Characterization of antibiotic overuse for common infectious disease states at hospital discharge

Objective

To evaluate rates of and outcomes associated with antibiotic overuse at hospital discharge for patients with common infectious diseases states.

Design

Single-center, respective cohort study.

Setting

A large, academic medical center in the Midwest United States.

Patients

Adult patients who received antibiotics for community-acquired pneumonia (CAP), uncomplicated cystitis, or mild, non-purulent cellulitis. Patients were excluded if they did not receive antibiotic(s) upon hospital discharge, were pregnant, severely immunocompromised, had concomitant infections, died during hospitalization, or were transferred to another hospital or to an intensive care unit.

Methods

Data were abstracted from the electronic medical record of ambulatory antibiotic orders for included patients based on inpatient encounters from August 1, 2021 through July 31, 2022.

Results

Of the 182 patients included in the study, antibiotic overuse was common for all three infectious disease states: CAP (n = 87/125, 69.6%), uncomplicated cystitis (n = 21/28, 75.0%), mild, non-purulent cellulitis (n = 28/29, 96.6%). The prevailing reason for overuse was excessive antibiotic duration (n = 127/182, 69.8%; mean antibiotic duration 5.39 vs. 8.32 days, p = 0.001). Antibiotic overuse was associated with approximately one additional day in the hospital (2.48 vs. 3.32 days, p = 0.001), and an increase in emergency department visits within 30 days after discharge (1 vs. 31, p = 0.001) compared to patients without antibiotic overuse at discharge.

Conclusion

Antibiotic overuse was prevalent upon hospital discharge for these three common infectious disease states. Transitions of care should be prioritized as an area for antimicrobial stewardship intervention.

Patient Access to Hepatitis C Treatment After Incorporation of Pharmacists in a Hepatology Clinic

Background: Modern hepatitis C virus (HCV) treatment regimens yield cure rates greater than 90%. However, obtaining approval for treatment through the prior authorization (PA) process can be time consuming and require extensive documentation. Lack of experience with this complex process can delay HCV medication approval, ultimately increasing the amount of time before patients start treatment and in some cases, prevent treatment altogether. Objectives: Assess the impact of incorporating clinical pharmacists into specialty pharmacy and hepatology clinic services on medication access, patient adherence, and outcomes in patients being treated for HCV. Methods: We performed a retrospective cohort exploratory study of patients seen in an academic medical center hepatology clinic who had HCV prescriptions filled between 8/1/15 and 7/31/17. Patients were categorized by whether they filled prescriptions prior to (Pre-Group) or after (Post-Group) the implementation of a pharmacist in clinic. The Post-Group was further divided according to whether the patient was seen by a pharmacist in clinic (Post-Group 2) or if the patient was not seen by the pharmacist, but had their HCV therapy evaluated by the pharmacist before seeking insurance approval (Post-Group 1). Results: The mean time from the prescription being ordered to being dispensed was longer in the Pre-Group (50.8 ± 66.5 days) compared to both Post-Groups (22.2 ± 27.8 days in Post-Group 1 vs 18.9 ± 17.7 days in Post-Group 2; P < .05). The mean time from when the prescription was ordered to when the PA was submitted was longer in the Pre-Group (41.6 ± 71.9 days) compared to both Post-Groups (6.3 ± 16 in Post-Group 1 vs 4.1 ± 9.7 in Post-Group 2; P < .05). Rates of medication adherence and sustained virologic response were similar between all groups. Conclusion: Incorporation of clinical pharmacists into a hepatology clinic significantly reduced the time patients waited to start HCV treatment. In addition to improving access to medications, implementation of the model helped to maintain excellent medication adherence and cure rates.

Evaluation of low dose prazosin for PTSD-associated nightmares in children and adolescents

Introduction

Knowledge about fundamental sleep disorders and dysregulation that occurs in children with PTSD is limited. Prazosin is an alpha-1 receptor antagonist often used off label for the treatment of PTSD-associated nightmares in adults; however, evaluation of its use in pediatrics and adolescents is limited. The primary objective of this study was to assess the impact of prazosin on nightmares associated with PTSD in this population. Secondary objectives included assessing side effects, changes in blood pressure, and 30-day readmission rates.

Methods

This was a retrospective, single-center chart review of inpatients diagnosed with PTSD nightmares from January 1, 2017, to July 31, 2019. Patients 4 to 18 years old with a PTSD diagnosis, experiencing nightmares, and initiating any dose of prazosin were assessed to determine efficacy and tolerance.

Results

Forty-two patients were evaluated to determine symptom improvement after initiation of prazosin for PTSD nightmares in children and adolescents. Of the 42 patients, 24 (57.1%) reported improvement in nightmares (average dose 1.05 mg). For secondary results, 38 (90.5%) patients continued prazosin at discharge, and 2 (5%) were readmitted within 30 days for reasons other than PTSD-associated nightmares. Thirty-four (81%) reported having no adverse effects to prazosin. There was no significant difference in systolic (P = .1883) or diastolic (P = .2777) blood pressure preinitiation and postinitiation of prazosin.

