Prescriptions for Bedtime Sedatives After the Introduction of a General Admission Order Set at an Academic Health Center: The Potential and Pitfalls of Order Sets.

OBJECTIVE: This study describes the impact of modifications to a general admission order set on physician prescribing of 2 as-needed or pro re nata (PRN) bedtime sedatives. METHODS: The hospitalists at our institution have used a general medical admission order set since 2005. Zolpidem was the only as-needed (PRN) bedtime sedative option on the order set until trazodone was added in December 2008. Trazodone is preferred over zolpidem in the geriatric population. We identified patients admitted by the hospitalists between January 2007 and August 2013 who were prescribed with either zolpidem or trazodone as a PRN sedative. Patient demographics, date and time of the order, and number of sedative doses administered during the hospitalization were recorded. Orders placed within 12 hours of admission were attributed to admission orders. RESULTS: Between 2007 and 2013, the number of patients admitted by the hospitalists with an order for PRN trazodone on admission increased by 18-fold. During the same period, the number of admissions by the hospitalists increased by 2.3 times. Zolpidem orders exceeded those for trazodone in all age groups until 2008. After the addition of trazodone, its use exceeded that of zolpidem. Almost half (48%) of all patients did not have a dose of the PRN trazodone administered. CONCLUSIONS: Although order sets can be leveraged to align practitioners with established guidelines, the expediency of using medications on an order set may overcome physicians\u27 clinical judgment. The content of an order set therefore deserves careful scrutiny before implementation

Student-generated e-learning for clinical education

Background Within clinical education, e-learning facilitates a standardised learning experience to augment the clinical experience while enabling learner and teacher flexibility. With the shift of students from consumers to creators, student-generated content is expanding within higher education; however, there is sparse literature evaluating the impact of student-developed e-learning within clinical education. The aim of this study was to implement and evaluate a student-developed e-learning clinical module series within ambulatory care clinical pharmacy experiences. Methods Three clinical e-learning modules were developed by students for use prior to clinical experiences. E-learning modules were created by fourth-year professional pharmacy students and reviewed by pharmacy faculty members. A pre-/post-assessment was performed to evaluate knowledge comprehension before and after participating in the e-learning modules. Additionally, a survey on student perceptions of this educational tool was performed at the end of the clinical experience. There is sparse literature evaluating the impact of student-developed e-learning within clinical education Results Of the 31 students eligible for study inclusion, 94 per cent participated in both the pre- and post-assessments. The combined post-assessment score was significantly improved after participating in the student-developed e-learning modules (p = 0.008). The student perception survey demonstrated positive perceptions of e-learning within clinical education. Discussion Student-generated e-learning was able to enhance knowledge and was positively perceived by learners. As e-learning continues to expand within health sciences education, students can be incorporated into the development and execution of this educational tool

Analysis of a Standardized Perioperative Pain Management Order Set in Highly Opioid-Tolerant Patients

Objective: The aim was to assess a standardized order set for perioperative pain management in highly opioid-tolerant patients undergoing elective orthopedic surgery.Methods: This retrospective chart review evaluated a pain order set in highly opioid-tolerant patients undergoing elective total knee or total hip arthroplasty from January 2010 through August 2012. Based on the date of the surgery, patients were allocated into preimplementation or postimplementation order set groups. The primary outcome assessed whether an adjustment in daily opioid dosage was required within the first 48 hours postoperatively. Secondary outcomes included pain scores, length of hospitalization, and safety outcomes.Results: Sixty patients were included in the analysis. An adjustment to postoperative opioid therapy occurred in 62% of the patients in the preimplementation group and in 56% of postimplementation group patients (P = 0.786). There were no differences in median pain scores 48 hours postoperatively (P = 0.348). Cumulative toxicity was increased after order set implementation compared with previous patients (44% versus 5%, P \u3c 0.005); however, opioid doses held for sedation was the only individual toxicity to reach statistical significance (P = 0.011).Conclusions: This study is the first to evaluate a standardized order set for pain management in highly opioid-tolerant patients undergoing elective orthopedic surgery. The order set demonstrated similar efficacy to previous treatment modalities, but opioid-induced sedation was of concern with the order set. After the initial analysis, the order set was modified to minimize opioid-induced sedation. Continual safety analysis is warranted for quality improvement to enhance perioperative pain management in highly opioid-tolerant patients

Design of Drug-Induced Diseases Elective Utilizing Active Learning

Objectives To describe active learning utilized in a drug-induced diseases (DID) elective and determine inter-rater reliability of the assessment rubric for oral case-based presentations. Methods The design of this DID elective focuses on problem-based learning to enhance students’ critical thinking and problem-solving skills pertaining to the treatment of inducible diseases and general medicine. Each class incorporates active learning, utilization of drug information resources, and group work. The primary course assessment is student developed oral case-based presentations evaluated with a standard rubric. Results The intra-class correlation coefficient (ICC) was calculated amongst evaluators to assess the inter-rater reliability of the DID rubric for 21 case-based presentations during the Fall 2013 semester. Composite scores for the case-based presentations demonstrated good inter-rater reliability with an ICC of 0.628. Conclusions Teaching methods utilizing active learning are described for this DID elective. The rubric for the student developed oral case-based presentations demonstrated good inter-rater reliability amongst evaluators and could be modified for use in other professional courses

Epidural Hematoma Following Cervical Spine Surgery.

