Synergistic and off-target effects of bacteriocins in a simplified human intestinal microbiome: implications for Clostridioides difficile infection control

Clostridioides difficile is a major cause of nosocomial diarrhea. As current antibiotic treatment failures and recurrence of infections are highly frequent, alternative strategies are needed for the treatment of this disease. This study explores the use of bacteriocins, specifically lacticin 3147 and pediocin PA-1, which have reported inhibitory activity against C. difficile. We engineered Lactococcus lactis strains to produce these bacteriocins individually or in combination, aiming to enhance their activity against C. difficile. Our results show that lacticin 3147 and pediocin PA-1 display synergy, resulting in higher anti-C. difficile activity. We then evaluated the effects of these L. lactis strains in a Simplified Human Intestinal Microbiome (SIHUMI-C) model, a bacterial consortium of eight diverse human gut species that includes C. difficile. After introducing the bacteriocin-producing L. lactis strains into SIHUMI-C, samples were collected over 24 hours, and the genome copies of each species were assessed using qPCR. Contrary to expectations, the combined bacteriocins increased C. difficile levels in the consortium despite showing synergy against C. difficile in agar-based screening. This can be rationally explained by antagonistic inter-species interactions within SIHUMI-C, providing new insights into how broad-spectrum antimicrobials might fail to control targeted species in complex gut microbial communities. These findings highlight the need to mitigate off-target effects in complex gut microbiomes when developing bacteriocin-based therapies with potential clinical implications for infectious disease treatment.

Vancomycin wound penetration in open-heart surgery patients receiving negative pressure wound therapy for deep sternal wound infection

INTRODUCTION

It is hypothesized that systemically administered antibiotics penetrate wound sites more effectively during negative pressure wound therapy (NPWT). However, there is a lack of clinical data from patients who receive NPWT for deep sternal wound infection (DSWI) after open-heart surgery. Here, we evaluated vancomycin penetration into exudate in this patient group.

PATIENTS AND METHODS

For this prospective observational study, we enrolled 10 consecutive patients treated with NPWT for post-sternotomy DSWI. On the first sampling day, serum and exudate samples were synchronously collected at 0 (pre-dose), 0.5, 1, 2, 3 and 6 h after vancomycin administration. On the following three consecutive days, additional samples were collected, only before vancomycin administration.

RESULTS

The ratio of average vancomycin concentration in wound exudate to in serum was higher for free (unbound) (1.51 ± 0.53) than for total (bound + unbound) (0.91 ± 0.29) concentration (p = 0.049). The percentage of free vancomycin was higher in wound exudate than serum (0.79 ± 0.19 vs. 0.46 ± 0.16; p = 0.04). Good vancomycin wound penetration was maintained on the following three days (vancomycin trough exudate-to-serum concentration ratio > 1). The total hospital stay was significantly longer in patients with DSWI (46 ± 11.6 days) versus without DSWI (14 ± 11.7 days) (p < 0.001). There was no in-hospital or 90-day mortality. Two patients experienced late DSWI recurrence. All-cause mortality was 4.8% during a median follow-up of 2.5 years.

CONCLUSION

Vancomycin effectively penetrates wound exudate in patients receiving NPWT for DSWI after open-heart surgery.The protocol for this study was registered at ClinicalTrials.gov on July 16, 2024 (NCT06506032).

Effect of oral potassium supplementation on urinary potassium excretion and its diagnostic value for primary aldosteronism

OBJECTIVES

We aimed to: (1) explore the effect of oral potassium supplementation on urinary potassium excretion, and (2) evaluate the value of urinary potassium-related indicators in distinguishing primary aldosteronism (PA) from non-PA patients.

DESIGN AND METHODS

A prospective study of 20 patients with hypertension and hypokalemia caused by renal potassium loss between November 2023 and April 2024 was conducted. Demographic features, 24-hour urine collection before and after potassium supplementation were all collected.

RESULTS

The patients had a mean age of 49.38 years and 70% were male. Following a median potassium supplement dose of 8.50 g, serum potassium increased from 3.25 to 3.90 mmol/L (p < .001), and 24-hour urinary potassium (24 h UK) rose from 41.40 to 59.75 mmol/24 h (p = .004). After supplementation, 20% of patients had decreased 24 h UK, while 25%, 25%, and 40% showed increases of 0-10, 10-20, and > 20 mmol/24 h. Urinary-to-serum potassium ratio (USR) decreased in 40% of patients, while it increased by 0-5, 5-10, and > 10 L/24 h in 25%, 25%, and 10% of patients, respectively. Both 24 h UK and USR after repletion predicted PA with moderate-to-high accuracy (AUC = 0.808 for both). The optimal cutoff of 24 h UK and USR after supplementation were 51 mmol/24 h and 17.43 L/24 h. The AUC for 24 h USR and 24 h UK before repletion in predicting PA were 0.788 and 0.652, respectively.

CONCLUSIONS

Urinary potassium does not increase proportionally with serum potassium levels or the oral potassium dose, showing individual variability. Post-supplementation urinary potassium has greater diagnostic value for distinguishing PA than pre-supplementation indicators.

The burden of venous thromboembolism in ten countries: a cost-of-illness Markov model on surgical and ICU patients

AIM

The objective of this study was to assess the burden of hospital-acquired venous thromboembolism (VTE) on healthcare systems and patients across ten countries.

METHODS

A multi-methodological approach was taken to estimate the burden of hospital-acquired VTE across five key clinical specialties and ten countries (Australia, Brazil, China, France, Mexico, South Korea, Spain, Taiwan, Thailand, and the United Kingdom). Surveys with healthcare professionals (surgeons, hematologists, and hospital management) were conducted to identify clinical specialties of interest. A systematic literature review and interviews were conducted to identify data for incidences and costs. A health-economic model was developed, using a decision tree and Markov model to estimate 1-year costs. Costs are presented in 2022 USD.

RESULTS

Orthopedics, oncology, long-term ICU, cardiology, and obstetrics and gynecology were identified as the clinical specialties of interest. The total cost burden of hospital-acquired VTE was estimated to be $41,280 million, which equals $503 per patient at risk. Expressed as a share of 2022 GDP, an average spending per country of 0.05% to 0.18% was observed. The VTE-associated mortality was substantial, accounting for 150,081 deaths in a 74.2 million population, translating into an average mortality rate of 2.02 (0.64-3.05) per 1,000 patients at risk.

LIMITATIONS

There were limited data available concerning VTE incidences in some countries and clinical specialties. Where data were available, there was heterogeneity of incidence definitions across the identified studies. Generalizations, imputations, and the country-agnostic structure of the model might have contributed to biases.

CONCLUSIONS

The burden of hospital-acquired VTE is substantial both from an economic and from a patient perspective in all countries evaluated.

Development of a conjunctival contact-type drug delivery device for latanoprost using hyaluronic acid

Effective topical drug delivery is crucial for glaucoma treatment, necessitating more convenient methods to enhance patient compliance. This study evaluates the efficacy and safety of using freeze-dried hyaluronic acid (HA) as a carrier for a novel conjunctival-contact drug delivery system. We developed HA tablets loaded with latanoprost (HA-latanoprost) and verified the concentration using high-performance liquid chromatography. Twenty mice (C57BL6) were divided into four groups (n = 5 per group): normal saline (group 1), control HA tablet (group 2), Xalatan™ (group 3), and HA-latanoprost tablet (group 4). Treatments were administered to the right eyes, with the left eyes serving as no-treatment controls. Intraocular pressure (IOP) and irritation (measured by scratching motions) were monitored for 10 days. On day 10, we quantified gene expression of inflammatory cytokines and IOP-affecting proteins using polymerase chain reaction, and performed histological and immunohistochemical analyses. Results showed that IOP was significantly lower in groups 3 and 4 compared to the other groups, with group 4 exhibiting the greatest reduction by day 10. Group 4 also experienced less irritation. Additionally, group 4 had lower expression of inflammatory cytokine genes and higher expression of IOP-lowering protein genes compared to group 3. No significant side effects were observed in any group. Overall, HA-latanoprost effectively lowered IOP and reduced ocular irritation more than latanoprost eyedrops in mice. However, these results are based on animal testing, so further development is needed for clinical use.

Interconnections between diabetic corneal neuropathy and diabetic retinopathy: diagnostic and therapeutic implications

Diabetic corneal neuropathy and diabetic retinopathy are ocular complications occurring in the context of diabetes mellitus. Diabetic corneal neuropathy refers to the progressive damage of corneal nerves. Diabetic retinopathy has traditionally been considered as damage to the retinal microvasculature. However, growing evidence suggests that diabetic retinopathy is a complex neurovascular disorder resulting from dysfunction of the neurovascular unit, which includes both the retinal vascular structures and neural tissues. Diabetic retinopathy is one of the leading causes of blindness and is frequently screened for as part of diabetic ocular screening. However, diabetic corneal neuropathy is commonly overlooked and underdiagnosed, leading to severe ocular surface impairment. Several studies have found that these two conditions tend to occur together, and they share similarities in their pathogenesis pathways, being triggered by a status of chronic hyperglycemia. This review aims to discuss the interconnection between diabetic corneal neuropathy and diabetic retinopathy, whether diabetic corneal neuropathy precedes diabetic retinopathy, as well as the relation between the stage of diabetic retinopathy and the severity of corneal neuropathy. We also endeavor to explore the relevance of a corneal screening in diabetic eyes and the possibility of using corneal nerve measurements to monitor the progression of diabetic retinopathy.

Correlations of vancomycin trough concentration and its efficacy and toxicity in patients in the intensive care unit

BACKGROUND

Plasma concentration monitoring is crucial for optimizing vancomycin use, particularly in patients in the intensive care unit (ICU). However, the reference interval for vancomycin plasma concentration remains undetermined.

AIM

To evaluate the correlations of area under the curve (AUC_0-24) and trough concentration (C_min) with efficacy and nephrotoxicity in patients in the ICU.