Discussion

Despite the limitations of this retrospective study, the data suggests that prazosin may be associated with an improvement in nightmares in children and adolescents with PTSD. Adverse events were rarely reported, and there was no significant change in blood pressure with initiation of prazosin.

Effects of filgrastim versus pegfilgrastim on outcomes of DA-R-EPOCH for non-Hodgkin's lymphoma

PURPOSE

Our study aimed to compare the median and average last dose level reached with DA-R-EPOCH, which includes the chemotherapy agents etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin, and rituximab, in patients using filgrastim versus pegfilgrastim as febrile neutropenia primary prophylaxis.

METHODS

A retrospective, single-center chart review from January 1, 2014, to September 30, 2019, at The University of Kansas Health System identified patients > 18 years old who received at least four cycles of DA-R-EPOCH in an inpatient or outpatient setting for any subtype of lymphoma along with at least one dose of filgrastim or pegfilgrastim. Data was collected to compare dosing levels reached, appropriate discontinuation of daily filgrastim when ANC > 5000 cells/mm³, completion of at least twice weekly complete blood count (CBC) monitoring after chemotherapy administration, the incidence of infections, FN, hospitalizations from infections or FN, and bone pain.

RESULTS

We hypothesized that patients receiving pegfilgrastim will achieve similar median and average dose levels of DA-EPOCH, event-free survival rates, overall response rates, completion of at least twice weekly CBC monitoring, and incidence of infections, FN, hospitalizations for infections or FN, and bone pain compared to patients receiving filgrastim.

CONCLUSIONS

The use of pegfilgrastim as a supportive care agent resulted in similar efficacy and safety outcomes compared to filgrastim with DA-R-EPOCH in terms of dose intensity levels and incidence of infections, FN, and bone pain.

Safety of inactivated vaccines in patients with genitourinary (GU) malignancies receiving immune checkpoint inhibitors (ICI)

e17108

Background: ICI therapy has become the standard of care for many advanced GU cancers, but immune-related adverse events (IRAE) may result in treatment delays or discontinuation. Concurrent vaccine use has been posited to increase the IRAE risk, but safety data is mixed. There are no published data regarding safety of concurrent inactivated vaccines other than influenza, including and especially in the GU cancer population. Methods: We performed a single-institution, retrospective, matched-cohort (1:2, cohort A:B, vaccinated to control) study of all GU cancer patients treated with an inactivated vaccine 30 days prior to or 60 days following ICI therapy from 2015-2019. Baseline clinical characteristics were abstracted from the electronic health record (EHR). Clinically significant IRAEs were defined as any event developing during or 30 days following ICI therapy requiring therapy with ≥ Prednisone 20 mg daily (or equivalent) or other immunosuppression. Delays were defined as ICI therapy given > 14 days past expected date for cycle 2 or beyond. Bivariate analysis with chi-squared statistics were used to describe incidence. Results: Sixty patients were included: 20 in cohort A (vaccinated) and 40 in cohort B (control). Thirty-seven (61.7%) patients had renal cell carcinoma, 17 (31.7%) had urothelial carcinoma, and 4 (6.7%) had prostate cancer. There was no difference in incidence of clinically significant IRAEs between cohorts A and B (15% vs 32.5%, p = 0.148), nor were differences observed in rates of treatment delays (10% vs 12.5%, p = 0.776) or discontinuation (10% vs 12.5%, p = 0.776) due to IRAEs. Most common vaccines were inactivated influenza (n = 18, 90%) and pneumococcal vaccine (n = 3, 15%). Among the 16 patients experiencing clinically-significant IRAEs, the most common were colitis (n = 3), dermatitis (n = 3), and pneumonitis (n = 3). All patients requiring immunosuppressive therapy received systemic corticosteroids. Conclusions: This retrospective cohort study demonstrates that GU cancer patients receiving inactivated vaccines during ICI therapy does not increase IRAE incidence, treatment delays, or discontinuation, suggesting that inactivated vaccines may be safely administered during ICI therapy in this population. Though influenza vaccines were still the most common, this is the first study to include other inactivated vaccines. Limitations include sample size, EHR accuracy and use of surrogate markers for determination of IRAE incidence. Next steps will include a multi-institutional retrospective study.

Intraperitoneal paclitaxel and cisplatin compared with dose-dense paclitaxel and carboplatin for patients with stage III ovarian cancer

Introduction

Patients diagnosed with stage III ovarian cancer are at high risk of recurrence and optimal adjuvant therapy is often debated. There is limited literature that directly compares intraperitoneal paclitaxel and cisplatin with dose-dense paclitaxel and carboplatin.

