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Impact of point-of-care implementation in pharmacist-run anticoagulation clinics within a community-owned health system: A two-year retrospective analysis
No full textBackground: Point-of-care (POC) testing devices allow laboratory monitoring to be performed in various settings and accessed immediately. Objective: To evaluate the outcomes of monitoring anticoagulation patients in pharmacist-managed, multicenter clinics utilizing i-STAT POC machines. Methods: This study was a retrospective, multicenter chart review of 150 patients before and after implementation of the POC intervention for anticoagulation monitoring. Data collected included international normalized ratio (INR) results, indication for warfarin, minor and major bleeds, thromboembolic events, emergency room (ER) visits, and hospitalizations before and after i-STAT POC implementation. Results: The time in therapeutic INR range (TTR) was significantly higher after i-STAT POC implementation than before implementation (60.4% ± 21.2% and 52.5% ± 21.5%, respectively; P =.0001). There were no reports of major bleeding during the study period. Twenty-three minor bleeds were reported after i-STAT POC implementation compared to 19 events before implementation (P \u3c.0001). One thromboembolic event was reported after i-STAT POC implementation. There was a significant difference in the number of hospitalizations before i-STAT POC implementation as opposed to after implementation (2 and 0, respectively; P \u3c.0001). There was also a significant increase in ER visits after i-STAT POC implementation (P \u3c.0001). Conclusion: The results of the study indicate improvement in TTR in pharmacist-managed anticoagulation clinics by 7.8%. Although the use of the i-STAT POC machine detected an increase in minor bleeds, thromboembolic events, and ER visits, there was a decrease in hospitalization. The outcomes of this multicenter study indicate that implementation on this scale provides improvement in regard to safety and cost
Development and validation of a clinical prediction rule for candidemia in hospitalized patients with severe sepsis and septic shock
No full textObjective: To develop and internally validate a prediction rule for the presence of candidemia in patients with severe sepsis and septic shock (candidemia rule) that will fill the gap left by previous rules. To compare the accuracy of the available Candida prediction models. Design: Retrospective cohort study. Setting: Barnes-Jewish Hospital, St. Louis, Missouri. Patients/Subjects: Two thousand five hundred ninety-seven consecutive patients with a positive blood culture and severe sepsis or septic shock. Interventions: Logistic regression and a bootstrap resampling procedure were employed for model development and internal validation. Measurements and Main Results: Two hundred sixty-six (10.2%) had blood cultures positive for Candida spp. Mortality was significantly higher in patients with candidemia than in patients with bacteremia (47.0% versus 28.4%; P\u3c. .001). Administration of total parenteral nutrition, prior antibiotic exposure, transfer from an outside hospital or admission from a nursing home, mechanical ventilation and presence of a central vein catheter were independent predictors of candidemia while the lung as a source for infection was protective. The prediction rule had an area under the receiver operating characteristic curve of 0.798 (95% CI 0.77-0.82). Internal validation using bootstrapping technique with 1000 repetitions produced a similar area under the receiver operating characteristic curve of 0.797 (bias, -. 0.037; root mean square error 0.039). Our prediction rule outperformed previous rules with a better calibration slope of 0.96 and Brier score of 0.08. Conclusions: We developed and internally validated a prediction rule for candidemia in hospitalized patients with severe sepsis and septic shock that outperformed previous prediction rules. Our study suggests that locally derived prediction models may be superior by accounting for local case mix and risk factor distribution
Edoxaban, a Novel Oral Factor Xa Inhibitor
No full textObjective: To evaluate the current literature and potential clinical role of edoxaban (Savaysa) for stroke prevention in nonvalvular atrial fibrillation (NVAF) and treatment of deep-vein thrombosis and pulmonary embolism. Data Sources: A PubMed and Cochrane Central Register of Controlled trials search was conducted in February2015 using the search terms edoxaban (ordu-176b) and atrial fibrillation, deep vein thrombosis, pulmonary embolism, or venous thromboembolism. Bibliographies of all retrieved articles were reviewed. All references included were published between 1998 and 2015. Study Selection/Data Extraction: All studies that included humans and contained data describing the use of edoxaban for either stroke prevention in patients with NVAF or the treatment of venous thromboembolism (VTE) were reviewed. Data Synthesis: Edoxaban is a target-specific oral anticoagulant, specifically a factor Xa inhibitor. It has been studied in 4 major randomized controlled trials for the prevention of stroke and systemic embolism in patients with NVAF. One randomized controlled trial was conducted for the treatment of VTE. Edoxaban demonstrated noninferiority of the primary efficacy end point compared with warfarin for both approved indications. The most common adverse effect is bleeding, similar to other anticoagulants. A dosing limitation exists related to patients treated for NVAF with creatinine clearance \u3e95 mL/min; these patients experienced decreased efficacy. Conclusions: Edoxaban is a safe and effective anticoagulant to reduce the risk of stroke in patients with NVAF and for the treatment of VTE