METHODS

A total of 103 patients treated with vancomycin for methicillin-resistant Staphylococcus aureus infections were analyzed in this study. The associations of clinicodemographic characteristics (including sex, age, weight, infection sites, main etiologies of ICU cases, comorbidities, acute physiological chronic health evaluation II score, and mechanical ventilation) and pharmacokinetics (daily dose, C_min, AUC_0-24, and AUC_0-24/minimum inhibitory concentration) with efficacy and nephrotoxicity of vancomycin were evaluated with univariate and multivariate logistic regression analyses. AUC_0-24 was calculated using VCM-TDM software based on vancomycin population pharmacokinetics and Bayesian feedback method.

RESULTS

C_min over 9.4 μg/mL and AUC_0-24 exceeding 359.6 μg × hour/mL indicated good efficacy against infection. C_min below 14.0 μg/mL predicted no significant nephrotoxicity.

CONCLUSION

In this study, the effective and safe concentration interval for vancomycin in patients in the ICU was C_min 9.4-14.0 μg/mL. Close attention should be paid to adverse effects and renal function during vancomycin treatment.

Improving medication safety with proactive reconciliation in acute coronary syndrome patients: A randomized trial

Background

Patients with acute coronary syndrome (ACS) are at an increased risk of medication errors due to the complexity of medication regimens, frequent transitions of care, the use of high-risk medications, and their vulnerability to adverse events.

Objective

This randomized controlled trial aimed to compare the effectiveness and time efficiency of proactive versus retroactive medication reconciliation models in preventing unintentional medication discrepancies in patients hospitalized with ACS.

Methods

Conducted from January to June 2024 at a specialty cardiovascular teaching hospital in West Iran, the study included 162 eligible patients admitted to the coronary care unit (CCU) with a diagnosis of ACS and taking at least five regular medications. Patients were randomly assigned to either the proactive or retroactive reconciliation group (81 each). A clinical pharmacist led both reconciliation models, supported by trained pharmacy interns who conducted patient interviews to obtain detailed medication histories. Primary outcome measures included the number and types of unintentional medication discrepancies identified, as well as their potential harm.

Results

A total of 654 medications were reconciled using the proactive approach, compared to 627 with the retroactive method. Among the discrepancies identified, 13 % were unintentional in the proactive group, whereas 44 % were unintentional in the retroactive group (p < 0.001). Additionally, 66.7 % of patients in the retroactive group had at least one discrepancy, compared to 38.3 % in the proactive group (p < 0.001). The average number of unintentional discrepancies per patient was significantly lower in the proactive approach (0.6) than in the retroactive model (1.7; p < 0.001). Over 51 % of errors in the retroactive group had the potential for moderate or severe harm, while most errors in the proactive model were assessed as having only mild harm (86.5 %; p < 0.001). The acceptance rate of pharmacist recommendations regarding unintentional medication discrepancies was higher in the retroactive reconciliation group compared to the retroactive group (68 % vs. 21 %; p < 0.001), and physicians reported greater satisfaction with the proactive method. Furthermore, the proactive model demonstrated superior time efficiency in completing the medication reconciliation process and resolving discrepancies.

Conclusions

Our findings demonstrate that the proactive model of medication reconciliation is more time-efficient and effective in preventing unintentional medication discrepancies in patients hospitalized with ACS compared to the retroactive approach.

Trial registration

The trial was registered at Iranian Registry of Clinical Trials (https://irct.behdasht.gov.ir/trial/74760, identifier code: IRCT20120215009014N494). Registration date: 2024-01-02.

Influence of smoking on glycaemic control in individuals with type 1 diabetes using flash glucose monitoring and its mediating role in the relationship between socioeconomic status and glycaemic control

Objective

This study examined the influence of smoking on glycaemic control in individuals with type 1 diabetes (T1D) using flash continuous glucose monitoring (F-CGM) systems, as well as its potential mediating role in the relationship between socioeconomic status (SES) and glycaemic control.

Methods

This study included 378 subjects with T1D (18% smokers). Glucose metrics cloud downloads were obtained over a period of 14 days. Mean annual net income per person based on census tract data was used as a proxy for SES. Mediation analysis was performed using four-way effect decomposition procedures.

Results

Smokers exhibited significantly lower net income than non-smokers (p < 0.001). Compared to smokers, non-smokers showed better glycaemic control characterized as higher time in range (TIR) 70-180 mg/dL (p = 0.002) and lower glycosylated haemoglobin levels (p = 0.008). Mediation analysis revealed a significant mediating role of smoking in the relationship between SES and glycaemic control (TIR).

Conclusions

Our data suggest that smoking exerts a detrimental effect on glycaemic control in individuals with T1D using F-CGM systems. In addition, tobacco use partially mediates the relationship between SES and glycaemic control. Thus, adopting smoking cessation measures could lead to improved glycaemic control and help mitigate the impact of social inequalities on T1D.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40200-024-01535-y.

Design and implementation of a risk-adapted, longitudinal, theory-driven medication adherence intervention: A protocol for a multi-phasic, hybrid effectiveness-implementation trial

BACKGROUND

The increasing use of targeted oral anticancer agents (OAAs) has transformed cancer treatment, yet patient adherence in real-world settings remains suboptimal. This protocol outlines a multi-phasic, hybrid effectiveness-implementation trial designed to develop, implement, and evaluate a risk-adapted, longitudinal medication adherence intervention for patients prescribed OAAs.

METHODS

Drawing on social cognitive theory, intervention mapping, and implementation science, the study aims to address barriers at cognitive, behavioral, and environmental levels that impact adherence. Phase 1 identifies implementation barriers and refines strategies, informed by expert input and semi-structured interviews. Phase 2 incorporates patient-centered feedback to tailor a theory-driven intervention targeting adherence barriers. In Phase 3, the intervention is piloted across diverse clinical settings to assess its effectiveness and implementation feasibility.

CONCLUSION

This trial aims to deliver a scalable and sustainable model for adherence support, with broad implications for improving patient outcomes and integrating adherence monitoring in routine cancer care.

Assessing the language availability, readability, suitability and comprehensibility of heat-health messaging content on health authority webpages and online resources in Canada

Objectives

Heat-health communication initiatives are a key public health protection strategy. Therefore, understanding the potential challenges that all Canadians and specific groups, such as those facing literacy barriers and non-native language speakers, may experience in accessing or interpreting information, is critical.

Methods

This study reviewed and evaluated the language availability, readability, suitability, and comprehensibility of heat-related webpages and online resources (n = 417) published on public health authority websites in Canada (n = 73). Six validated readability scales and a comprehensibility instrument were used.

Results

Most content was presented in English (90 %); however, only 7 % of the online resources were available in more than one language. The average reading grade level of the content (grade 8) exceeded the recommended level (grade 6), and only 22 % of the content was deemed superior for suitability and comprehensibility.

Conclusions

Our study evaluating web-based materials about extreme heat published by Canadian health authorities provides evidence that the current language availability, readability, suitability, and comprehensibility may be limiting the capacity for members of the public to discern key messaging.

Innovation

To ensure all Canadians can access and interpret information related to heat-health protection, public health authorities may consider translating their materials into additional languages and incorporating a readability evaluation to improve public understanding.

Ahmed glaucoma valve implantation in a case of volatile intraocular pressure and preoperative hypotony

Purpose

To describe a case of Ahmed glaucoma valve (AGV) implantation in a patient with clinical hypotony. In this instance, the AGV helped to stabilize labile intraocular pressures (IOP) by introducing a new outflow pathway that could buffer against variable aqueous inflow.

Observation

Our patient presented with severe mixed mechanism glaucoma in his only seeing eye and had a history of failed prior angle surgeries, filtration surgery, and cyclodestructive procedures. After a recent diode, the patient's IOP was difficult to control and ranged from 2 mmHg on a single topical medication to 28 mmHg with no medications. Preoperatively, the patient had visually significant hypotony (corneal and macular folds) while on one topical agent. An AGV was implanted with subsequent stabilization of IOP and vision after postoperative week 6 without the need for IOP lowering agents. The IOP and vision have maintained stability after greater than 1 year of follow-up.

Conclusion and Importance

When the outflow pathways are compromised, any fluctuation in the inflow has a much more dramatic effect on the IOP. In such instances, IOP lowering agents have a very narrow therapeutic window and lead to volatility in IOP. This case demonstrates the potential for tube shunt surgery to reduce the lability of IOP in a patient with volatile IOP control.

Trust in nurses and its association with medication adherence of cardiovascular patients: A descriptive correlational study

Background

Medication adherence plays an important role in managing cardiovascular diseases. Trust in nurses may be effective in enhancing medication adherence in patients with cardiovascular diseases.

Aim

This study aimed to investigate the correlation between trust in nurses among cardiac patients and their medication adherence and explore the predictors of medication adherence.

Methods

This descriptive correlational design was conducted among "302″ cardiac patients hospitalized at Amir Al-momenin Teaching Hospital affiliated with Maragheh University of Medical Sciences. Data was gathered using a demographic characteristics questionnaire, Medication Adherence Scale, and Trust in Nurses' Scale. Data was analyzed using descriptive (frequency, percentage, mean, standard deviation, median, and descriptive tables) and inferential (Kruskal-Wallis, Mann-Whitney, Spearman correlation coefficient, and quartile regression) statistics. Data was gathered from October 2023 to January 2024. The data was analyzed using SPSS software ver.21.

Findings

The mean and standard deviation of medication adherence and trust in nurses were 91.6 ± 6.9 and 10.5 ± 3.9, respectively. A significant positive correlation was found between trust in nurses and medication adherence(r = 0.61). There was a significant difference in medication adherence based on the type of disease. So that, the median medication adherence was the highest for coronary artery patients and the lowest for hypertensive patients. The results of quartile regression analysis showed that trust in nurses and type of disease are the main predictors of medication adherence (R2 =20 %.).

Discussion and conclusions

The results indicated that medication adherence among cardiovascular patients was moderate and patients' trust in nurses was less than average. Considering the type of disease as an unmodifiable variable, trust in nurses was the main modifiable factor that plays an important role in increasing medication adherence of cardiovascular patients. Therefore, appropriate strategies such as teaching communication skills to nurses, and training and attracting interested individuals with high communication skills should be taken to enhance patients' trust in nurses.

