Sublingual tacrolimus as an alternative to oral administration for solid organ transplant recipients

In this article, researched looked at available data to analyze sublingual tacrolimus and provide recommendations for solid organ transplant recipients.  Tacrolimus is an anti-rejection (immunosuppressant) medication that is available in many dosage forms but sublingual was analyzed in this study.

Typically, oral tacrolimus is used to prevent organ transplant rejection but due to it’s nature in a clinical setting many different situations occur that may prevent oral delivery.  For this reason, the researches wanted to explore the efficacy of a sublingual dosage form. The study found that about 50% of the oral dose needed to be delivered sublingually in order to get the targeted therapeutic effect.

Overall, the study helped to solidify the idea that sublingual dosing could be used as a short-term therapy for patient who cannot receive oral delivery.

Do you think that more drugs should be available sublingually? Especially ones used in a clinical setting?

Pennington CA, Jeong MP. Sublingual tacrolimus as an alternative to oral administration for solid organ transplant recipients.  Am J Health Syst Pharm.  2015;72(4):277-84.

Implementation and outcomes of a pharmacist-managed clinical video telehealth anticoagulation clinic

This article intrigued me because it was look at innovated health practices for pharmacists.  As a class, we heard a lot about these types of practices from Profession of Pharmacy 1, but I rarely ever saw them in practice.

In this case study, the investigators looked at the use of clinical video technology to optimize the use of pharmacy specialty resources in a community-based outpatient clinic.

The pharmacists in this experiment where located about 12 miles away from the practice site and used videoconferencing to conduct patient interviews, evaluate INRs and gather other data.  The study found that a high level of patient satisfaction was maintained and pharmacist resources were able to be allocated to other duties.

I think that this something that we will be seeing more and more often in practice.  I think that at the current time there are some members of the older population that are skeptical of this idea, but as our generation becomes older, I believe businesses will see the advantage in this and begin implementing it.  What do you think?

Singh LG, Accursi M, Black KK.  Implementation and outcomes of a pharmacist-managed clinical video telehealth anticoagulation clinic.  Am J Health Syst Phar.  2015;72:70-73.  

Effectiveness of Digital Breast Tomosynthesis Compared with Digital Mammography

In this article, the research team looked to determine whether improved initial outcomes of using DBT could be sustained over time.  The study was completed over 4 years and included 44,468 screenings attributable to 23,958 women.  The research team looked to compared recall rates, cancer cases per recalled patients, and biopsy and interval cancer rates.  Each women was followed over the course of 4 years and received either 1, 2, or 3 DBT screenings.  The number of screenings were then used as an intervention to determine the patient’s health.

The results of the study showed that the use of DBT remained significantly reduced compared with using digital mammography alone.  Overall, the study found that digital breast tonosynthesis outcomes are not only sustainable but provide significant recall reduction and a decline in interval cancers.

McDonald ES, Oustimov A, Weinstein SP, et al.  Effectiveness of digital breast tomosynthesis compared with digital mammography.  JAMA Oncol. doi:10.1001/jamaoncol.2015.553.  

(Article was published online first.)

Is the Definition of Sepsis Valid?

In this article, research was conducted at 12 hospitals in southwestern Pennsylvania.  The research team looked at the criteria used to determine whether or not a patient was diagnosed with sepsis and tried assess its validity.  UPMC was among the participating hospitals.

They looked at many different diagnosis criteria including SOFA, LODS, qSOFA, and SIRS.  SOFA was considered less complex than LODS but using the SOFA criteria did not result in significantly different in-hospital mortality rates compared to LODS.   However, qSOFA was statistically better able to predict mortality better than SOFA making it the most valid choice.

I chose this article because I recently went to do a chart review at UPMC Presbyterian with an infectious disease pharmacist.  Many of his cases dealt with sepsis so I was drawn to the article.  Furthermore, I thought it was interesting that the research took place around Pittsburgh.  I think this just helps to further illustrated the great opportunities presented to us as students at this school.  We are certainly in a healthcare mecca and articles like this help to prove that.

Seymour Cw, Liu VX, Iwashya TJ, et al.  Assessment of clinical criteria for sepsis.  JAMA. 2016;315(8):762-774.

Implementation of Penicillin Allergy Screening Tool to Optimize Aztreonam Use

In this article from the American Journal of Health System Pharmacy, researchers looked to determine whether pre-screening for a penicillin allergy could help to reduce the use of aztreonam.  Aztreonam is an antibiotic used to treat gram-negative infections.