Objectives

The primary objective was to compare progression-free survival, overall survival, and tolerability of adjuvant intraperitoneal paclitaxel and cisplatin to dose-dense paclitaxel and carboplatin in stage III ovarian cancer patients.

Methods

A retrospective, IRB-approved, single center chart review was conducted reviewing adult patients with stage III ovarian cancer undergoing adjuvant intraperitoneal therapy or dose-dense therapy between 2010 and 2018.

Results

Eighty-two patients were included in the final analysis; 44 in the intraperitoneal group and 38 in the dose-dense group. Intraperitoneal therapy was not associated with a longer progression-free survival (35.4 vs. 31.1 months; P = 0.97). The duration of overall survival did not differ between intraperitoneal and dose-dense (56.3 vs. 54.5 months; P = 0.55). Dose reductions were less frequent with intraperitoneal than dose-dense (11.36% vs. 31.58%; P = 0.02). No difference in treatment delays (45.5% vs. 65.8%; P = 0.07), dose cancellations (59.1% vs. 57.9%; P = 0.91), supportive care additions (95.5% vs. 84.2%; P = 0.09), or therapy discontinuation (59.1% vs. 39.5%; P = 0.07) between groups was noted.

Conclusions

Intraperitoneal therapy with paclitaxel and cisplatin, as compared with dose-dense paclitaxel and carboplatin, did not prolong progression-free or overall survival in the adjuvant setting among stage III ovarian cancer patients. A trend towards decreased tolerability was noted with intraperitoneal therapy.

Retrospective evaluation of fidaxomicin versus oral vancomycin for treatment of Clostridium difficile infections in allogeneic stem cell transplant

OBJECTIVE/BACKGROUND

Clostridium difficile infection (CDI) is a potential complication during hematopoietic stem cell transplantation (HSCT), and no specific recommendations exist regarding treatment of CDI in allogeneic SCT patients. Use of metronidazole and oral vancomycin has been associated with clinical failure. Fidaxomicin has previously been found noninferior to the use of oral vancomycin for the treatment of CDI, and no studies have compared the use of oral vancomycin with fidaxomicin for the treatment of CDI in allogeneic SCT.

METHODS

This retrospective chart review included 96 allogeneic SCT recipients who developed CDI within 100 days following transplantation. Participants were treated with oral vancomycin (n = 52) or fidaxomicin (n = 44). The primary outcome was clinical cure, defined as no need for further retreatment 2 days following completion of initial CDI treatment. Secondary outcomes were global cure, treatment failure, and recurrent disease.

RESULTS

No differences in clinical cure were observed between patients receiving oral vancomycin or fidaxomicin (75% vs. 75%, p = 1.00). Secondary outcomes were similar between oral vancomycin and fidaxomicin in regards to global cure (66% vs. 67%, p = .508), treatment failure (28% vs. 27%, p = .571), and recurrent disease (7% vs. 5%, p = .747). In a subanalysis of individuals that developed acute graft-versus-host disease following CDI, the difference in mean onset of acute graft-versus-host disease was 21.03 days in the oral vancomycin group versus 32.88 days in the fidaxomicin group (p = .0031).

CONCLUSION

The findings of this study suggest that oral vancomycin and fidaxomicin are comparable options for CDI treatment in allogeneic SCT patients within 100 days following transplant.

Assessment of cetuximab-induced infusion reactions and administration rechallenge at an academic medical center

Cetuximab is approved for treatment of squamous cell carcinoma of the head and neck (SCCHN). Cetuximab is generally well tolerated, but does carry a black box warning for infusion reactions (IRs). Incidence of IR in clinical trials was 15-20% for all grades and 3-5% for grades III-IV. Retrospective studies reported a higher incidence of all grade IRs and grades III-IV IR in areas of the Southeastern United States. Information regarding rechallenge doses after an IR has not been well described. At our institution, we frequently rechallenge on the same day after an initial IR. The primary objective was to determine the incidence, timing, IR grade, and completion of a rechallenge dose in patients who experienced an initial IR. Secondary objectives included: (1) determining the incidence and grade of IR in patients who received a first dose of cetuximab and (2) identifying specific risk factors for cetuximab IR with the first dose. A single-center retrospective chart review was conducted in SCCHN patients treated with cetuximab between June 2008 and September 2015 at the University of Kansas Hospital Cancer Center and inpatient setting. The majority of patients (87.9%) were able to be quickly and successfully rechallenged after an initial IR. Minimal patients (27.6%) experienced a rechallenge IR, resulting in only 1 patient discontinuation. Rechallenge doses were most frequently (37.9%) administered between 30 and 59 min after initial dose discontinuation. This was a single-center retrospective study based on data collected from electronic medical records. Other limitations include interpretation of infusion reactions on a subjective basis by providers. These findings demonstrate the practice of same-day rechallenges in initial IR patients is feasible and safe.