Automated dispensing cabinets and the effect on omitted doses of ward stock medicines; can implementation reduce delays to first dose antimicrobials?

Omitted doses are a subset of medication administration errors which have the potential to cause severe harm. Sepsis is a clinical condition where dose omissions or delays in medicines administration can be fatal. Automated dispensing cabinets (ADCs) provide a medicines management solution which keeps track of stock in real time and can automatically generate orders, reducing the likelihood of medication stockouts. This study aims to assess the impact of ADC implementation on the rate of omitted doses due to unavailability of ward stock medicines. Secondary aims are to investigate the effect of ADCs on omitted doses of first dose antimicrobials. Due doses data was compiled from the electronic prescribing and medicines administration (EPMA) system for ten wards pre-ADC implementation between July and September 2022 and was compared with data post-ADC implementation between July and September 2023. Omitted doses were selected and filtered for those marked 'drug not available'. Ward stock lists were used to determine which omitted doses were for medicines held as ward stock. A secondary analysis filtered this data further to isolate omitted doses of ward stock medicines which were systemically administered antimicrobials. The overall number of prescribed doses during the pre-implementation period was comparable to those in the post-implementation period. There was a total of 393 omitted doses of ward stocked medicines due to unavailability pre-ADC implementation, and 817 post-ADC implementation. This represents an omission rate due to unavailability of ward stock medicines as a percentage of all prescribed doses, of 0.08 % pre-ADC and 0.18 % post-ADC implementation. Statistical analysis showed no difference (p = 0.1655). There was also no statistical difference in omitted doses of ward stocked antimicrobials pre vs post-ADC implementation (p = 0.3363). It has been identified that a potential way to reduce rates of omitted doses is by optimising stock stored in each cabinet. This research is encouraging and may warrant further data collection once stock optimisation has occurred.

Outcomes of pharmacist-led patient education on oral anticoagulant therapy: A scoping review

BACKGROUND

Oral anticoagulants (OACs) are commonly used to prevent and treat thromboembolism and stroke prevention in patients with nonvalvular atrial fibrillation (NVAF). Vitamin K antagonist (VKAs) and direct oral anticoagulant (DOACs) therapies are challenging because of the possible risk of bleeding. Patient education by pharmacists could be beneficial for reducing the risk of adverse effects and improving therapeutic outcomes.

OBJECTIVE

This scoping review aimed to investigate the outcomes of pharmacist-led patient education interventions regarding VKAs and DOACs therapies.

METHOD

Three databases (PubMed, Web of Science, and Scopus) were used following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines to identify articles published between January 1, 2008, and December 31, 2024. The data were synthesized using Rayyan AI.

RESULTS

A total of 1102 records were identified. After title and abstract screening, 77 studies were selected for full-text review, and 57 articles were ultimately included. The percentages of studies that examined VKAs, DOACs, and both (OACs) were 66.7 %, 19.3 %, and 14.0 %, respectively. At least one statistically significant outcome was detected in 81.6 % (31 out of 38) of the studies on VKAs, 36.4 % (4 out of 11) of the studies on DOACs and 50 % (4 out of 8) of the studies on OACs.

CONCLUSION

This review revealed that pharmacist-led patient education was particularly effective in cases of VKAs, while the outcomes in cases of DOACs were modest. Moreover, while the role of pharmacists in patient education on VKAs has been widely studied, limited research has focused on the effect of pharmacist-led education on DOACs.

Role of disturbance coefficient in monitoring and treatment of cerebral edema in patients with cerebral hemorrhage

BACKGROUND

At present, the conventional methods for diagnosing cerebral edema in clinical practice are computed tomography (CT) and magnetic resonance imaging (MRI), which can evaluate the location and degree of peripheral cerebral edema, but cannot realize quantification. When patients have symptoms of diffuse cerebral edema or high cranial pressure, CT or MRI often suggests that cerebral edema is lagging and cannot be dynamically monitored in real time. Intracranial pressure monitoring is the gold standard, but it is an invasive operation with high cost and complications. For clinical purposes, the ideal cerebral edema monitoring should be non-invasive, real-time, bedside, and continuous dynamic monitoring. The disturbance coefficient (DC) was used in this study to dynamically monitor the occurrence, development, and evolution of cerebral edema in patients with cerebral hemorrhage in real time, and review head CT or MRI to evaluate the development of the disease and guide further treatment, so as to improve the prognosis of patients with cerebral hemorrhage.

AIM

To offer a promising new approach for non-invasive adjuvant therapy in cerebral edema treatment.

METHODS

A total of 160 patients with hypertensive cerebral hemorrhage admitted to the Department of Neurosurgery, Second Affiliated Hospital of Xi’an Medical University from September 2018 to September 2019 were recruited. The patients were randomly divided into a control group (n = 80) and an experimental group (n = 80). Patients in the control group received conventional empirical treatment, while those in the experimental group were treated with mannitol dehydration under the guidance of DC. Subsequently, we compared the two groups with regards to the total dosage of mannitol, the total course of treatment, the incidence of complications, and prognosis.

RESULTS

The mean daily consumption of mannitol, the total course of treatment, and the mean hospitalization days were 362.7 ± 117.7 mL, 14.8 ± 5.2 days, and 29.4 ± 7.9 in the control group and 283.1 ± 93.6 mL, 11.8 ± 4.2 days, and 23.9 ± 8.3 in the experimental group (P < 0.05). In the control group, there were 20 patients with pulmonary infection (25%), 30 with electrolyte disturbance (37.5%), 20 with renal impairment (25%), and 16 with stress ulcer (20%). In the experimental group, pulmonary infection occurred in 18 patients (22.5%), electrolyte disturbance in 6 (7.5%), renal impairment in 2 (2.5%), and stress ulcers in 15 (18.8%) (P < 0.05). According to the Glasgow coma scale score 6 months after discharge, the prognosis of the control group was good in 20 patients (25%), fair in 26 (32.5%), and poor in 34 (42.5%); the prognosis of the experimental group was good in 32 (40%), fair in 36 (45%), and poor in 12 (15%) (P < 0.05).

CONCLUSION

Using DC for non-invasive dynamic monitoring of cerebral edema demonstrates considerable clinical potential. It reduces mannitol dosage, treatment duration, complication rates, and hospital stays, ultimately lowering hospitalization costs. Additionally, it improves overall patient prognosis, offering a promising new approach for non-invasive adjuvant therapy in cerebral edema treatment.

Exploring the mechanisms of action of probiotics in depression: Results from a randomized controlled pilot trial

BACKGROUND

We previously reported greater reductions in depression and anxiety following probiotic supplementation in people with major depressive disorder (MDD) in a randomised double-blind placebo-controlled pilot trial (Nikolova et al., 2023). Here, we investigate the mechanisms underlying these effects.

METHODS

49 people with MDD received a multi-strain probiotic (n = 24) or placebo (n = 25) for 8 weeks in addition to their antidepressant. Stool and blood samples were collected to analyse gut microbiota composition and inflammatory cytokines. Stool samples from 25 matched healthy volunteers (HVs) were also obtained.

RESULTS

Within the probiotic group, there was a significant increase in richness according to Chao1(bias-corrected) (w4 p = 0.04) and a trend for increased Total count (w4 p = 0.06, w8 p = 0.09) compared to baseline, but not to placebo. When compared to HVs post-treatment, only the placebo group had a significant decrease in Shannon' entropy (p = 0.03) and a trend for decreased Total count (p = 0.08) and Simpson's index (p = 0.09). Between-group differences in beta diversity were observed at week 4 (p = 0.04), but not week 8. Consistent between-group differences were seen in family Bacilleceae post-treatment (FDR p < 0.05), which correlated with decreases in anxiety (FDR p < 0.05). There were no differences in inflammatory markers.

LIMITATIONS

This study was limited by data loss during the COVID-19 Pandemic.

CONCLUSION

Probiotics may positively impact the microbiota by normalising diversity and increasing levels of health-related taxa, which may partially account for their benefits in MDD. Understanding how these changes relate to symptom improvement can inform their targeted use in clinical practice. Larger trials incorporating functional multi-omics are needed.

TRIAL REGISTRATION

NCT03893162.

Leadership competencies and behaviours in pharmacy: A qualitative content analysis

BACKGROUND

Across complex healthcare systems, effective leadership rises as a cornerstone for improving patient care, promoting innovation, and maintaining a thriving professional landscape. As with most healthcare professions, pharmacists are confronted with medication complexity, changing legislation, and technological integration into healthcare delivery. Lack of leadership in a pharmacy can lead to unorganized medicine dispensing, patient care, and stagnant innovation. Effective leadership requires competencies that blend knowledge, abilities, and behaviours to achieve tasks successfully. Leadership competencies empower pharmacists to lead change in their profession and healthcare system. Despite extensive research and development in various industries, the development of pharmacy leadership competencies and frameworks is limited due to specific challenges. It is essential for the pharmacy profession to continue investing in the development of leadership competencies to drive innovation and improve patient outcomes.

OBJECTIVE

The objective of the document analysis is to identify pharmacy leadership competencies and analyse related behaviour statements from a global perspective.

METHOD

This study employs an integrative review utilizing a document analysis to conduct a qualitative content analysis on various sources to identify leadership competencies and behaviours within the pharmacy sector. A systematic approach was followed by searching five electronic databases (Medline, CINAHL, SCOPUS, ERIC, and Google Scholar) in addition to grey literature, policy documents and seeking experts for related documents to ensure comprehensive coverage of relevant field-based literature.

RESULTS

Forty-eight documents were selected for analysis from the literature, most of which originated from Western countries with few representing the Middle East and African countries. Eighteen pharmacy frameworks incorporating leadership competencies were identified, two of which were healthcare frameworks encompassing pharmacists. A total of 96 competencies and 155 behaviour statements were identified from the documents. When grouped and similar competencies conjoined, 8 themes with 34 competencies emerged.

CONCLUSION

The document analysis portrays a comprehensive picture of the multifaceted landscape of pharmacy leadership competencies. By exploring the eight themes, their associated competencies and behaviour statements this study offers a roadmap for pharmacists to embark on their own leadership journeys. Future research, armed with the clarity and action-oriented language of effective behaviours, can bridge the gap between leadership and tangible impact.

