Opioid Dispensing Practices in the Acute Care Setting: A Retrospective Study

Background: Ohio remains one of the most afflicted states nationally with 46.3 per 100 000 deaths due to drug overdose. Opioids are commonly administered in emergency departments for the management of pain. Given the high volume of patients presenting with pain, emergency clinicians must be cognizant of responsible opioid dispensing practices. Ohio established guidelines in April 2012 to provide a general approach for responsible opioid prescribing practices in the emergency setting. The purpose of this study assesses clinician opioid dispensing before and after the implementation of the Ohio Opioid Prescribing Guidelines. Methods: The study design used retrospective data analysis of opioid medications ordered by emergency clinicians to be administered in the emergency room between January 1, 2007, to December 31, 2017, at the University of Toledo Medical Center. A segmented regression analysis with an interrupted time series was used to determine impact. Results: All opioid medication usage showed a significant decrease after guideline implementation except for morphine and fentanyl which showed statistically significant increases in administration over time (P < 0.05). Conclusion: There was a significant decrease in the use of opioids since the implementation of the Ohio Opioid Prescribing Guidelines, yet morphine and fentanyl use has generally increased across all age groups. Age demographics frequently receiving opioids in the emergency room have seemed to shift over time as well as specific opioid drugs dispensed for the management of pain in certain age groups. Further study is needed to evaluate the use of opioids prescribed by emergency physicians after discharge from the emergency department

ABCC5, ERCC2, XPA and XRCC1 transcript abundance levels correlate with cisplatin chemoresistance in non-small cell lung cancer cell lines

BACKGROUND: Although 40–50% of non-small cell lung cancer (NSCLC) tumors respond to cisplatin chemotherapy, there currently is no way to prospectively identify potential responders. The purpose of this study was to determine whether transcript abundance (TA) levels of twelve selected DNA repair or multi-drug resistance genes (LIG1, ERCC2, ERCC3, DDIT3, ABCC1, ABCC4, ABCC5, ABCC10, GTF2H2, XPA, XPC and XRCC1) were associated with cisplatin chemoresistance and could therefore contribute to the development of a predictive marker. Standardized RT (StaRT)-PCR, was employed to assess these genes in a set of NSCLC cell lines with a previously published range of sensitivity to cisplatin. Data were obtained in the form of target gene molecules relative to 10(6 )β-actin (ACTB) molecules. To cancel the effect of ACTB variation among the different cell lines individual gene expression values were incorporated into ratios of one gene to another. Each two-gene ratio was compared as a single variable to chemoresistance for each of eight NSCLC cell lines using multiple regression. In an effort to validate these results, six additional lines then were evaluated. RESULTS: Following validation, single variable models best correlated with chemoresistance (p < 0.001), were ERCC2/XPC, ABCC5/GTF2H2, ERCC2/GTF2H2, XPA/XPC and XRCC1/XPC. All single variable models were examined hierarchically to achieve two variable models. The two variable model with the highest correlation was (ABCC5/GTF2H2, ERCC2/GTF2H2) with an R(2 )value of 0.96 (p < 0.001). CONCLUSION: These results provide markers suitable for assessment of small fine needle aspirate biopsies in an effort to prospectively identify cisplatin resistant tumors

Calculation of Splicing Potential from the Alternative Splicing Mutation Database

© 2008 Bechtel et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution Licens

Low Hydrophobic Mismatch Scores Calculated for HLA-A/B/DR/DQ Loci Improve Kidney Allograft Survival

We evaluated the impact of human leukocyte antigen (HLA) disparity (immunogenicity; IM) on long-term kidney allograft survival. The IM was quantified based on physicochemical properties of the polymorphic linear donor/recipient HLA amino acids (the Cambridge algorithm) as a hydrophobic, electrostatic, amino acid mismatch scores (HMS\AMS\EMS) or eplet mismatch (EpMM) load. High-resolution HLA-A/B/DRB1/DQB1 types were imputed to calculate HMS for primary/re-transplant recipients of deceased donor transplants. The multiple Cox regression showed the association of HMS with graft survival and other confounders. The HMS integer 0-10 scale showed the most survival benefit between HMS 0 and 3. The Kaplan-Meier analysis showed that: the HMS=0 group had 18.1-year median graft survival, a 5-year benefit over HMS\u3e0 group; HMS ≤ 3.0 had 16.7-year graft survival, a 3.8-year better than HMS\u3e3.0 group; and, HMS ≤ 7.8 had 14.3-year grafts survival, a 1.8-year improvement over HMS\u3e7.8 group. Stratification based on EMS, AMS or EpMM produced similar results. Additionally, the importance of HLA-DR with/without -DQ IM for graft survival was shown. In our simulation of 1,000 random donor/recipient pairs, 75% with HMS\u3e3.0 were re-matched into HMS ≤ 3.0 and the remaining 25% into HMS≥7.8: after re-matching, the 13.5 years graft survival would increase to 16.3 years. This approach matches donors to recipients with low/medium IM donors thus preventing transplants with high IM donors

