, respectively, RC of the items was 0.94. Students who reported receiving formal PI training were 0.3 times more likely to have high perception of PI than those who did not report training. Conclusion: The instrument exhibited fair validity and reliability evidence for assessing the perception of PI among student pharmacists. Additional items to fill identified item gaps are needed to improve the instrument\u27s content validity
Postdischarge opioid use and persistent use after general surgery: A retrospective study
No full textBackground: Opioid overprescribing after surgery is a significant public health issue in most developed countries, including New Zealand. However, there is a lack of literature on the patterns and risk factors for postoperative opioid use among general surgical patients in New Zealand. This study aimed to examine opioid use in patients undergoing general surgery at Auckland District Health Board between January and December 2019 and to identify factors associated with opioid use after surgery and persistent opioid use (defined as having filled ≥1 opioid prescription in the 91 to 180 days after surgery). Methods and Materials: This is a retrospective cohort study. Data from patients’ electronic clinical records and community pharmacy dispensing records were extracted to obtain data on sociodemographics, surgical characteristics, comorbidities, co-prescribed medications, and opioid use. Results: A total of 1,110 patients were included in the study, with 42.4% dispensed an opioid following discharge after surgery. Of opioid-naïve patients who filled opioids after surgery (n = 401), 9.5% became persistent opioid users. Preoperative use of nonopioid analgesics, longer hospital stays, higher operation severity, procedure type, and higher pain scores were positively associated with opioid use, whereas older age was a negative predictor. Longer hospital stays, an initial discharge prescription with high opioid load, and female sex increased the risk of persistent opioid use. Conversely, a higher severity of surgery was associated with lower risk of persistent opioid use. Conclusion: The findings suggest that a considerable proportion of patients become persistent opioid users after surgery. The risk factors identified can guide clinicians to prescribe in a manner that reduces opioid-related adverse outcomes and help guide future interventions
Engineered Bacteria Enhance Immunotherapy and Targeted Therapy through Stromal Remodeling of Tumors
No full textDesmoplastic solid tumors are characterized by the rapid build-up of extracellular matrix (ECM) macromolecules, such as hyaluronic acid (HA). The resulting physiological barrier prevents the infiltration of immune cells and also impedes the delivery of anticancer agents. The development of a hypervesiculating Escherichia coli Nissle (ΔECHy) based tumor targeting bacterial system capable of distributing a fusion peptide, cytolysin A (ClyA)-hyaluronidase (Hy) via outer membrane vesicles (OMVs) is reported. The capability of targeting hypoxic tumors, manufacturing recombinant proteins in situ and the added advantage of an on-site OMV based distribution system makes the engineered bacterial vector a unique candidate for peptide delivery. The HA degrading potential of Hy for stromal modulation is combined with the cytolytic activity of ClyA followed by testing it within syngeneic cancer models. ΔECHy is combined with immune checkpoint antibodies and tyrosine kinase inhibitors (TKIs) to demonstrate that remodeling the tumor stroma results in the improvement of immunotherapy outcomes and enhancing the efficacy of biological signaling inhibitors. The biocompatibility of ΔECHy is also investigated to show that the engineered bacteria are effectively cleared, elicit minimal inflammatory and immune responses, and therefore could be a reliable candidate as a live biotherapeutic