Anticoagulation in patients with atrial fibrillation undergoing inpatient total knee arthroplasty: A matched analysis

Background

Patients with atrial fibrillation (AF) often require lifetime anticoagulation using drugs such as Warfarin and Direct-acting Oral Anticoagulants (DOAC). It is important to assess the impact that prior anticoagulant use has on the post-operative complications in patients with AF undergoing TKA.

Methods

This is a retrospective analysis of the PearlDiver database querying all patients who underwent an inpatient TKA. Patients who had AF and filled a prescription for at least 30 days of either Warfarin or a DOAC were matched to control cohorts. Medical and surgical complications 30 and 90 days post-operatively were compared between the two groups.

Results

4396 patients made up the group with AF on warfarin, while 5383 patients made up the cohort with AF on DOAC and their corresponding controls. Patients on anticoagulation had more AKI (OR 2.70, OR: 2.37), pneumonia (OR: 2.89, OR: 2.46), MI (OR: 2.70, OR: 3.14), transfusion (OR: 6.94, OR: 3.16), sepsis (OR: 2.47, OR: 1.96), and aseptic loosening at 90 days (OR: 17.06, OR:7.01). However, PE (OR: 3.32) and hematoma (OR: 1.71) were only higher in the warfarin cohort. TKA instability was higher in the DOAC cohort (OR: 6.00). Conversely, patients in the control group exhibited more wound dehiscence compared to the warfarin group (OR: 0.28), and higher rates of revision surgery compared to both the DOAC (OR:0.27) and Warfarin (OR:0.31) groups at 90 days.

Conclusion

Patients on DOAC and Warfarin for AF, and undergoing TKA are exposed to a higher risk of post-operative complications.

Physiologically-based pharmacokinetic modeling to predict the exposure and to assess pharmacodynamics of daptomycin in infants within 1 year old

Daptomycin is widely used in pediatric patients for serious infections caused by Gram-positive bacteria, however, studies regarding its safety and efficacy in infants within 1 year old are very limited. A physiologically-based pharmacokinetic (PBPK) model of daptomycin was built for children aged 1-17 years old and extrapolated to infants within 1 year old to evaluate pharmacodynamics (PD) based on efficacy and safety considerations. Monte Carlo Simulations (MCSs) were conducted to determine the probabilities of target attainment (PTA) and cumulative fractions of response (CFR) of daptomycin. The pharmacokinetic (PK) of daptomycin did not differ much in the population of infants within 1 year of age, with peak plasma concentration (Cmax) and area under the curve (AUC) maintained at an approximate level at all months of age, while the average trough concentration of daptomycin was 3.49 μg/mL when 10 mg/kg daptomycin was given, and 4.98 ug /mL at 15 mg/kg. According to the results of the MCSs, 10mg/kg daptomycin provides good antimicrobial effect for S.pneumoniae and MSSA. With the increase of dosage, the CFR value of daptomycin against MRSA, E.faecalis and E.faecium also gradually reached >90 %, except for E.faecalis with an average CFR of only 82.94 % at 12mg/kg. This is a daptomycin PBPK model in infants within 1 year of age, dose regimen higher than 10 mg/kg should be recommended for this population in the treatment of MRSA, E. faecalis, and E. faecalis.

Working memory capacity improves checking performance for errors on a simulated rail control task

Checking performed by workers is crucial if safety is to be effectively managed in high-risk settings. We aimed to examine the influence of working memory capacity, mindfulness, sleep, and interruptions on checking performance for the detection of errors. A total of 86 participants completed a 32-min rail control simulation. Participants performed checks that involved matching versus critical analysis and assimilation with interruptions occurring during the task. Higher working memory capacity was associated with higher response accuracy and faster response latency. Response accuracy was also higher when participants engaged in matching compared to critical analysis and assimilation. Mindfulness and interruptions were not associated with performance. These results raise important questions about how checking and error detection can be optimised given differences in performance due to individual characteristics and task requirements.

Examining clinicians' fatigue in a pediatric emergency department

We examined fatigue among emergency department (ED) clinicians. ED clinicians are susceptible to burnout, because of fatigue. Fatigue represents a latent hazard in ED care, being associated with impaired clinician performance, poor patient outcomes, and a negative impact on patient safety. Thirty-five pediatric clinicians were surveyed at the beginning and end of their shifts. The 20-item Swedish Occupational Fatigue Inventory survey was used to evaluate fatigue. Paired t-tests were used to examine whether fatigue scores changed over the course of a shift. The associations between the five fatigue subscales and various factors were modeled with multilevel linear regressions. Surveys (N = 827) were administered over 425 shifts. Clinician fatigue depended on time spent within the shift, shift type, clinician's gender, age, and clinician's role. Analysis showed other individual characteristics and shift factors also may affect fatigue. Clinicians with varying fatigue levels have different needs that should be considered in information technology design and evaluation.

Assessing the safety of midazolam: A comprehensive analysis of adverse events from FAERS

Midazolam, a potent sedative from the benzodiazepine class, is widely used in anesthesia and intensive care, but it has been linked to severe and life-threatening cardiopulmonary adverse events (AEs). This study investigated real-world AEs associated with midazolam using data from the U.S. Food and Drug Administration (FDA) adverse event reporting system (FAERS) from 2004 to 2024. Disproportionality analysis was performed using four signal detection methods-reporting odds ratio, proportional reporting ratio, Bayesian confidence propagation neural network, and multi-item gamma Poisson shrinker-to assess midazolam-related AEs. A total of 2952 AE reports were identified, involving seven system organ classes, with 31 specific AEs meeting criteria across all four algorithms. Unexpected AEs not listed in the product label, such as seizure, coma, respiratory failure, anaphylactic shock, and hypothermia, were also observed, with most AEs occurring within the first 10 days of midazolam use. This pharmacovigilance study highlights the need for increased awareness of serious and unexpected AEs, including respiratory failure, anaphylactic shock, hypothermia, and metabolic acidosis, to promote safer use of midazolam in clinical practice.

Return on investment of pharmacists' services among non-hospitalized patients: A scoping review

BACKGROUND

As pharmacists' role has evolved to encompass medication management services, there has been limited expansion of insurance coverage of these services. Investment in services by employers and insurance plans may be limited due to concerns regarding financial viability and an unclear return on investment (ROI).

OBJECTIVES

This scoping review described reported ROI of studies evaluating pharmacist driven medication management services among non-hospitalized patients. A secondary objective was to describe key details of included studies that could impact the ROI analysis.

METHODS

Reporting for this scoping review was conducted in consultation with the preferred reporting items for systematic reviews and meta-analyses extension for scoping reviews (PRISMA-ScR). Search was conducted in PubMed, Embase, and Web of Science from inception up to the search date. Two-stage process in the Covidence web platform was utilized to screen and identify studies. For studies to be included, the study (1) needed to be a pharmacy service provided to a non-hospitalized patient, (2) needed to have evaluated the effect of the intervention on medical costs or medical and prescription costs, and (3) needed to report ROI as an outcome. Extracted data included year of publication, study design, follow-up, or observation period, setting, sample size, perspective of analysis, inclusion and exclusion criteria, type and description of intervention, and details and outcomes of economic analysis.

RESULTS

There were 28 studies included. ROI ranged from -3% to 504 % among the nine studies that reported ROI as percentages. ROI ranged from $1.29 to $18.5 per dollar spent on the pharmacy service among the 19 studies that reported ROI as a ratio. Only one study reported a negative ROI. A total of five studies did not report how ROI was calculated.

CONCLUSION

There was a largely positive return on investment of pharmacists' services provided in outpatient settings from the perspective of payers and employers. However, a lack of consistency and clarity in the reporting of study characteristics and economic outcomes was noted, which may partly limit the generalizability and utility of economic analyses to support the implementation of new pharmacists' services in other settings.

The importance of rigor in pharmacy research: Challenges and solutions

Scientific rigor broadly refers to upholding basic principles within the conduct of research. Various threats associated with rigor exist in today's research environment, such as the replication crisis, the increasing prevalence of misconduct, and a loss of public trust in regulatory and educational institutions. The purpose of this commentary is to identify problems and solutions associated with research rigor, with a focus on pharmacy research. Problems exist at many levels, including within variable research training/funding, institutional pressures associated with career advancement, and norms associated with academic publishing. However, solutions are possible as methods of harm reduction, including (but not limited to) focused initiatives supporting rigor, team-based approaches to research that include diverse interested parties, and a reimagining of what constitutes value within science. Pharmacists and pharmacy researchers are called upon to uphold research rigor as a professional and ethical responsibility.

Alienation and/or anomie in pharmacists: A systematic review and narrative synthesis of the international literature

BACKGROUND

Flourishing and belonging are key concepts for the wellbeing of staff and the success of a profession. Alienation and anomie are distinct types of psycho-social ills which inhibit flourishing and belonging. A better understanding of these may offer hope in preventing many negative work endpoints, including burnout and intention to leave.

OBJECTIVES

To systematically review and narratively synthesise alienation and/or anomie in pharmacists across the globe, reviewing all types of methodological designs, published in peer-reviewed journals.

METHODS

We identified published peer-reviewed research through searching eight electronic databases (MEDLINE, Embase, PsycINFO, CINAHL, Cochrane Library, Web of Science - Core Collection, Scopus, and Google Scholar) and extensive hand/citation searching. Two independent reviewers identified and critiqued eligible studies, extracted data, and synthesised the findings. The synthesis evaluated the focuses, causes, associated factors, and/or consequences of alienation and/or anomie and aligned these to six deductive themes from alienation theory: care; values; meaning; recognition; autonomy; and shared responsibility.

RESULTS

Searches identified 886 papers, with 47 included in the final results. From the synthesis, ten key causes of alienation and/or anomie were identified; 1) Changing Professional Identity, 2) Reimbursement Models & Corporatisation, 3) Focus on Medicines Rather than People, 4) Misunderstanding & Deprofessionalisation, 5) Environments & Culture, 6) Suboptimal Societal Mandate, 7) Roles Misaligned with Aspirations, 8) Systematic Underutilisation, 9) Lack of Professional Agency, and 10) Value Conflict. From the evidence, there was high confidence that inhibitions of care, values, recognition, and/or autonomy (four of the six deductive themes) were associated with alienation and/or anomie.