Evaluation of weekly paclitaxel, carboplatin, and cetuximab in head and neck cancer patients with incurable disease

Weekly paclitaxel, carboplatin, and cetuximab (PCC) has been found to be efficacious and well-tolerated in patients with squamous cell carcinoma of the head and neck (SCCHN) with good performance status (PS) when used as induction chemotherapy. Use of PCC in incurable SCCHN in patients with poor PS or in a non-induction setting is an area which warrants further evaluation. Current recommendations for incurable disease consist of a platinum-based regimen with fluorouracil and cetuximab. Studied in patients with PS of 0 to 1, the fluorouracil-based regimens were associated with significant toxicities. Therefore, weekly PCC may offer an appealing, less toxic alternative for incurable patients with poor PS. This retrospective analysis evaluated 41 patients with very advanced or metastatic head and neck cancer who had received PCC (paclitaxel 80 mg/m(2), carboplatin AUC 2, and a cetuximab 400 mg/m(2) loading dose, followed by 250 mg/m(2) weekly) for up to 6 cycles between April 2008 and September 2014. Maximal response achieved and progression-free survival (PFS), as well as dose intensity and adverse effects, were evaluated. Of the 41 patients evaluated, baseline PS ranged as follows: PS of 2 (41 %), PS of 1 (54 %), and PS of 0 (5 %). Patients received 2 to 6 cycles, averaging 4 cycles. Thirty-one patients (76 %) required treatment to be held, delayed or dose reduced, most commonly for hematologic toxicities. Grades 3/4 neutropenia occurred in 16 patients (39 %), grades 1/2 neutropenia in 12 patients (29 %), with grades 3/4 thrombocytopenia in 1 patient (2 %), and grades 1/2 thrombocytopenia in 2 patients (4 %). No patients developed febrile neutropenia or required hospitalization due to treatment. Partial radiographic response occurred in 15 patients (37 %), complete radiographic response in 2 patients (5 %), stable disease in 14 patients (34 %), and progression in 8 patients (20 %). PFS ranged from 1.6 to 45 months, with a median duration of 4.6 months, and median overall survival of 5.25 months. Analysis indicates that use of weekly PCC appears to be an effective and well-tolerated treatment option for patients with incurable squamous cell carcinoma of the head and neck, specifically with PS of 0 to 2.

Outcomes for newly diagnosed patients with acute myeloid leukemia dosed on actual or adjusted body weight

PURPOSE

Data from solid tumor malignancies suggest that actual body weight (ABW) dosing improves overall outcomes. There is the potential to compromise efficacy when chemotherapy dosages are reduced, but the impact of dose adjustment on clinical response and toxicity in hematologic malignancies is unknown. The purpose of this study was to evaluate the outcomes of utilizing a percent of ABW for acute myeloid leukemia (AML) induction chemotherapy dosing.

METHODS

This retrospective, single-center study included 146 patients who received 7 + 3 induction (cytarabine and anthracycline) for treatment of AML. Study design evaluated the relationship between percentage of ABW dosing and complete response (CR) rates in patients newly diagnosed with AML.

RESULTS

Percentage of ABW dosing did not influence CR rates in patients undergoing induction chemotherapy for AML (p = 0.83); nor did it influence rate of death at 30 days or relapse at 6 months (p = 0.94). When comparing patients dosed at 90-100 % of ABW compared to <90 % ABW, CR rates were not significantly different in patients classified as poor risk (p = 0.907). All favorable risk category patients obtained CR.

CONCLUSIONS

Preemptive dose reductions for obesity did not influence CR rates for patients with AML undergoing induction chemotherapy and did not influence the composite endpoint of death at 30 days or disease relapse at 6 months.

Implementation of standardized dosing units for i.v. medications

PURPOSE

The implementation of standardized dosing units for six i.v. medications at an academic medical center is described.

SUMMARY

During the implementation of an electronic health record system at an academic medical center, it was noticed that providers could order some i.v. medications in multiple dosing units, including epinephrine, isoproterenol, midazolam, nitroglycerin, norepinephrine, and phenylephrine. Possible options to standardize i.v. medications along with their pros and cons were presented for discussion to key providers in all of the intensive care units. Once the providers agreed on a solution, the information was presented to the pharmacy and therapeutics committee for final approval. A nursing education plan was created and administered before the standardization of dosing units was implemented. A nursing survey was conducted before and after implementation of dosing-unit standardization to determine the effectiveness of nursing education on compliance with the standardization of the dosing units for the listed medications. The survey was designed to evaluate, when given a choice, what dosing units nurses would use to administer epinephrine, isoproterenol, midazolam, nitroglycerin, norepinephrine, and phenylephrine. The decision was made by the key providers to use weight-based dosing-micrograms per kilograms per minute-to allow for consistency of use of these medications for pediatric and adult patients. Nursing education was completed to ensure that nurses were aware of how to safely administer these medications using the new dosing units.