Predicting future links between disjoint research areas using heterogeneous bibliographic information network
No full textLiterature-based discovery aims to discover hidden connections between previously disconnected research areas. Heterogeneous bibliographic information network (HBIN) provides a latent, semi-structured, bibliographic information model to signal the potential connections between scientific papers. This paper introduces a novel literature-based discovery method that builds meta path features from HBIN network to predict co-citation links between previously disconnected literatures. We evaluated the performance of our method in predicting future co-citation links between fish oil and Raynaud’s syndrome papers. Our experimental results showed that HBIN meta path features could predict future co-citation links between these papers with high accuracy (0.851 F-Measure; 0.845 precision; 0.857 recall), outperforming the existing document similarity algorithms such as LDA, TF-IDF, and Bibliographic Coupling
Pseudomonas aeruginosa nosocomial pneumonia: Impact of pneumonia classification
No full textobjective. To describe and compare the mortality associated with nosocomial pneumonia due to Pseudomonas aeruginosa (Pa-NP) according to pneumonia classification (community-onset pneumonia [COP], hospital-acquired pneumonia [(HAP], and ventilator-associated pneumonia [VAP]). design. We conducted a retrospective cohort study of adults with Pa-NP. We compared mortality for Pa-NP among patients with COP, HAP, and VAP and used logistic regression to identify risk factors for hospital mortality and inappropriate initial antibiotic therapy (IIAT). setting. Twelve acute care hospitals in 5 countries (United States, 3; France, 2; Germany, 2; Italy, 2; and Spain, 3). patients/participants. A total of 742 patients with Pa-NP. results. Hospital mortality was greater for those with VAP (41.9%) and HAP (40.1%) compared with COP (24.5%) (P\u3c.001). In multivariate analyses, independent predictors of hospital mortality differed by pneumonia classification (COP: need for mechanical ventilation and intensive care; HAP: multidrug-resistant isolate; VAP: IIAT, increasing age, increasing Charlson comorbidity score, bacteremia, and use of vasopressors). Presence of multidrug resistance was identified as an independent predictor of IIAT for patients with COP and HAP, whereas recent antibiotic administration was protective in patients with VAP. conclusions. Among patients with Pa-NP, pneumonia classification identified patients with different risks for hospital mortality. Specific risk factors for hospital mortality also differed by pneumonia classification and multidrug resistance appeared to be an important risk factor for IIAT. These findings suggest that pneumonia classification for P. aeruginosa identifies patients with different mortality risks and specific risk factors for outcome and IIAT
Evaluation of a pharmacy-managed pharmacokinetic dosing program
No full textPurpose: The objective of this study was to determine the impact of a pharmacy-managed pharmacokinetic dosing program on appropriate dosing of famotidine, enoxaparin, and ketorolac. Methods: A large community teaching hospital implemented a pharmacy-managed pharmacokinetic dosing program for famotidine, enoxaparin, and ketorolac. Subjects were included if they received famotidine and had a creatinine clearance (CrCl) of \u3c50 mL/min; received therapeutic enoxaparin and had a CrCl of \u3c30 mL/min; or received ketorolac and had a CrCl \u3c30 mL/min, age \u3e 65 years or weight \u3c50 kg. Results: One hundred and forty-six patients were included in the preimplementation group (famotidine [n = 50], enoxaparin [n = 46], and ketorolac [n = 50]) and 143 patients were included in the postimplementation group (famotidine [n = 50], enoxaparin [n = 43], and ketorolac [n = 50]). In all, 66% of patients were dosed appropriately in the preimplementation group (famotidine 28%, enoxaparin 85%, and ketorolac 86%) compared to 94% in the postimplementation group (famotidine 92%, enoxaparin 95%, and ketorolac 94%), P \u3c.001. Conclusion: Implementation of a pharmacy-managed pharmacokinetic dosing program significantly improved appropriate dosing of famotidine, enoxaparin, and ketorolac. These findings could justify expansion of pharmacist autonomy through institution-approved, pharmacy-managed programs for other medications to improve appropriate dosing. Analyses specifically evaluating patient-oriented or financial outcomes may provide additional support for expansion
Off-label use of gastrointestinal medications in the intensive care unit
No full textPurpose: Determine the level of evidence supporting off-label gastrointestinal (GI) medication use and identify the medication class and indication whereby off-label use was most common. Materials and Methods: This prospective, multicentered observational study evaluated all medication orders written in 37 intensive care units (ICUs) in the United States, over a 24-hour period. All medications classified as \u27\u27GI\u27\u27 according to a national reference were identified. The class and indication whereby offlabel use was most prominent were determined and the level of evidence was described. Results: There were 774 orders from 363 patients and 63% (489 of 774) were considered off-label. Proton pump inhibitors (PPIs) accounted for most of the off-label usage (55% [271 of 489]), followed by laxatives (16% [77 of 489]) and histamine-2-receptor antagonists (H2RAs; 15% [71 of 489]). When prescribed, 99% (271 of 274) of PPIs, 99% (71 of 72) of H2RAs, and 79% (30 of 38) of promotility agents were off-label. Stress ulcer prophylaxis (100% [309 of 309]), GI bleeding (100% [18 of 18]), and gastric motility (88% [30 of 34]) were the most common off-label indications. The most common strength of recommendation and level of evidence for off-label use was indeterminate (58% [282 of 489]) and none (57% [280 of 489]), respectively. Conclusion: The PPIs are the most widely used off-label medications in the ICU. Stress ulcer prophylaxis is the most common indication. The level of evidence supporting off-label GI medication use is poor