CONCLUSION

Alienation and/or anomie are present across many countries and regions. This paper helps us understand the aetiology of this complex psycho-social syndrome, a necessary first step in creating an inclusive profession where all pharmacists can flourish. Future research needs to trial new interventions targeted at correcting this professional malady.

Optimized suction patch design for enhanced transbuccal macromolecular drug delivery

Peptides represent a rapidly expanding class of drugs with broad therapeutic potential. However, due to their large molecular weight and susceptibility to degradation in the gastrointestinal tract, most peptide drugs are administered via subcutaneous injections. Despite extensive research, a painless broad delivery platform for these drugs is still lacking. Recently, an octopus-inspired buccal patch has shown promise in addressing this challenge by leveraging a synergistic combination of mechanical stretching and permeation enhancers. In this study, the patch and the loaded formulation were optimized to improve ease of use, scalability, and efficacy. Through assessments of mechanical properties, finite element simulations, and ex vivo experiments, we evaluated the effects of patch design and material, as well as the drug matrix composition and the formulation preparation methods on the delivery performance. A patch with a > 9-fold larger effective surface area, produced via mold casting of medical-grade silicone (shore hardness 50) and loaded with a lyophilized drug matrix, emerged as the most promising system. In beagle dogs, 30-min application of this patch resulted in a 14.6 % bioavailability for teriparatide (4118 g mol-1), while bioavailability of semaglutide (4114 g mol-1) was 9.6 times higher than that of the commercial tablet. This work showcases how systematic optimization of this technology can improve and simplify the buccal administration of macromolecular drugs, facilitating the clinical translation of this non-invasive dosage form.

Recent advances in PKC inhibitor development: Structural design strategies and therapeutic applications

Protein kinase C (PKC) isozymes play critical roles in diverse cellular processes and are implicated in numerous diseases, including cancer, diabetes, and autoimmune disorders. Despite extensive research efforts spanning four decades, only one PKC inhibitor has received clinical approval, highlighting the challenges in developing selective and efficacious PKC-targeting therapeutics. Here we review recent advances in the development of small-molecule PKC inhibitors, focusing on structural design strategies, pharmacological activities, and structure-activity relationships. We analyze emerging approaches including fragment-based drug design, allosteric targeting, and natural product derivatization that have yielded promising new scaffold classes. Special attention is given to innovations in achieving isozyme selectivity, particularly for PKCα and PKCβ, which have proven crucial for therapeutic applications. We discuss how integration of computational methods, structural biology insights, and rational design principles has advanced our understanding of PKC inhibition mechanisms. This comprehensive analysis reveals key challenges in PKC drug development, including the need for enhanced selectivity and reduced off-target effects, while highlighting promising directions for future therapeutic development. Our findings provide a framework for designing next-generation PKC inhibitors with improved clinical potential.

Patient-psychologist telemedicine interactions in an intensive care unit recovery clinic: Qualitative secondary analysis

OBJECTIVES

We aimed to describe the content of patient-psychologist mental health related dialogues during a telemedicine intensive care unit recovery clinic visit.

RESEARCH METHODOLOGY/DESIGN

Qualitative descriptive study nested within a randomized controlled pilot trial to assess a telemedicine intensive care unit recovery clinic feasibility and preliminary efficacy. Participants included adults hospitalized with sepsis and/or respiratory failure. Telemedicine visits occurred at 3- and 12-weeks post-discharge involving a critical care pharmacist, physician, and psychologist. The psychologist conducted cognitive and mental health screenings, providing tailored brief psychotherapy and education. Audio-recorded visits were transcribed verbatim and underwent inductive reflexive thematic analysis.

SETTING

Intensive care unit recovery clinic at an academic medical center in the southeastern United States.

MAIN OUTCOME MEASURES

N/A.

FINDINGS

17 participants completed 31 telemedicine intensive care unit recovery clinic visits between December 2019 and March 2022. Caregivers participated in 13 visits. Participant experiences and psychologist responses were identified and separated into two overarching themes: 1) Patient-Identified Challenges and 2) Psychologist-Delivered Strategies. Patient subthemes included 1) mental health challenges (negative thoughts), 2) minimization of mental health impact, and 3) use of coping methods. Psychologist subthemes included 1) rapport building and validation 2) use of psychological assessments, and 3) psychological interventions.

CONCLUSION

The collaborative effort, including a psychologist, exemplifies the role of a mental health professional within the multidisciplinary intensive care unit recovery clinic team, contributing to a comprehensive approach in identifying and managing post-intensive care syndrome impairments. The focus extends to shaping compassionate care strategies for addressing mental health challenges associated with post-intensive care syndrome, fostering a holistic approach to whole-person recovery.

IMPLICATIONS FOR CLINICAL PRACTICE

A mental health professional (e.g., psychologist, psychiatrist, psychiatric nurse practitioner) can contribute to shaping care strategies for the mental health symptoms associated with post-intensive care syndrome, fostering whole-person recovery after hospital discharge.

CLINICAL TRIAL REGISTRATION NUMBER

NCT03926533.

Investigation of Precepting-Related Burnout in Dietetics Preceptors

BACKGROUND

Dietetics preceptors are at risk of abandoning their role because of potential burnout. Identifying factors associated with greater and lesser burnout can help key stakeholders identify and implement strategies to prevent or mitigate burnout in dietetics preceptors.

OBJECTIVE

The purpose of this study was to identify factors associated with the burnout preceptors attribute specifically to the work of precepting.

DESIGN

This study used a cross-sectional study design. A survey instrument including burnout measures, precepting measures, and items querying personal and work characteristics was distributed via e-mail to a random sample of 10 000 credentialed nutrition and dietetics practitioners.

PARTICIPANTS SETTING

Respondents who lived in the United States, were currently practicing, and had precepted during the past year were included in the sample (n = 310). The survey was conducted in October and November of 2022.

MAIN OUTCOME MEASURES

Precepting-related burnout was measured using scores on the Copenhagen Burnout Inventory; scores ranged from 0 to 100 and higher numbers indicated greater burnout.

STATISTICAL ANALYSES PERFORMED

Factors associated with precepting-related burnout were identified using an analysis of covariance. Pairwise comparisons with Tukey adjustments were done to determine differences across categories for the categorical variable in the model (ie, percent of interns requiring additional coaching). A stepwise variable selection process was performed to determine the best analytic models.

RESULTS

Factors associated with lower precepting-related burnout in dietetics preceptors included higher Commitment to the Preceptor Role scores, lower percentages of interns requiring additional coaching, feeling appreciated by the dietetic interns, and higher Preceptors' Perceptions of Support scores. A factor associated with higher precepting-related burnout was precepting a greater number of dietetic interns in the past year. For every 1-point change in each variable, the degree of change in precepting-related burnout was -7.9 for Commitment to the Preceptor Role, -3.2 for feeling appreciated by dietetic interns, -4.5 for Preceptors' Perceptions of Support, and +1.2 for number of dietetic interns per year. The mean ± SE difference in precepting-related burnout scores between preceptors who reported < 10% of dietetic interns requiring additional coaching and those who reported > 50% of dietetic interns requiring additional coaching was -13.7 ± 3.7.

CONCLUSIONS

The factors found to be associated with precepting-related burnout scores in dietetics preceptors are potentially modifiable, suggesting this burnout might be prevented or mitigated to some degree.

Mycophenolate-associated colitis in an orthotopic heart transplant patient- an unusual case presentation

Mycophenolate mofetil (MMF), an immunosuppressive, is a pharmacologically inactive compound of mycophenolic acid, which has been widely used in solid organ transplant and autoimmune conditions. It mostly exerts gastrointestinal (GI) adverse effects, which include diarrhea, abdominal pain, nausea, and vomiting. It can lead to MMF-colitis, a challenging condition to diagnose due to its similarity with other GI-related conditions and infections. This case report discusses a heart transplant recipient who developed severe MMF-induced colitis. It adds significantly to the limited literature available for this difficult-to-diagnose condition. It also highlights the severity of the condition and underscores the importance of vigilant monitoring and the need for future cohort studies to set guidelines for diagnosing and treating MMF-associated colitis due to its widespread use.

Prenatal and Early Childhood Exposure to Proton Pump Inhibitors and Antibiotics and the Risk of Childhood Cancer: A Nationwide Population-Based Cohort Study

BACKGROUND

Our microbiome is established during infancy, a time important for later health and long-term effects. Proton pump inhibitors and antibiotics are regularly prescribed during pregnancy. Both drugs cause microbiome disturbance and have been associated with increased cancer risk in adults, but effects of these drugs on the growing foetus and infant remain understudied.

AIM

The aim of this study is to study the association between prenatal and early life proton pump inhibitor and antibiotics exposure and the risk of childhood cancer.

METHODS

This study is a retrospective population-based cohort design, using registry data on all births (n = 722,372) in Sweden between 2006 and 2016, according to the STROBE checklist. For women who had multiple children in the timeframe of the study, only the first child during the time period was included in the cohort. Exposure was defined as either ≥ 1 proton pump inhibitor or antibiotics prescription during pregnancy, or during the first 2 years of life. Outcome was defined as cancer at any time during the follow-up or cancer after the age of 2 years for early life exposure. Multivariable Cox proportional hazard models were used to calculate hazard ratios.

RESULTS

In total, 1091 (0.2%) children were diagnosed with malignant cancer during the follow-up. Prenatal exposure to proton pump inhibitors and antibiotics were not associated with an increased risk of cancer. Regarding early life exposure, proton pump inhibitors were associated with an increased risk of cancer at age two or older (adjusted hazard ratio [aHR] 3.68, 95% confidence interval [CI] 2.24-6.06).

CONCLUSIONS

We did not find evidence that prenatal proton pump inhibitors and antibiotics were associated with overall childhood cancer. However, proton pump inhibitors during early life were associated with an increased risk of childhood cancer, but indication on drug use was not available and confounding by indication may be present.