CONCLUSION

Dosing-unit standardization for dose-adjustable i.v. infusions can provide improved consistency and decrease the potential for dosing errors when administering epinephrine, isoproterenol, midazolam, nitroglycerin, norepinephrine, and phenylephrine.

Tolerability and outcome of once weekly liposomal amphotericin B for the prevention of invasive fungal infections in hematopoietic stem cell transplant patients with graft-versus-host disease

BACKGROUND

Invasive fungal infections remain problematic in immunosuppressed allogeneic stem cell transplant recipients and the use of corticosteroids for the treatment of graft-versus-host-disease can increase the risk threefold. Although antifungal prophylaxis has been shown to decrease the incidence of infection, the optimal antifungal prophylactic regimen in this patient population has yet to be identified.Since early diagnosis of fungal infections might not be possible and the treatment of established fungal infections might be difficult and associated with high infection-related mortality, prevention has become an important strategy in reducing overall morbidity and mortality. While triazoles are the preferred agents, some patients are unable to tolerate them and an alternative drug is warranted.

OBJECTIVES

To assess the tolerability of once weekly liposomal amphotericin B as a prophylactic strategy in patients undergoing stem cell transplantation by evaluating any adverse events leading to its discontinuation. In terms of efficacy, to also compare the outcome and incidence of invasive fungal infections in patients who received amphotericin B, triazoles, and echinocandins.

RESULTS

A total of 101 allogeneic transplant recipients receiving corticosteroids for the treatment of graft-versus-host-disease and antifungal prophylaxis were evaluated from August 2009 to September 2012. Liposomal amphotericin B 3 mg/kg intravenous once weekly was found to be well tolerated. The incidence of invasive fungal infections was 19%, 17%, and 7% in the liposomal amphotericin B, echinocandin, and triazole groups, respectively. Two deaths occurred in the liposomal amphotericin B group and one death occurred in the echinocandin group. None of the deaths were fungal infection related.

CONCLUSION

Antifungal prophylaxis with liposomal amphotericin B was well tolerated, but the incidence of invasive fungal infections in patients receiving liposomal amphotericin B was higher than other antifungal agents in this study. The optimal dose and schedule of liposomal amphotericin B for antifungal prophylaxis in this patient population are still not known and considering its broad spectrum activity, prospective trials in comparison to triazoles are warranted.

Publication rates of abstracts presented at five national pharmacy association meetings

BACKGROUND

Abstract presentations at professional meetings provide a medium for disseminating the findings of scholarly activity. Rates of abstract publication from various biomedical disciplines have been evaluated, with pharmacy noted to be lower than other specialties. Previous research on pharmacy abstract publication rates was conducted for a limited number of professional meetings but has not been assessed using Google Scholar.

OBJECTIVE

To determine the full publication rate of abstracts presented at the 2005 American College of Clinical Pharmacy (ACCP) Spring and Annual Meetings, American Pharmacists Association (APhA) Annual Meeting, and American Society of Health-System Pharmacists (ASHP) Summer and Midyear Clinical Meetings.

METHODS

Publication status was assessed for abstracts presented during the 2005 ACCP Spring and Annual Meetings, APhA Annual Meeting, and ASHP Summer and Midyear Clinical Meetings using PubMed and Google Scholar. Data collected included abstract category, study category, practice site, database(s) in which publication appeared, time in months to publication, publication type, and journal of publication.

RESULTS

Evaluation of 2,000 abstracts presented in 2005 revealed an overall full publication rate of 19.8% (n = 384). Nearly all pharmacy abstracts were published as manuscripts (98.4%; n=378) and indexed in PubMed and Google Scholar (91.9%; n = 353), although a significant percentage were indexed in Google Scholar only (7.8%; n = 30). The mean time to full publication was 16.8 months (SD ±11.9 months).

CONCLUSIONS

Results were consistent with previously reported full publication rates of abstracts from pharmacy association meetings, indicating that abstracts presented at pharmacy meetings continue to have a lower full publication rate than other health disciplines.

The Use of Individualized Pharmacist Performance Reports to Reduce Pharmacist-Related Medication Order Entry Errors following Electronic Medical Record Implementation

Purpose

To measure the impact of an individual pharmacist performance report (IPPR) program on pharmacist-related medication order entry errors (MOEEs) at an academic medical center.

Methods

The number and type of pharmacist-related MOEEs were collected at 2 different times: immediately following implementation of an electronic medical record (baseline) and following completion of the IPPR program. Three different collection methods were utilized to identify and categorize pharmacist-related MOEEs: 1) Patient Safety Net (PSN) incident reporting system, 2) manual event reporting, and 3) a nursing to pharmacy electronic messaging system. The IPPR program consisted of mandatory educational sessions for pharmacist staff. The program content focused on strategies to reduce pharmacist-related MOEEs identified in the baseline data collection period as well as an individualized report generated for each pharmacist having caused an MOEE that showed their performance compared to the department's performance.