Patients’ Awareness, Perceived Benefit, and Intent to Participate in Pharmacy Services

Objective: To determine patient awareness, perceived benefit, and intent to participate in 1) adherence packaging 2) Medication therapy management (MTM), 3) delivery, 4) automatic refill, and 5) refill synchronization. Methods: This cross-sectional exploratory study used convenience sampling to survey participants from January 26th, 2016 and March 28th, 2016. A 25-question survey and service sheet were developed. The survey consisted of four sections 1) awareness, 2) perceived benefit, 3) intent to participate, and 4) demographics. Descriptive statistics, linear regression, and logistic regression were conducted. Results: A total of 336 people were approached. Thirty-four people only filled out the demographic section and 32 refused to participate. Therefore, 270 surveys were considered usable for statistical analysis (90.4% response rate). The majority of the participants were not aware of refill synchronization (77.0%), MTM (64.8%), and adherence packaging (87.0%). There were multiple factors that contributed to how patients perceived the benefits of adherence packaging and automatic refill. Participants who were middle aged or older (p&lt;.05), had a higher income (p&lt;.01), were on multiple medications (p&lt;.01), and from Ohio (p&lt;.05) saw a higher benefit in adherence packaging. Participants who were middle aged or older (p&lt;.05), male (p&lt;.01), had a higher income (p&lt;.01), had a Bachelor’s degree or lower (p&lt;.05), and were aware of the service (p&lt;.01) were more likely to see a benefit in automatic refill. In contrast there was only one predictor for refill synchronization showing that non-white participants were more likely to see a benefit. There were not any factors that contributed to how patients perceived the benefits of delivery, refill synch, and MTM. There were several predictors that increased a patient’s intent to participate in a service. Some of the key predictors for each service included, participants who felt that adherence packaging will help them feel more in control of taking their medications were 2.81 times more likely to participate. Participants who felt that delivery would allow them more time to do other things were 6.89 times more likely to participate. Those who believed that automatic refill would help them take their medications on time were 8.30 times more likely to participate. Participants who felt refill synchronization would decrease multiple trips to the pharmacy were 2.26 times more likely to participate. Those that felt MTM would build their relationship with their pharmacist were 0.47 times more likely to participate. Overall, a consistent predictor for every service was feeling in control of taking their medications. Conclusion: Overall, there is a lack of awareness of pharmacy services. Specifically services such as medication therapy management, refill synchronization, and adherence packaging. Pharmacists should take a proactive approach in informing patients of the services offered at their pharmacy. Additionally to increase participation, pharmacists can educate patients on how a service may help them feel more in control of taking their medications. &nbsp; Type:&nbsp;Original Researc

Lung cancer risk test trial: study design, participant baseline characteristics, bronchoscopy safety, and establishment of a biospecimen repository

BACKGROUND: The Lung Cancer Risk Test (LCRT) trial is a prospective cohort study comparing lung cancer incidence among persons with a positive or negative value for the LCRT, a 15 gene test measured in normal bronchial epithelial cells (NBEC). The purpose of this article is to describe the study design, primary endpoint, and safety; baseline characteristics of enrolled individuals; and establishment of a bio-specimen repository. METHODS/DESIGN: Eligible participants were aged 50-90 years, current or former smokers with 20 pack-years or more cigarette smoking history, free of lung cancer, and willing to undergo bronchoscopic brush biopsy for NBEC sample collection. NBEC, peripheral blood samples, baseline CT, and medical and demographic data were collected from each subject. DISCUSSION: Over a two-year span (2010-2012), 403 subjects were enrolled at 12 sites. At baseline 384 subjects remained in study and mean age and smoking history were 62.9 years and 50.4 pack-years respectively, with 34% current smokers. Obstructive lung disease (FEV1/FVC \u3c0.7) was present in 157 (54%). No severe adverse events were associated with bronchoscopic brushing. An NBEC and matched peripheral blood bio-specimen repository was established. The demographic composition of the enrolled group is representative of the population for which the LCRT is intended. Specifically, based on baseline population characteristics we expect lung cancer incidence in this cohort to be representative of the population eligible for low-dose Computed Tomography (LDCT) lung cancer screening. Collection of NBEC by bronchial brush biopsy/bronchoscopy was safe and well-tolerated in this population. These findings support the feasibility of testing LCRT clinical utility in this prospective study. If validated, the LCRT has the potential to significantly narrow the population of individuals requiring annual low-dose helical CT screening for early detection of lung cancer and delay the onset of screening for individuals with results indicating low lung cancer risk. For these individuals, the small risk incurred by undergoing once in a lifetime bronchoscopic sample collection for LCRT may be offset by a reduction in their CT-related risks. The LCRT biospecimen repository will enable additional studies of genetic basis for COPD and/or lung cancer risk. TRIAL REGISTRATION: The LCRT Study, NCT 01130285, was registered with Clinicaltrials.gov on May 24, 2010