Apixaban plasma levels in patients with HeartMate 3 support

BACKGROUND

Apixaban is increasingly used instead of vitamin K antagonists (VKAs) for long-term anticoagulation during HeartMate 3 (HM3) support. However, data on its pharmacokinetics in this context is lacking. We present real-world data on apixaban levels and outcomes in adult and pediatric HM3 patients, and evaluate our dosing strategy based on plasma sampling.

METHODS

Since June-2023, all new HM3 recipients were initiated on apixaban. Additionally, hospitalized adult HM3 patients were transitioned from VKA to apixaban. Trough apixaban levels were measured in all patients, and dose adjustment was considered to exceed 50ng/ml.

RESULTS

This retrospective study includes 34 HM3 patients, 4 pediatric (all primary use) and 30 adult patients (16 primary use). In primary use, apixaban was started at median of 14 (interquartile range [IQR]: 11-16, pediatric) and 11 (IQR: 6-13, adult) days postoperatively. No major coagulopathic events occurred during an overall follow-up of 3,191 patient-days. Six minor bleeding events occurred (0.69 events per patient-year), mostly (67%) during dual therapy with aspirin. Fourteen patients had dose adjustment; median trough and peak levels on final dosage were 73 (IQR: 50-92) and 179 (IQR: 133-242) ng/ml in the pediatric group and 109 (IQR: 83-144) and 176 (IQR: 134-228) ng/ml in the adult cohort, respectively. Inter- and intraindividual variation in apixaban peak levels was considerable, while trough levels showed less variability.

CONCLUSIONS

With a dosing strategy to target trough apixaban levels of >50ng/ml, there were no thrombotic events during a follow-up of 3,191 patient-days (of which 820 patient-days in children). We observed no major, and only few non-major bleeds, mainly in patients concomitantly taking aspirin.

Injectable vancomycin loaded hyaluronic acid-chitosan hydrogel for the treatment of Staphylococcus aureus septic arthritis

Staphylococcus aureus (S. aureus) is a Gram positive opportunistic pathogen and a major cause for bacterial septic arthritis. Vancomycin is the preferred antibiotic for the treatment of methicillin resistance S. aureus septic arthritis. Patients undergoing vancomycin treatment need to be hospitalized and their serum vancomycin level should be monitored, as increase in vancomycin concentration in serum may lead to hepatotoxicity. To overcome vancomycin mediated cytotoxicity, we have prepared a local injectable delivery system by incorporating vancomycin into hyaluronic acid (HA)-chitosan (van-HA-chitosan) hydrogel. The prepared van-HA-chitosan hydrogel was characterized using Fourier Transform Infrared Spectroscopy (FTIR) and rheometer. The van-HA-chitosan hydrogel is injectable, has shear thinning behaviour; and is hemo- and cyto-compatible. In vitro drug release assay showed that 95 % of vancomycin was released from the hydrogel in 8 days. Under in vitro conditions the load of S. aureus decreased from 6.4 Log10 CFU/ml to 3.5 Log10 CFU/ml when treated with van-HA-chitosan hydrogel for 6 h. Significant decrease in bacterial counts was observed when S. aureus infected synovial fluid and bone samples were treated with van-HA-chitosan hydrogel. Our results suggest that the prepared van-HA-chitosan could be used for the treatment of septic arthritis caused by S. aureus.

Implementation and Evaluation Strategies for Pharmacogenetic Testing in Hospital Settings: A Scoping Review

BACKGROUND

Pharmacogenetic testing in clinical settings has improved the safety and efficacy of drug treatment. There is a growing number of studies evaluating pharmacogenetic implementation and identifying barriers and facilitators. However, no review has focused on bridging the gap between identifying barriers and facilitators of testing and the clinical strategies adopted in response. This review was conducted to understand the implementation and evaluation strategies of pharmacogenetic testing programs.

METHODS

A PRISMA-compliant scoping review was conducted. The included studies discussed pharmacogenetic testing programs implemented in a hospital setting. Quantitative, qualitative, and mixed design methods were included.

RESULTS

A total of 232 of the 7043 articles that described clinical pharmacogenetic programs were included. The most common specialties that described pharmacogenetic implementation were psychiatry (26%) and oncology (16%), although many studies described institutional programs implemented across multiple specialties (19%). Different specialties reported different clinical outcomes, but all reported similar program performance indicators, such as test uptake and the number of times the test recommendations were followed. There were benefits and drawbacks to delivering test results through research personnel, pharmacists, and electronic alerts, but active engagement of physicians was necessary for the incorporation of pharmacogenetic results into clinical decision making.

CONCLUSIONS

Further research is required on the maintenance and sustainability of pharmacogenetic testing initiatives. These findings provide an overview of the implementation and evaluation strategies of different specialties that can be used to improve pharmacogenetic testing.

Furosemide with adjunctive acetazolamide vs furosemide only in critically ill patients: A pilot two-center randomized controlled trial

PURPOSE

Furosemide is the most commonly used diuretic in intensive care units (ICU). We aimed to evaluate the physiological effects of adjunctive acetazolamide with furosemide on diuresis and the prevention of potential furosemide-induced metabolic alkalosis.

MATERIALS AND METHODS

We performed a two-center, pilot, open-label, randomized trial. Where the treating physicians planned intravenous diuretic therapy, we randomized ICU patients to a bolus of furosemide (40 mg) plus acetazolamide (500 mg) (n = 15) or furosemide alone (40 mg) (n = 15). Urine output, additional furosemide use, acid-base parameters, and electrolytes were compared following a Bayesian framework.

RESULTS

Adjunctive acetazolamide didn't increase urine output in the first six hours (mean difference: -112 ml, credible interval: [-742, 514]). However, compared with furosemide alone, it maintained a greater urine output response to furosemide over 24 h, with 100 % probability. Acetazolamide also acidified plasma (pH difference: -0.045, [-0.081, -0.008]) while alkalinizing urine (1.10, [0.04, 2.11]) at six hours, compared to furosemide alone with >95 % probability. Finally, we didn't observe severe acidosis or electrolyte disturbances over 24 h.

CONCLUSIONS

Adjunctive acetazolamide may increase diuretic efficacy and counterbalance furosemide-induced metabolic alkalosis without safety concerns. Larger trials are warranted to verify these findings and assess their impacts on clinical outcomes.

REGISTRATION NUMBER

ACTRN12623000624684.

REGISTRATION TITLE

A pilot trial of single versus dual diuretic therapy in the intensive care unit.

Pharmacist preceptor perceptions of diversity, equity, and inclusion in experiential learning experiences

INTRODUCTION

Societal inequities and public discourse have prompted healthcare organizations to focus on Diversity, Equity, and Inclusion (DEI). While DEI initiatives and strategic plans have been established within academia and applied to didactic curricula, literature is limited on preceptor perspectives in engagement with DEI. This study aimed to assess pharmacist preceptor perception of DEI in learning experiences and areas for improvement in the context of experiential teaching and learning within a large, multi-site pharmacy residency program to provide guidance for strategies to improve organizational approaches.

METHODS

Pharmacist preceptors of residents or student pharmacists identified through residency preceptor directories and Office of Experiential Education records were invited to participate in a survey consisting of twelve Likert scale questions, four closed, binary questions, and two free-text responses. Quantitative data was analyzed in Microsoft Excel. Qualitative survey data was coded by three of the researchers on the study team. Researchers independently identified preliminary codes from the data, then collaboratively created a list of consensus-based codes. Researchers then independently assigned codes to individual responses. The codes were then finalized for each individual response through consensus.

RESULTS

261 pharmacist preceptors were invited to participate, of which 80 participants responded to at least one question, with 69 participants completing the survey. Preceptors had more agreement in domains such as "equitable evaluation of learners" and less agreement in "readiness to provide diverse, equitable, and inclusive training and education" and "having access to ample preceptor development opportunities to stay updated on DEI topics". Consensus and thematic analysis of the qualitative results revealed strengths in program incorporation of pharmacist education, diversity of patients served, and DEI education provided to learners prior to experiential education, but an overall lack of awareness of what initiatives surrounding DEI were in progress within the organization. Primary areas of opportunity focused on additional continuing education and preceptor development, as well as incorporation of DEI training into existing preceptor development or orientation.

CONCLUSIONS

This study offers some insight into pharmacist preceptors' perceptions of DEI within a large, multi-site pharmacy residency program. Continued evaluation and further iterative work are needed to address areas of opportunity and assess success of initiatives and training. Future collaboration in national pharmacy organizations to develop best practices or standards for inclusive experiential education may be warranted.

Real-world retrospective study in elderly patients aged 65 years and older with type 2 diabetes mellitus treated with daily oral semaglutide (SEMA-elderly)

AIM

This real-world, retrospective cohort study aimed to assess the efficacy, safety and tolerability of oral semaglutide-the first GLP-1 receptor agonist available in oral form-in patients aged 65 years and older with type 2 diabetes mellitus (T2DM).

MATERIALS AND METHODS

The primary endpoint was the change in glycated haemoglobin (HbA1c) from baseline (V1) to six months (V3). Secondary endpoints included change in body weight, proportion of patients achieving HbA1c <7%, proportion of patients achieving both an HbA1c reduction of ≥1% and a body weight reduction of ≥5%. Exploratory endpoints were also assessed, including evaluations at three months (V2).

RESULTS

One hundred and one patients (mean age 74.7 ± 6.1 years) started oral semaglutide treatment. Mean HbA1c decreased significantly from V1 to V3 (change: -0.44%, p < 0.001), with reductions already evident at V2. The proportion of patients achieving an HbA1c ≤7% increased from 36.6% at V1 to 61.7% at V3. At V3, 9.6% of patients achieved an HbA1c reduction of ≥1% and a weight loss of ≥5%. Body weight decreased from a baseline mean of 76.8-73.7 kg at V3 (p < 0.001). Body mass index, waist circumference, total cholesterol, low-density lipoprotein cholesterol and systolic blood pressure decreased significantly from V1 to V3, with changes already evident at V2. Eleven patients (10.9%) reported adverse events. Seven patients (6.9%) discontinued treatment.