Results

The percentage of event reports containing a pharmacist-related MOEE decreased from baseline to post IPPR program (13.7% and 6.3%, respectively; P < .001). In addition, the total number of pharmacist-related MOEEs was halved after the IPPR program (321 vs 148; P < .001). Significant reductions were noted in the following MOEE categories: duplicate orders, missed orders, wrong frequency, wrong dose, and other. Nonsignificant reductions were noted in errors related to no order and wrong drug.

Conclusion

Based on the observations and results of this study, it is proposed that individualized performance feedback can be a successful method to improve MOEE performance by pharmacists.

Compliance with recommendations for prevention and detection of controlled-substance diversion in hospitals

PURPOSE

The use of recommended practices for preventing and detecting diversion of prescription controlled substances at U.S. acute-care institutions, as reported by a sample of pharmacy service providers, were characterized.

METHODS

A 41-item questionnaire was developed for an online survey of directors of pharmacy regarding strategies to combat controlled-substance diversion at their institutions. The survey questions were based on recommendations presented in a 2007 series of articles in the professional literature focusing on diversion control in three areas (the pharmacy, the operating room, and nursing units). Only institutions that had an accredited pharmacy residency program or were members of the University HealthSystem Consortium (UHC), an alliance of U.S. academic medical centers and affiliated hospitals, were targeted for the survey. Four hundred ninety-nine pharmacists were invited to participate in the survey, and 140 survey responses were received; all respondents did not answer all questions.

RESULTS

The survey responses indicated considerable variation among the institutions in the use of 37 specific recommended practices, as reported by the pharmacy providers. Statistical analysis of comparative data suggested that larger institutions (400 or more licensed beds) were more likely to be using more of the recommended practices.

CONCLUSION

The results of a survey of directors of pharmacy at a sample of U.S. institutions (hospitals that had pharmacy residency programs or were UHC members) suggest wide variation in facilities' use of recommended practices for the prevention and detection of controlled-substance diversion.

Adherence, asthma control, generic and disease-specific quality-of-life instruments in asthma

Prior studies have investigated the association between generic health-related quality of life and medication adherence. The objective of this study was to assess the association between medication adherence and health-related quality of life using both a disease-specific and generic metric in a community setting. Overall, the authors' study findings show no association between adherence and health-related quality of life, supporting the results by Cote and colleagues that factors other than medication adherence are important in explaining health-related quality of life. Furthermore, adherence was not significantly associated with asthma severity, although the strong association between asthma control and health-related quality of life, and asthma control and adherence indicates that asthma control is an important vital sign.

Observation of time-reversal-protected single-dirac-cone topological-insulator states in Bi2Te3 and Sb2Te3

We show that the strongly spin-orbit coupled materials Bi2Te3 and Sb2Te3 and their derivatives belong to the Z2 topological-insulator class. Using a combination of first-principles theoretical calculations and photoemission spectroscopy, we directly show that Bi2Te3 is a large spin-orbit-induced indirect bulk band gap (delta approximately 150 meV) semiconductor whose surface is characterized by a single topological spin-Dirac cone. The electronic structure of self-doped Sb2Te3 exhibits similar Z2 topological properties. We demonstrate that the dynamics of spin-Dirac fermions can be controlled through systematic Mn doping, making these materials classes potentially suitable for topological device applications.

A tunable topological insulator in the spin helical Dirac transport regime

Helical Dirac fermions-charge carriers that behave as massless relativistic particles with an intrinsic angular momentum (spin) locked to its translational momentum-are proposed to be the key to realizing fundamentally new phenomena in condensed matter physics. Prominent examples include the anomalous quantization of magneto-electric coupling, half-fermion states that are their own antiparticle, and charge fractionalization in a Bose-Einstein condensate, all of which are not possible with conventional Dirac fermions of the graphene variety. Helical Dirac fermions have so far remained elusive owing to the lack of necessary spin-sensitive measurements and because such fermions are forbidden to exist in conventional materials harbouring relativistic electrons, such as graphene or bismuth. It has recently been proposed that helical Dirac fermions may exist at the edges of certain types of topologically ordered insulators-materials with a bulk insulating gap of spin-orbit origin and surface states protected against scattering by time-reversal symmetry-and that their peculiar properties may be accessed provided the insulator is tuned into the so-called topological transport regime. However, helical Dirac fermions have not been observed in existing topological insulators. Here we report the realization and characterization of a tunable topological insulator in a bismuth-based class of material by combining spin-imaging and momentum-resolved spectroscopies, bulk charge compensation, Hall transport measurements and surface quantum control. Our results reveal a spin-momentum locked Dirac cone carrying a non-trivial Berry's phase that is nearly 100 per cent spin-polarized, which exhibits a tunable topological fermion density in the vicinity of the Kramers point and can be driven to the long-sought topological spin transport regime. The observed topological nodal state is shown to be protected even up to 300 K. Our demonstration of room-temperature topological order and non-trivial spin-texture in stoichiometric Bi(2)Se(3).M(x) (M(x) indicates surface doping or gating control) paves the way for future graphene-like studies of topological insulators, and applications of the observed spin-polarized edge channels in spintronic and computing technologies possibly at room temperature.