The study looked at patients prior to and after intervention to account for inappropriate aztreonam use.  After intervention, the number of inappropriate doses decreased significantly.  And overall, the screening allowed for a cost avoidance of up to $100,000.  Use of B-lactam alternatives became more popular over the use of aztreonam.

This article is interesting because it shows that educating providers and doing pre-screening can help patients receive the appropriate medication and avoid adverse reactions.

Stacie ML, Brundige ML, Brown J, et al.  Implementation of a penicillin allergy screening tool to optimize aztreonam use.  Am. J. Health Syst. Pharm.  2016;73:298-306.

In-Hospital Outcomes and Costs Among Patients Hospitalized During a Return Visit to the Emergency Department

In this article, researchers explored what types of outcomes patients experience as well as what resources are utilized when patients are hospitalized during a unscheduled return visit to the ED.  The study looked at parameters including in-hospital mortality, ICU admission, length of stay, and inpatient costs.

Unexpectedly, patients who returned to the ED after initially being discharged had a lower in-hospital mortality rate. They also had lower ICU admission rates, lower hospital costs, and longer lengths of stay.  They article attempts to suggest that the idea of readmission as a negative might not tell the whole story.  It may not be as telling about deficits in the quality of care as we previously thought.

The problem that I have with these findings is that the data seems to suggest that patients who are initially admitted to the ED are not receiving a high quality of care.  In both cases, being discharged or returning, something is not going right.  If a patient is leaving the ED, they should be able to rest assure that they were taken care of properly.  They should not worry about having to return when their condition worsens.

One way I believe we could fix this problem is with the use of pharmacists.  In POP we learned about the many mistakes patients make with their medication upon discharge.  Having a pharmacist on staff to explain medications to the patients might help to reduce the number of readmissions.

Sabbatini AK, Kocher KE, Basu A, et al. In-hospital outcomes and costs among patients hospitalized during a return visit to the emergency department. JAMA. 2016;315(7):663-671.

Predictive Performance of Glomerular Filtration Rate Estimation Equations Based on Cystatin C versus Serum Creatinine Values in Critically Ill Patients

In this study, researches looked to determine whether Cystatin C or serum creatinine levels were better indicators of a critically ill patient’s GFR.  Patient data on serum creatinine, cystatin c, serum albumin, blood urea nitrogen, and 24-hour urine creatinine clearance was collected.  After studying 131 critically ill patients, researchers concluded that there was no evidence of either cystatin c or serum creatinine being superior over the other.  In other words, no matter what parameter was used to calculate GFR, the clinician still came to the same conclusion.

Though it may seem that this study didn’t find anything significant, I believe that it may be helpful for future patients.  If the data were to be confirmed by other studies, we could use either parameter to calculate GFR.  This could be useful if one parameter is easier to collect or more readily available than another.  One could get vital health information more quickly with out being concerned that s/he did was not as accurate as s/he could have been.

Diego E, Castro P, Soy D, et al. Predictive performance of glomerular filtration rate estimation equations based on cystatin C versus serum creatinine values in critically ill patients. AM J Health-Syst Pharm. 2016;73:206-15.

Effect of Behavioral Interventions on Inappropriate Antibiotic Prescribing Among Primary Care Practices

In this article, the scientists involved looked at the effects of behavioral interventions and rates of inappropriate antibiotic prescribing during ambulatory visits for acute respiratory tract infections.  The experiment had clinicians held responsible for their antibiotic prescriptions in 3 ways: they were either given electronic alternative suggestions, had to enter a rationale for prescribing into the patient chart, or had to report their prescribing numbers to a group of other clinicians.  The study found that two of the interventions had a statistically significant impact on the rates of antibiotic prescriptions. Having the clinicians enter rationale for their prescriptions and reporting their prescribing numbers to peers both reduced the number of inappropriate antibiotic prescribing for respiratory tract infection.

I think that this article is really interesting because we all know that there is a widespread problem with antibiotics.  We know that antibiotic resistance is becoming more and more of a serious threat. If there is a way that we may reduce the number of  antibiotic prescriptions that could have a significant impact on fighting/reducing resistance.

Reference:

Meeker D, Linder JA, Fox CR, et al. Affect of behavioral interventions on inappropriate antibiotic prescribing among primary care practices. JAMA 2016; 315(6):562-570.

Effect of Behavioral Interventions on Inappropriate Antibiotic Prescribing Among Primary Care Practices