CONCLUSION

Oral semaglutide effectively improves glycaemic control and weight management in elderly patients with T2DM while improving lipid and cardiovascular parameters and proving to be safe and well tolerated.

Established and emerging roles for pharmacy in operating theatres: a scoping review

BACKGROUND

Pharmacy services at surgical pre-assessment clinics and on inpatient wards are well-documented, but services to theatre appear comparatively under-developed. High-risk and high-cost medicines are used routinely in theatre; pharmacists are well-qualified to optimise their use and improve patient care.

AIM

To determine the range, extent and nature of pharmacy services to theatre internationally, and to describe any reported outcomes of these services.

METHOD

This scoping review was conducted and reported as per PRISMA-ScR and Joanna Briggs Institute methodology. A search was conducted across MEDLINE, Embase, CINAHL, PsycInfo, Bielefeld Academic Search Engine, Canada's Drug and Health Technology Agency, Google and Google Scholar in April 2023. One reviewer screened titles and abstracts. Two reviewers screened full texts. Data extraction was completed by one reviewer. Two reviewers used the Mixed Methods Appraisal Tool (MMAT) to perform quality appraisal. For work completed by one reviewer, a 10% sample was randomly selected for screening by a second reviewer.

RESULTS

Ninety-two publications were included from 3924. Fifty-seven were primary research articles. Other publication types included conference abstracts, journal columns, letters to the editor, practice standards/guidelines, opinion papers, narrative reviews and newsletter articles. Medication management and clinical services across five continents were described. Most reported outcomes related to cost savings. Nine of the 57 articles met the criteria for MMAT appraisal: of these, adherence to quality criteria ranged from 40 to 100%.

CONCLUSION

Evidence for theatre pharmacy services is extensive and varied. Empirical research of high methodological quality is required to assess the outcomes of these services.

Psychometric Properties of the Critical Appraisal Tool for Anatomical Meta-Analysis

The hallmark of evidence-based anatomy (EBA) is the anatomical meta-analysis (AMA). The Critical Appraisal Tool for Anatomical Meta-Analysis (CATAM) was recently published to enable users to appraise AMAs quickly and effectively. The tool is valuable for students and clinicians who need to judge the quality of AMAs, which informs clinical decision making and results in better patient care. Subjective measures of the tool's face and content validity have been established, but establishing its reliability provides a more objective measure of the instrument's dependability. This study investigated the interrater reliability (IRR) of the CATAM between novice and expert raters. Three graduate students and three professors (two anatomists and one pharmacist) read the original CATAM paper, and then had a post hoc meeting to discuss scoring with the tool. Three recent AMAs (published between 2017 and 2022) were randomly chosen from PubMed, and all six raters scored the papers blindly. The intraclass correlation coefficient (ICC) statistic was used to calculate the interrater reliability (IRR) between all scores, and then the ICCs between novice and expert scores were compared. Cronbach's alpha (internal consistency) of the CATAM was also calculated (SPSS 25, Armonk, NY). ICC for AMA-1 was 0.999 (95% CI, 0.997-0.999), p = 0.000, and alpha was 0.999. ICC for AMA-2 was 0.994 (95% CI, 0.988-0.998), p = 0.000, and alpha was 0.994. ICC for AMA-3 was 0.998 (95% CI, 0.995-0.999), p = 0.000, and alpha was 0.998. ANOVA showed no significant differences (p > 0.05) in mean ICCs between raters. The CATAM is a robust tool with excellent IRR (ICC > 0.990) and internal consistency (alpha > 0.990). No significant difference in ICC scores between novices and experts suggests the tool does not require prior expert knowledge to be effective. Now that the reliability of the CATAM is established, it can be more widely adopted by students and physicians worldwide to evaluate the quality of AMAs. The CATAM offers widespread applicability, and can be adopted in medical education, journal clubs, and clinical seminars to critically evaluate AMAs.

The medium-fluorescence reticulocyte ratio is an independent predictor of G6PD deficiency neonates

OBJECTIVE

G6PD deficiency is a potentially life-threatening condition in neonates presenting with hyperbilirubinemia. This study aims to identify clinical and laboratory predictors of G6PD deficiency in neonates presenting with hyperbilirubinemia.

METHODS

This was a retrospective study of 227 term neonates admitted to Heyuan People's Hospital from January 2019 to October 2023. Hematological parameters and bilirubin were compared between those with G6PD deficiency and those with normal G6PD.

RESULTS

Term neonates with G6PD deficiency had higher levels of total bilirubin, indirect bilirubin, mean corpuscular volume, mean corpuscular hemoglobin, immature reticulocyte fraction, high-fluorescence reticulocyte ratio, medium-fluorescence reticulocyte ratio, and content of reticulocytes than those with normal G6PD, but lower levels of red blood cells, hemoglobin, hematocrit, and low-fluorescence reticulocyte ratio. Medium-fluorescence ratios (OR = 1.291, P = 0.028) independently predicted G6PD deficiency in neonates. The optimal cut-off value for medium-fluorescence ratios was > 18.55%. The area under the curve for diagnosing G6PD deficiency was 0.924 (95% confidence interval: 0.886-0.962, P < 0.0001), with a sensitivity of 82.6% and specificity of 86.2%.

CONCLUSION

MFR emerged as a potentially valuable predictor for G6PD deficiency in neonates.

Use of a drug-related problem oriented medical record in the medication review of critically ill patients - Randomized clinical trial

BACKGROUND

The identification and reduction of drug-related problems (DRPs) through DRP-oriented medical records during the hospitalization of critically impatients can optimize health indicators, such as length of hospital stay.

OBJECTIVE

To determine the effect of medical records focused on drug-related problems on the duration of stay for patients in intensive care units.

METHOD

A randomized controlled clinical trial was conducted with patients assigned to intervention or the usual care groups involving clinical pharmacists. This trial occurred between March 2018 and March 2019 and was completed in two intensive care units within two hospitals in Brazil. Exploratory secondary outcomes included the mortality rate and reductions in Sequential Organ Failure Assessment (SOFA) and Δ SOFA scores.

RESULTS

A total of 150 patients participated-54.6 % were women, most being white (77.3 %). Further, the main diagnosis was Acute Coronary Syndrome (22.6 %), followed by Congestive Heart Failure (12.6 %) and Heart Failure (10 %). A significant difference was observed in the length of stay between the intervention group and the control group, respectively 7.08 days (±4.38) and 10.7 days (±6.32). Among the secondary outcomes, a significant difference was observed in the mortality rates between the two groups: (6.58 %) in the intervention group and 25.68 % in the control group. Regarding Δ SOFA, the intervention group exhibited a reduction of 4.63 in the SOFA score during hospitalization. The control group showed an increase of 1.88 in the score during the same period.

CONCLUSION

This study demonstrated that the use of Diagnoses - Adverse Clinical Findings - Medications (DAM), a medical record model aimed at resolving drug-related problems, reduced the length of hospital stay and mortality rates among patients. Furthermore, this model proved to be more effective than the usual care provided by clinical pharmacists.

A retrospective Cohort study on the effect of the LOw-molecular weighT heparin (LMWH) nadroparin dose on anti-XA levels in a mixed medical-surgical ICU population: CLOT-Xa

PURPOSE

Low-molecular-weight heparins (LMWHs) are widely used for prevention and treatment of venous thromboembolism (VTE) in critically ill patients. The objective of this study was to assess the dose-response relationship between nadroparin dose and anti-Xa activity in ICU patients.

MATERIALS AND METHODS

Critically ill adult patients who were admitted to the ICU, and received at least three subcutaneous injections of nadroparin were included. The dose-effect relationship between nadroparin dose and anti-Xa level was analysed through a mixed-effects logistic regression model.

RESULTS

In total, 327 ICU patients were included. Median anti-Xa levels ranged from <0.1 IU/mL after nadroparin 0-37 IU/kg/day to 0.6 IU/mL after nadroparin >85 IU/kg/day (p < 0.01). Among all 1520 anti-Xa measurements, 859 (57 %) measurements were in the desired anti-Xa range. The best adequacy of anti-Xa levels was observed in nadroparin doses of 38-85 IU/kg (73 %). No differences in the odds of bleeding events or VTE between different anti-Xa levels were found.

CONCLUSIONS

We found a clear dose-response relationship between nadroparin dose and anti-Xa levels. Increasing nadroparin doses led to more adequate anti-Xa levels without a change in the occurrence of VTE or major bleeding events, suggesting that LMWH therapy can be successfully and safely personalized using anti-Xa guided dosing.

Ligand-based cheminformatics and free energy-inspired molecular simulations for prioritizing and optimizing G-protein coupled receptor kinase-6 (GRK6) inhibitors in multiple myeloma treatment

Multiple myeloma (MM) is the second most frequently diagnosed hematological malignancy, presenting limited treatment options with no curative potential and significant drug resistance. Recent studies involving genetic knockdown established the crucial role of GRK6 in upholding the viability of MM cells, emphasizing the need to identify potential inhibitors. Computational exploration of GRK6 inhibitors has not been attempted previously. Herein, the present study reports a multilayered lead prioritization and optimization framework using chemometrics and molecular simulations. 2D QSAR studies revealed that hydrogen bonding and polar interactions enhanced GRK6 inhibitory activity, while increased electron accessibility posed a risk of off-target effects. The pharmacophore hypothesis (DDHRRR_1) featured two hydrogen bond donors, one hydrophobic region, and three aromatic rings, laying the foundation for the 3D QSAR models. Hydrophobic groups, such as pyridine and pyrazole, were shown to enhance inhibition, while smaller groups, like ethyl and hydroxyl, reduced activity. 12,557 DrugBank compounds were screened using the developed chemometric models and molecular docking in tandem, which led to the identification of 7 potential parent leads for subsequent QSAR-guided structural optimizations. 350 lead analogs were generated and the top 4 were further analyzed using molecular docking, ADMET, molecular dynamics, and metadynamics analysis based on Principal Component Analysis (PCA), Probability Density Function (PDF), and Free Energy Landscapes (FEL). Upon cumulative retrospection, we propose a novel analog of DB07168 (DB07168-A13) (docking score: -11.2 kcal/mol, MM-GBSA binding energy: -55.2 kcal/mol) as the most promising GRK6 inhibitor, warranting further in vitro validation, for addressing prospective therapeutic intervention in MM.