Pharmacist-acquired medication histories in a university hospital emergency department

PURPOSE

A study was conducted to identify discrepancies between medication histories taken by emergency department (ED) providers (physicians, nurses, and medical students) and medication histories taken by clinical pharmacists.

METHODS

During a three-month period, a clinical pharmacist was assigned to the ED in a 475-bed, tertiary care teaching facility that serves as a level I trauma center. On the arrival of a patient, ED providers completed a standard assessment that included the patient's medication history. Patients to be admitted through the ED were interviewed by the clinical pharmacist. In addition to a medication history, the pharmacist collected the patient's height, weight, immunization history, and allergy information. The medication history obtained by the ED provider was compared with the history obtained by the clinical pharmacist, and discrepancies were documented.

RESULTS

The clinical pharmacists in the ED performed 286 medication histories; 34 were excluded. The remaining 252 histories taken were used in the study. The pharmacists identified 1096 home medications versus 817 home medications documented by ED providers. Of the 817 home medications documented by the ED, the regimens of 637 (78%) were incomplete and were supplemented with dosing information by the pharmacists. Pharmacists reported 375 medication allergies versus 350 reported by ED providers. Immunization histories were obtained in 252 of the 252 (100%) pharmacist-acquired medication histories versus 45 of the 252 (18%) acquired by ED personnel.

CONCLUSION

Pharmacist-acquired medication histories in the ED were more complete than those acquired by other health professionals.

Nationwide antibiogram analysis using NCCLS M39-A guidelines

Lack of standardization in antibiogram (ABGM) preparation (the overall profile of antimicrobial susceptibility results of a microbial species to a battery of antimicrobial agents) has not been addressed until recently. The objective of this study was to analyze current antibiograms using the recently published NCCLS M39-A guidelines for preparation of antibiograms to identify areas for improvement in the reporting of antibiogram susceptibility data. Antibiograms from across the United States were obtained by various methods, including direct mailings, Internet searches, and professional contacts. Each ABGM collected was analyzed using prospectively defined elements from the M39-A guidelines. Additionally, seven quality indicators were also evaluated to look for the reporting of any atypical or inappropriate susceptibility data. The 209 antibiograms collected from 149 institutions showed at least 85% compliance to 5 of the 10 M39-A elements analyzed. Clinically relevant elements not met included annual analysis, duplicate isolate notation, and the exclusion of organisms with fewer than 10 isolates. As for the quality indicators evaluated, unexpected results included the 7% of antibiograms that reported <100% vancomycin susceptibility for Staphylococcus aureus, 24% that had inconsistent beta-lactam susceptibility for Staphylococcus aureus, 20% that reported <100% imipenem susceptibility for Escherichia coli, and 37% that reported >0% ampicillin susceptibility for Klebsiella pneumoniae. These findings suggest that antibiograms should be reviewed thoroughly by infectious disease specialists (physicians and pharmacists), clinical microbiologists, and infection control personnel for identification of abnormal findings prior to distribution.

Effect of duplicate isolates of methicillin-susceptible and methicillin-resistant Staphylococcus aureus on antibiogram data

Duplicate Staphylococcus aureus isolates were analyzed to determine the impact of multiple isolates from the same patient on annual antibiogram data. During a 6-year period (1996 to 2001), 3,227 patients with 4,844 S. aureus isolates were evaluated. A total of 39% of patients with methicillin-resistant S. aureus (MRSA) (n = 860) and 23% of patients with methicillin-susceptible S. aureus (MSSA) (n = 2,367) infections had duplicate isolates. Cumulative data show that 91% of the patients during this 6-year period with duplicate isolates (2 to 13 duplicates/year) did not switch between MSSA and MRSA but retained the original S. aureus strain whether it was MSSA or MRSA. Rates of MRSA were calculated for each year by using all isolates and then eliminating duplicates. The impact of duplicate MRSA and MSSA isolates was evaluated by using the ratio of isolates per patient such that ratios of >1.0 indicate >1 isolate per patient. The 6-year ratio for MRSA was 1.90 isolates/patient, and the ratio for MSSA was 1.35. A significant difference (P < 0.05) was noted in the MRSA rates in 4 of 6 years when duplicate isolates were removed. Common phenotypic antibiogram patterns were compared for all MRSA isolates during the 6-year period, and 64% were of a single antibiogram phenotype. Eighty-eight percent of patients with duplicate MRSA isolates had phenotypically identical multiple isolates. The rate of MRSA differs when duplicate isolates are removed from the antibiogram data.