STUDY DESIGN: A multicentered retrospective case series. OBJECTIVE: To determine the incidence and circumstances surrounding the development of a symptomatic postoperative epidural hematoma in the cervical spine. METHODS: Patients who underwent cervical spine surgery between January 1, 2005, and December 31, 2011, at 23 institutions were reviewed, and all patients who developed an epidural hematoma were identified. RESULTS: A total of 16 582 cervical spine surgeries were identified, and 15 patients developed a postoperative epidural hematoma, for a total incidence of 0.090%. Substantial variation between institutions was noted, with 11 sites reporting no epidural hematomas, and 1 site reporting an incidence of 0.76%. All patients initially presented with a neurologic deficit. Nine patients had complete resolution of the neurologic deficit after hematoma evacuation; however 2 of the 3 patients (66%) who had a delay in the diagnosis of the epidural hematoma had residual neurologic deficits compared to only 4 of the 12 patients (33%) who had no delay in the diagnosis or treatment (P = .53). Additionally, the patients who experienced a postoperative epidural hematoma did not experience any significant improvement in health-related quality-of-life metrics as a result of the index procedure at final follow-up evaluation. CONCLUSION: This is the largest series to date to analyze the incidence of an epidural hematoma following cervical spine surgery, and this study suggest that an epidural hematoma occurs in approximately 1 out of 1000 cervical spine surgeries. Prompt diagnosis and treatment may improve the chance of making a complete neurologic recovery, but patients who develop this complication do not show improvements in the health-related quality-of-life measurements

C5 Palsy After Cervical Spine Surgery: A Multicenter Retrospective Review of 59 Cases.

STUDY DESIGN: A multicenter, retrospective review of C5 palsy after cervical spine surgery. OBJECTIVE: Postoperative C5 palsy is a known complication of cervical decompressive spinal surgery. The goal of this study was to review the incidence, patient characteristics, and outcome of C5 palsy in patients undergoing cervical spine surgery. METHODS: We conducted a multicenter, retrospective review of 13 946 patients across 21 centers who received cervical spine surgery (levels C2 to C7) between January 1, 2005, and December 31, 2011, inclusive. P values were calculated using 2-sample t test for continuous variables and χ(2) tests or Fisher exact tests for categorical variables. RESULTS: Of the 13 946 cases reviewed, 59 patients experienced a postoperative C5 palsy. The incidence rate across the 21 sites ranged from 0% to 2.5%. At most recent follow-up, 32 patients reported complete resolution of symptoms (54.2%), 15 had symptoms resolve with residual effects (25.4%), 10 patients did not recover (17.0%), and 2 were lost to follow-up (3.4%). CONCLUSION: C5 palsy occurred in all surgical approaches and across a variety of diagnoses. The majority of patients had full recovery or recovery with residual effects. This study represents the largest series of North American patients reviewed to date

Biological, clinical and population relevance of 95 loci for blood lipids.

Plasma concentrations of total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol and triglycerides are among the most important risk factors for coronary artery disease (CAD) and are targets for therapeutic intervention. We screened the genome for common variants associated with plasma lipids in >100,000 individuals of European ancestry. Here we report 95 significantly associated loci (P < 5 x 10(-8)), with 59 showing genome-wide significant association with lipid traits for the first time. The newly reported associations include single nucleotide polymorphisms (SNPs) near known lipid regulators (for example, CYP7A1, NPC1L1 and SCARB1) as well as in scores of loci not previously implicated in lipoprotein metabolism. The 95 loci contribute not only to normal variation in lipid traits but also to extreme lipid phenotypes and have an impact on lipid traits in three non-European populations (East Asians, South Asians and African Americans). Our results identify several novel loci associated with plasma lipids that are also associated with CAD. Finally, we validated three of the novel genes-GALNT2, PPP1R3B and TTC39B-with experiments in mouse models. Taken together, our findings provide the foundation to develop a broader biological understanding of lipoprotein metabolism and to identify new therapeutic opportunities for the prevention of CAD

Evaluation of polygenic risk scores for breast and ovarian cancer risk prediction in BRCA1 and BRCA2 mutation carriers

Background: Genome-wide association studies (GWAS) have identified 94 common single-nucleotide polymorphisms (SNPs) associated with breast cancer (BC) risk and 18 associated with ovarian cancer (OC) risk. Several of these are also associated with risk of BC or OC for women who carry a pathogenic mutation in the high-risk BC and OC genes BRCA1 or BRCA2. The combined effects of these variants on BC or OC risk for BRCA1 and BRCA2 mutation carriers have not yet been assessed while their clinical management could benefit from improved personalized risk estimates. Methods: We constructed polygenic risk scores (PRS) using BC and OC susceptibility SNPs identified through population-based GWAS: for BC (overall, estrogen receptor [ER]-positive, and ER-negative) and for OC. Using data from 15 252 female BRCA1 and 8211 BRCA2 carriers, the association of each PRS with BC or OC risk was evaluated using a weighted cohort approach, with time to diagnosis as the outcome and estimation of the hazard ratios (HRs) per standard deviation increase in the PRS. Results: The PRS for ER-negative BC displayed the strongest association with BC risk in BRCA1 carriers (HR = 1.27, 95% confidence interval [CI] = 1.23 to 1.31, P = 8.2 x 10(53)). In BRCA2 carriers, the strongest association with BC risk was seen for the overall BC PRS (HR = 1.22, 95% CI = 1.17 to 1.28, P = 7.2 x 10(-20)). The OC PRS was strongly associated with OC risk for both BRCA1 and BRCA2 carriers. These translate to differences in absolute risks (more than 10% in each case) between the top and bottom deciles of the PRS distribution; for example, the OC risk was 6% by age 80 years for BRCA2 carriers at the 10th percentile of the OC PRS compared with 19% risk for those at the 90th percentile of PRS. Conclusions: BC and OC PRS are predictive of cancer risk in BRCA1 and BRCA2 carriers. Incorporation of the PRS into risk prediction models has promise to better inform decisions on cancer risk management