Frequency, type and severity of drug-related problems and pharmacist interventions in Paxlovid® prescribing: a descriptive analysis

BACKGROUND

Paxlovid® (nirmatrelvir and ritonavir) is the only licensed oral antiviral for COVID-19. Ritonavir is a potent inhibitor of cytochrome P450 enzymes causing numerous drug-drug interactions (DDIs).

AIM

To describe the frequency, type, and severity of detected drug related problems (DRPs) associated with Paxlovid®.

METHOD

This study involved a retrospective quantitative analysis including all patients prescribed Paxlovid® at a public hospital in Vienna, Austria. Data were collected from the patients' records by a clinical pharmacist. A customised, piloted data collection form was used. A sample of data was checked for consistency by an independent clinical pharmacist. Any DDI and severity classification was recorded using an established interaction checker tool. Dosage adjustments due to renal impairment were recorded.

RESULTS

One hundred twenty-two of 140 patients (87.1%) required interventions to prevent DRPs. Pharmacists' intervention at dispensing was needed in 63.6% (n = 89) of cases. In 3 (2.1%) patients, Paxlovid® was prescribed despite being contraindicated due to severe renal impairment. The most common were DDIs (n = 80; 57.1%). Renal impairment and DDIs were noted in 24.3% (n = 34) of cases. A total of 313 DDIs were recorded in 114 (81.4%) patients, with severe interactions in 24 (17%) patients.

CONCLUSION

Pharmacists' involvement in prescribing highly interacting drugs such as Paxlovid® is essential to enhance patient safety.

Mortality after concurrent treatment with gabapentin and opioids in older adults with spine diagnoses

ABSTRACT

Given the negative impact of opioid use on population health, prescriptions for alternative pain-relieving medications, including gabapentin, have increased. We wanted to determine whether people who filled gabapentin and opioid prescriptions concurrently ("gabapentin + opioids") had greater mortality than those who filled an active control medication (tricyclic antidepressants [TCAs] or duloxetine) and opioids concurrently ("TCAs/duloxetine + opioids"). In this population-based, propensity score-matched cohort study, we identified Medicare beneficiaries with spine-related diagnoses from 2017 to 2019. We compared people treated with gabapentin + opioids (n = 67,133) to people treated with TCAs/duloxetine + opioids (n = 67,133) who were matched on demographic and clinical factors. The primary outcome was mortality at any time, and a secondary outcome was occurrence of a major medical complication at any time. Among 134,266 participants (median age 73.4 years; 66.7% female), 2360 died before the end of follow-up. No difference in mortality was observed between groups (adjusted hazard ratio and 95% confidence interval for gabapentin + opioids 0.98 [0.90-1.06]; P = 0.63). However, people treated with gabapentin + opioids were at slightly increased risk of a major medical complication (1.02 [1.00-1.04]; P = 0.03) compared to those treated with TCAs/duloxetine + opioids. Results were similar in analyses (1) restricted to ≤30-day follow-up and (2) that required ≥2 fills of each prescription. When treating pain in older adults taking opioids, the addition of gabapentin did not increase mortality risk relative to addition of TCAs or duloxetine.

Unraveling Neurotoxicity Discrepancies: Comparative In vitro and In vivo Analysis of Colistin and Polymyxin B and the Underlying Mechanisms

Polymyxins, including colistin and polymyxin B, are the final resort against Gram-negative bacterial infections. However, its clinical application is restricted due to concerns related to neurotoxicity. Despite the similar antibacterial spectrum and mode of action shared between colistin and polymyxin B, there is still a lack of definitive evidence to support the idea that their neurotoxicity profiles are identical. To comprehensively compare the neurotoxicity between colistin and polymyxin B both in vivo and in vitro and establish a theoretical foundation to guide the rational use of polymyxins within clinical settings. in vitro experiments simulated nerve damage by exposing N2a and RSC96 cells to colistin and polymyxin B. The evaluation of nerve injury included assessments of cell viability and apoptosis. To discern the variance in the mechanisms of nerve injury between colistin and polymyxin B, oxidative stress levels were examined, such as SOD, CAT, GSH, and malondialdehyde (MDA). In in vivo experiments, a rat nerve injury model was created by intraventricular injections of colistin and polymyxin B, respectively. The impact of these drugs on brain injury in rats, particularly within the hippocampus and medulla oblongata, was measured using HE and Nissl staining. The potential influence of polymyxins on the ferroptosis pathway was evaluated by assessing LPO and Fe2+ levels and the degree of mitochondrial impairment. At equivalent doses, colistin demonstrated a reduced level of neurotoxicity compared to polymyxin B, both in vitro and in vivo. in vitro experiments revealed greater cell viability and a lower apoptosis rate after colistin treatment than after polymyxin B treatment. This variance in outcomes could be attributed to the comparatively lower levels of oxidative stress associated with colistin administration. In a rat model, nerve injury resulted in observable damage to both the hippocampus and the medulla oblongata. A comprehensive assessment of the extent of damage in the CA1 to CA4 regions of the hippocampus, and the solitary tract nucleus of the medulla oblongata underscored that the neurotoxic effects of colistin remained milder compared to those elicited by polymyxin B. Even when evaluated at equivalent multiples of clinically recommended doses, colistin exhibited lower neurotoxicity in vivo than polymyxin B. For the first time, this study demonstrated the role of ferroptosis in polymyxin B-induced nerve damage. The activation levels observed within the ferroptosis pathway due to polymyxin B exceeded those triggered by colistin. Colistin exhibited a marked reduction in neurotoxicity compared to polymyxin B, evident in both the equivalent and clinically recommended doses. These findings suggest that, from the perspective of neurotoxicity, colistin presents a more favorable option for clinical use.

Mindfulness-based Interventions for Surgeons: A Scoping Review

OBJECTIVE

To review the evidence on mindfulness-based interventions (MBIs) for surgeons.

BACKGROUND

Health care professionals have alarmingly high rates of burnout, yet little is known about psychological factors that support resilience. MBIs, which involve codified training in specific skills such as self-awareness, emotional regulation, and perspective-taking, have shown benefit to professionals in high-stress environments but have had limited implementation in the health care workplace and in surgery. To our knowledge, there has not been a scoping review of MBIs in surgery to date.

METHODS

We conducted a scoping review of the evidence for the feasibility and effectiveness of MBIs for surgeons, including evidence on interventions that explicitly train mindfulness, which spans multiple cohorts and settings, utilizing different methodologies and outcome measures.

RESULTS

This scoping review yielded 24 studies, including 2 mixed method/qualitative studies, 9 randomized control trials, 3 nonrandomized interventional studies, and 8 single-arm interventional studies.

CONCLUSIONS

We find that MBIs in surgery (1) are feasible in surgical contexts, with implementation science providing insights on sustainability; (2) increase mindfulness, (3) improve well-being in terms of burnout and both psychological and neurophysiological measures of stress, and (4) enhance performance as measured in executive function, surgical skills, and communication skills. These conclusions are supported by psychometric measures, observations of technical skills, and neurophysiological evidence. Future directions include studying MBIs in larger and more diverse populations and iteratively tailoring mindfulness-based interventions to other health care contexts.

Vancomycin-associated acute kidney injury in underweight patients: a propensity score matching analysis

PURPOSE

To investigate the effect of being underweight on the incidence of vancomycin-associated acute kidney injury (AKI) using propensity score matching analysis.

METHODS

This study is a retrospective analysis of patients who received vancomycin and had their serum concentration measured at Kitasato University Hospital between January 1, 2016 and December 31, 2020. Patients were divided into underweight and non-underweight groups based on body mass index (BMI), and propensity score matching analysis was used to evaluate whether underweight affected the incidence of acute kidney injury.

RESULTS

480 patients met the selection criteria, and 111 patients from each group (BMI < 18.5 and BMI ≥ 18.5) were successfully matched using propensity score matching. After matching, there were no differences in non-physical characteristics between the two groups. The incidence of AKI was 23.4% (26 of 111) in the BMI < 18.5 group and 37.8% (42 of 111) in the BMI ≥ 18.5 group, with the BMI < 18.5 group having a significantly lower incidence. The odds ratio was 0.503 [95% CI 0.281-0.900].

CONCLUSION

This study showed that underweight patients (BMI < 18.5) had a significantly lower incidence of vancomycin-associated AKI compared to those with BMI ≥ 18.5. As there have been no previous reports on the association between underweight and vancomycin-associated AKI, this study provides novel insights.

Cervicocephalic force steadiness and force sense in people with and without neck pain

BACKGROUND

Proprioceptive and motor control impairments have been identified in people with neck pain, but there is limited data regarding deficits and reliability of cervical force steadiness and force sense.

OBJECTIVES

To evaluate between-group differences and test-retest reliability of cervical force steadiness and force sense in people with and without neck pain.

DESIGN

Cross-sectional comparative study.

METHOD

Fourteen people with chronic neck pain (CNP) and 15 healthy participants of comparable age range completed a force-matching protocol of randomised isometric contractions for cervical flexion, extension, rotation (left and right), and lateral flexion (left and right) at intensities of 10% and 25% of their maximal voluntary contraction (MVC). Twenty-four participants completed a second session 4-7 days later to evaluate reliability. Force was converted to coefficient of variation (COV) to measure force steadiness, and absolute error (AE), constant error (CE), and variable error (VE) for force sense.

RESULTS

CNP participants demonstrated worse total VE at 10% MVC (mean difference 36.96%, p < .001). Reliability of force sense varied between poor to good, with best reliability shown for CE (ICC estimates 0.21-0.88). Force steadiness was significantly worse in the CNP population for 10% MVC (mean difference 42.26%, p < .001) and 25% MVC (mean difference 23.97%, p < .001), and reliability was moderate-good for all contractions (ICC estimates 0.53-0.87) except two.

CONCLUSIONS

People with CNP demonstrated impairments in force steadiness and force sense, particularly at 10% MVC intensity contractions. Reliability was varied for force sense and most contractions demonstrated moderate-good reliability for force steadiness.