Adherence to antiretroviral therapy for pediatric HIV infection: review of the literature and recommendations for research

This review described and compared empirical investigations of adherence to pediatric antiretroviral therapy (ART) and predictors/correlates of adherence with regard to methodology and outcome. Thirteen empirical studies of children's adherence to ART, conducted between the years 1981 and 2002 were identified. Investigations varied by age of participant, drug therapy regimen, method of adherence assessment, and by the reporting of predictors/correlates of adherence. Conclusions from the literature are limited by the lack of common sample characteristics and adherence assessment methodologies. Nevertheless, consistent with much of the pediatric adherence literature, adherence to antiretroviral medications among children and adolescents appears to be frequently suboptimal. Few investigations identified predictors/correlates of adherence, but these appear generally similar to those found in adult samples. Recommendations for future investigations are proposed.

Points to consider about prescription drug prices: an overview of federal policy and pricing studies

Pharmaceutical prices in the United States are under evaluation as policy makers decide how to reduce health care expenditures and public subsidy of the pharmaceutical industry. Furthermore, evidence of higher drug prices in the United States, compared with those in other countries, fuels the prescription drug price debate. These issues are not new to the public forum and much can be learned from prior debates and policies. This paper begins by reviewing the pricing debate with the Kefauver hearings on monopolies held during the late 1950s and early 1960s and continues with the current price debate. Government reports and academic studies are discussed, addressing the methodological differences and their implications to policy makers. Finally, the literature review includes foreign government prescription drug programs with their respective prescription drug expenditures. Evidence provided by academics about the pricing practices of the drug manufacturers indicates product quality and price information would force firms to compete on the price level, thus reducing pharmaceutical product pricing to the "true" market price.

Expression of a novel Muller glia specific antigen during development and after optic nerve lesion

To generate monoclonal antibodies, immunogen fractions were purified from embryonic chick retinae by temperature-induced detergent-phase separation employing Triton X-114. Under reducing conditions, the monoclonal antibody (mAb) 2M6 identifies a protein doublet at 40 and 46 × 10(3) Mr, which appears to form disulfide-coupled multimers. The 2M6 antigen is regulated developmentally during retinal histogenesis and its expression correlates with Muller glial cell differentiation. Isolated glial endfeet and retinal glial cells in vitro were found to be 2M6-positive, identified with the aid of the general glia marker mAb R5. mAb 2M6 does not bind to any other glial cell type in the CNS as judged from immunohistochemical data. Cell-type specificity was further substantiated by employing retinal explant and single cell cultures on laminin in conjunction with two novel neuron-specific monoclonal antibodies. MAb 2M6 does not bind either to neurites or to neuronal cell bodies. Incubation of retinal cells in vitro with bromodeoxyuridine (BrdU) and subsequent immunodouble labelling with mAb 2M6 and anti-BrdU reveal that mitotic Muller cells can also express the 2M6 antigen. To investigate whether Muller cell differentiation depends on interactions with earlier differentiating ganglion cells, transections of early embryonic optic nerves in vivo were performed. This operation eliminates ganglion cells. Muller cell development and 2M6 antigen expression were not affected, suggesting a ganglion-cell-independent differentiation process. If, however, the optic nerve of juvenile chicken was crushed to induce a transient degeneration/regeneration process in the retina, a significant increase of 2M6 immunoreactivity became evident. These data are in line with the hypothesis that Muller glial cells, in contrast to other distinct glial cell types, might facilitate neural regeneration.

The effects of intermittent passive exercise on joint stiffness following periarticular fracture in rabbits

To determine the effects of intermittent passive motion on joint stiffness following periarticular fracture, bilateral distal tibia fractures were produced in 31 rabbits. Following immobilization and fracture union at three weeks, one ankle on each rabbit underwent passive exercise daily until sacrifice at six weeks. The contralateral ankle remained immobile, except for weekly stiffness determinations. Passive exercise produced limb swelling and resulted in temporarily decreased ankle stiffness to, but not significantly below, control values. Between exercise sessions, the exercised ankles became significantly stiffer than the contralateral immobilized ankles. The cause of stiffness was not determined, but extrapolation from other work would suggest that the regimens of intermittent passive exercise tested in this study additionally traumatized the healing tissues surrounding the fracture.

The grid radiograph. A simple technique for consistent high-resolution visualization of the hip

The grid radiograph, a new technique for radiographic evaluation of total hip replacements, ensures reproducible positioning of the hip and the x-ray beam. When this method was used, the images of stable acetabular and femoral components on one radiograph could be superimposed perfectly on the images of these components on subsequent radiographs. Subtle shifts in the positions of the components, such as tilting of the femoral surface replacement, subsidence of the femoral component, or migration of the acetabular component, were detected. When used with high-contrast radiographic technique and film, the implant-bone interfaces were depicted better by this method than by others. Grid radiographs can be used for detailed prospective evaluation of total hip replacements and are of practical value in counseling patients about the probable durability of the replacement.