Clinical effectiveness of a sedation protocol minimizing benzodiazepine infusions and favoring early dexmedetomidine: A before-after study
No full textIntroduction: Randomized controlled trials suggest clinical outcomes may be improved with dexmedetomidine as compared with benzodiazepines; however, further study and validation are needed. The objective of this study was to determine the clinical effectiveness of a sedation protocol minimizing benzodiazepine use in favor of early dexmedetomidine. Methods: We conducted a before-after study including adult surgical and medical intensive care unit (ICU) patients requiring mechanical ventilation and continuous sedation for at least 24 hours. The before phase included consecutive patients admitted between 1 April 2011 and 31 August 31 2011. Subsequently, the protocol was modified to minimize use of benzodiazepines in favor of early dexmedetomidine through a multidisciplinary approach, and staff education was provided. The after phase included consecutive eligible patients between 1 May 2012 and 31 October 2012. Results: A total of 199 patients were included, with 97 patients in the before phase and 102 in the after phase. Baseline characteristics were well balanced between groups. Use of midazolam as initial sedation (58% versus 27%, P \u3c0.0001) or at any point during the ICU stay (76% versus 48%, P \u3c0.0001) was significantly reduced in the after phase. Dexmedetomidine use as initial sedation (2% versus 39%, P \u3c0.0001) or at any point during the ICU stay (39% versus 82%, P \u3c0.0001) significantly increased. Both the prevalence (81% versus 93%, P =0.013) and median percentage of days with delirium (55% (interquartile range (IQR), 18 to 83) versus 71% (IQR, 45 to 100), P =0.001) were increased in the after phase. The median duration of mechanical ventilation was significantly reduced in the after phase (110 (IQR, 59 to 192) hours versus 74.5 (IQR, 42 to 148) hours, P =0.029), and significantly fewer patients required tracheostomy (20% versus 9%, P =0.040). The median ICU length of stay was 8 (IQR, 4 to 12) days in the before phase and 6 (IQR, 3 to 11) days in the after phase (P =0.252). Conclusions: Implementing a sedation protocol that targeted light sedation and reduced benzodiazepine use led to significant improvements in the duration of mechanical ventilation and the requirement for tracheostomy, despite increases in the prevalence and duration of ICU delirium
Black celebrities, selfhood, and psychiatry in the civil rights era: The wiltwyck school for boys and the floyd patterson house
No full textThis paper contends that a color-blind psychologisation of black interiority constituted one way in which activists imagined African Americans as both fully human and deserving of equal citizenship during the long civil rights era. Between 1954 and 1964, the Wiltwyck School for Boys, a reform school with a predominantly black student body in Esopus, New York, expanded their therapeutic services into Manhattan, creating one of the US\u27s first psychiatric aftercare programmes. Singer Harry Belafonte and boxing champion Floyd Patterson, two black culture heroes linked to the civil rights movement, lent their support as the Wiltwyck Board of Directors sought the funds needed to build a halfway home named in Patterson\u27s honor. The public support of these black celebrity-Activists helped create the impression that the mental health of black children was a matter of civil rights import, underscoring the black psyche as both the very source of equality between the races and as a site where racial progress could be measured
Clostridium difficile recurrence is a strong predictor of 30-day rehospitalization among patients in intensive care
No full textobjective. While incidence, mortality, morbidity, and recurrence rates of C. difficile infection (CDI) among the critically ill have been investigated, the impact of its recurrence on 30-day rehospitalization (ReAd), an important policy focus, has not been examined. design. Secondary analysis of a multicenter retrospective cohort study patients. Adult critically ill patients who survived their index hospitalization complicated by CDI methods. CDI was defined by diarrhea or pseudomembranous colitis and a positive assay for C. difficile toxins A and/or B. CDI recurrence (rCDI) was defined as diarrhea, positive C. difficile toxin and need for retreatment after cessation of therapy. Descriptive statistics and a logistic regression examined ReAd rates and characteristics, and factors that impact it. results. Among 287 hospital survivors, 76 (26.5%) required ReAd (ReAd+). At baseline, the ReAd+ group did not differ significantly from the ReAd– group based on demographics, comorbidities, APACHE II scores, or ICU type. ReAd+ patients were more likely to have hypotension at CDI onset (48.7% vs 34.1%, P=.025) and to require vasopressors (40.0% vs 27.1%, P=.038); they were less likely to require mechanical ventilation (56.0% vs 77.3%, P\u3c.001). A far greater proportion of ReAd+ than ReAd– had developed a recurrence either during the index hospitalization or within 30 days after discharge (32.89% vs 2.84%, P\u3c.001). In a logistic regression, rCDI was a strong predictor of ReAd+ (adjusted odd ratio, 15.33, 95% confidence interval, 5.68–41.40). conclusions. Greater than 25% of all survivors of critical illness complicated by CDI require readmission within 30 days of discharge. CDI recurrence is a strong predictor of such rehospitalizations