Intensivist supervision of resident-placed central venous catheters decreases the incidence of catheter-related blood stream infections

Catheter-related blood stream infections (CRBSI) cause significant morbidity and mortality. A retrospective study of a performance improvement project in our teaching hospital's surgical intensive care unit (SICU) showed that intensivist supervision was important in reinforcing maximal sterile barriers (MSB) use during the placement of a central venous catheter (CVC) in the prevention of CRBSI. A historical control period, 1 January 2001–31 December 2003, was established for comparison. From 1 January 2003–31 December 2007, MSB use for central venous line placement was mandated for all operators. However, in 2003 there was no intensivist supervision of CVC placements in the SICU. The use of MSB alone did not cause a significant change in the CRBSI rate in the first year of the project, but close supervision by an intensivist in years 2004–2007, in conjunction with MSB use, demonstrated a significant drop in the CRBSI rate when compared to the years before intensivist supervision (2001–2003), p < .0001. A time series analysis comparing monthly rates of CRBSI (2001–2007) also revealed a significant downward trend, p = .028. Additionally, in the first year of the mandated MSB use (2003), 85 independently observed resident-placed CVCs demonstrated that breaks in sterile technique (34/85), as compared those placements that had no breaks in technique (51/85), had more CRBSI, 6/34 (17.6%) vs. 1/51 (1.9%), p < .01. Interventions to reduce CRBSI in our SICU needed emphasis on adequate supervision of trainees in CVC placement, in addition to use of MSB, to effect lower CRBSI rates

Implementation of the "FASTHUG" concept decreases the incidence of ventilator-associated pneumonia in a surgical intensive care unit

<p>Abstract</p> <p>Background</p> <p>Ventilator-associated pneumonia (VAP) is a leading cause of morbidity and mortality in critically ill patients. The Institute for Healthcare Improvement 100,000 Lives Campaign made VAP a target of prevention and performance improvement. Additionally, the Joint Commission on Accreditation of Health Organizations' 2007 Disease Specific National Patient Safety Goals included the reduction of healthcare-associated infections. We report implementation of a performance improvement project that dramatically reduced our VAP rate that had exceeded the 90^thpercentile nationally.</p> <p>Methods</p> <p>From 1 January 2004 to 31 December 2005 a performance improvement project was undertaken to decrease our critical care unit VAP rate. In year one (2004) procedural interventions were highlighted: aggressive oral care, early extubation, management of soiled or malfunctioning respiratory equipment, hand washing surveillance, and maximal sterile barrier precautions. In year two (2005) an evaluative concept called FASTHUG (daily evaluation of patients' feeding, analgesia, sedation, thromboembolic prophylaxis, elevation of the head of the bed, ulcer prophylaxis, and glucose control) was implemented. To determine the long-term effectiveness of such an intervention a historical control period (2003) and the procedural intervention period of 2004, i.e., the pre-FASTHUG period (months 1–24) were compared with an extended post-FASTHUG period (months 25–54).</p> <p>Results</p> <p>The 2003 surgical intensive care VAP rate of 19.3/1000 ventilator-days served as a historical control. Procedural interventions in 2004 were not effective in reducing VAP, p = 0.62. However, implementation of FASTHUG in 2005, directed by a critical care team, resulted in a rate of 7.3/1000 ventilator-days, p ≤ .01. The median pneumonia rate was lower after implementation of FASTHUG when compared to the historical control year (p = .028) and the first year after the procedural interventions (p = .041) using follow-up pairwise comparisons. The pre-FASTHUG period (2003–2004, months 1–24) when compared with an extended post-FASTHUG period (2005–2007, 25–54 months) also demonstrated a significant decrease in the VAP rate, p = .0004. This reduction in the post-FASTHUG period occurred despite a rising Severity of Illness index in critically ill patients, p = .001.</p> <p>Conclusion</p> <p>Implementation of the FASTHUG concept, in the daily evaluation of mechanically ventilated patients, significantly decreased our surgical intensive care unit VAP rate.</p