Community pharmacists-Leaders for antibiotic stewardship in respiratory tract infection

WHAT IS KNOWN AND OBJECTIVE

Hospital-based pharmacists are established antibiotic stewards, but the potential for community pharmacists is largely untapped. This commentary explores the potential leadership role of the community pharmacist in antibiotic stewardship using upper respiratory tract infection (URTI) as an example.

COMMENT

Community pharmacists are well placed for antibiotic stewardship, possessing the capability (knowledge of medicines), opportunity (contact with prescribers and patients) and inherent commitment. Providing further motivation with information on patient education has great potential to change patient behaviour with respect to consulting a healthcare professional for an antibiotic prescription. A Global Respiratory Infection Partnership pharmacy-led educational initiative was shown to have a positive impact and can promote appropriate self-management of URTI and reduce levels of inappropriate antibiotic use.

WHAT IS NEW AND CONCLUSION

Community pharmacists are ideally placed as antibiotic stewards to lead the quest to contain the threat of antibiotic resistance.

Columbus® computer navigated total knee arthroplasty: Gap balancing versus measured resection

BACKGROUND

The aim of this study was to compare the medium term functional outcome and patient satisfaction of gap balanced (GB) with measured resection (MR) total knee arthroplasty (TKA) using computer navigation.

METHODS

A cohort of 144 consecutive computer navigated TKA were retrospectively identified from an arthroplasty database. Functional assessment using the Oxford Knee Score (OKS) and patient satisfaction were obtained from 113 patients at a mean follow-up of 5.4 (range four to seven) years. There were 44 patients in the GB group and 69 patients in the MR group.

RESULTS

The mean OKS for the GB group was 36.9 (SD 9.2) and for the MR was 33.6 (SD 9.8), with a difference of 3.3 (95% CI 0.3 to 6.3) points, which was statistically significant (p=0.01). Linear regression analysis confirmed the independent effect of surgical technique when adjusting for confounding factors and surgeon, with the GB group achieving a greater post-operative OKS (R²=0.39, 3.0 points, 95% CI 1.2 to 4.8, p=0.001). There was a greater rate of patient satisfaction in the GB group (88.6%, n=39/44) compared to the MR group (81.1%, n=56/69), but this was not statistically significant (odds ratio 1.8, 95% CI 0.6 to 5.5, p=0.31).

CONCLUSION

Computer navigated Columbus® TKA using a GB technique results in a statistically significantly greater functional outcome but no significant difference in patient satisfaction in the medium term compared to patients undergoing a MR technique.

Exercise Training Reduces Liver Fat and Increases Rates of VLDL Clearance But Not VLDL Production in NAFLD

CONTEXT

Randomized controlled trials in nonalcoholic fatty liver disease (NAFLD) have shown that regular exercise, even without calorie restriction, reduces liver steatosis. A previous study has shown that 16 weeks of supervised exercise training in NAFLD did not affect total very low-density lipoprotein (VLDL) kinetics.

OBJECTIVE

The objective of the study was to determine the effect of exercise training on intrahepatocellular fat (IHCL) and the kinetics of large triglyceride (TG)-rich VLDL₁ and smaller denser VLDL₂, which has a lower TG content.

DESIGN

This was a 16-week randomized controlled trial.

PATIENTS

A total of 27 sedentary patients with NAFLD participated in the trial.

INTERVENTION

The intervention was composed of supervised exercise with moderate-intensity aerobic exercise or conventional lifestyle advice (control).

MAIN OUTCOME

VLDL₁ and VLDL₂-TG and apolipoprotein B (apoB) kinetics were investigated using stable isotopes before and after the intervention.

RESULTS

In the exercise group, maximal oxygen uptake increased by 31% ± 6% (mean ± SEM) and IHCL decreased from 19.6% (14.8%, 30.0%) to 8.9% (5.4%, 17.3%) (median [interquartile range]) with no significant change in maximal oxygen uptake or IHCL in the control group (change between groups, P < .001 and P = .02, respectively). Exercise training increased VLDL₁-TG and apoB fractional catabolic rates, a measure of clearance, (change between groups, P = .02 and P = .01, respectively), and VLDL₁-apoB production rate (change between groups, P = .006), with no change in VLDL₁-TG production rate. Plasma TG did not change in either group.

CONCLUSION

An increased clearance of VLDL₁ may contribute to the significant decrease in liver fat after 16 weeks of exercise in NAFLD. A longer duration or higher-intensity exercise interventions may be needed to lower the plasma TG and VLDL production rate.

A protocol for management of blood loss in surgical treatment of peritoneal malignancy by cytoreductive surgery and hyperthermic intraperitoneal chemotherapy

BACKGROUND AND AIMS

The treatment of peritoneal malignancies with cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) has been shown to be associated with massive surgical blood loss. Maintaining high fibrinogen levels throughout surgery may reduce blood loss in these patients. The primary aim of the study was to see if Tranexamic Acid (TXA) and cryoprecipitate reduced surgical blood loss and hence red cell transfusions. A comparison was made with a cohort of patients treated with fresh frozen plasma (FFP) alone. The secondary aim was to measure the effect of both protocols on coagulation parameters and the incidence of arterial or venous thrombosis.

METHOD

We used prospectively collected data from 201 patients who had complete CRS with HIPEC for peritoneal malignancy using different protocols during two discrete 12-month time periods.

RESULTS

The new transfusion protocol led to a higher average fibrinogen level intra-operatively and post-operatively, with a significant reduction in average RBC, FFP and platelet transfusion intra-operatively per patient from 4·2 to 1·8 units, 6·2 to 0·2 units and 0·1 to 0 units, respectively. No significant difference in PT or APTT was seen between patients treated with the standard and new protocols. Venous thrombosis occurred in seven patients treated with the standard protocol and five with the new protocol. A single case of arterial thrombosis was seen in both groups.

CONCLUSION

Patients treated with upfront TXA and cryoprecipitate during CRS required less RBC transfusion than those treated with the standard protocol of early FFP.