Pharmacist-led implementation of a vancomycin guideline across medical and surgical units: impact on clinical behavior and therapeutic drug monitoring outcomes

This work is published by Dove Medical Press Limited, and licensed under Creative Commons Attribution – Non Commercial (unported, v3.0) License. The full terms of the License are available at http://creativecommons.org/licenses/by-nc/3.0/. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. Permissions beyond the scope of the License are administered by Dove Medical Press Limited. Information on how to request permission may be found at: http://www.dovepress.com/permissions.phpBackground: Vancomycin is the antibiotic of choice for the treatment of serious infections such as methicillin-resistant Staphylococcus aureus (MRSA). Inappropriate prescribing of vancomycin can lead to therapeutic failure, antibiotic resistance, and drug toxicity. Objective: To examine the effectiveness of pharmacist-led implementation of a clinical practice guideline for vancomycin dosing and monitoring in a teaching hospital. Methods: An observational pre–post study design was undertaken to evaluate the implementation of the vancomycin guideline. The implementation strategy principally involved education, clinical vignettes, and provision of pocket guidelines to accompany release of the guideline to the hospital Intranet. The target cohort for clinical behavioral change was junior medical officers, as they perform the majority of prescribing and monitoring of vancomycin in hospitals. Assessment measures were recorded for vancomycin prescribing, therapeutic drug monitoring, and patient outcomes. Results: Ninety-nine patients, 53 pre- and 46 post-implementation, were included in the study. Prescribing of a loading dose increased from 9% to 28% (P=0.02), and guideline adherence to starting maintenance dosing increased from 53% to 63% (P=0.32). Dose adjustment by doctors when blood concentrations were outside target increased from 53% to 71% (P=0.12), and correct timing of initial concentration measurement increased from 43% to 57% (P=0.23). Appropriately timed trough concentrations improved from 73% to 81% (P=0.08). Pre-dose (trough) concentrations in target range rose from 33% to 44% (P=0.10), while potentially toxic concentrations decreased from 32% to 21% (P=0.05) post-implementation. Infection cure rates for patients increased from 85% to 96% (P=0.11) after the guideline was implemented. Conclusion: The implementation strategy employed in this study demonstrated potential effectiveness, and should prompt additional larger studies to optimize strategies that will translate into improved clinical practice using vancomycin

Evaluating the climate effects of mid-1800s deforestation in New England, USA, using a Weather, Research, and Forecasting (WRF) Model Multi-Physics Ensemble

The New England region of the northeastern United States has a land use history characterized by forest clearing for agriculture and other uses during European colonization and subsequent reforestation following widespread farm abandonment. Despite these broad changes, the potential influence on local and regional climate has received relatively little attention. This study investigated wintertime (December through March) climate impacts of reforestation in New England using a high-resolution (4 km) multiphysics ensemble of the Weather Research and Forecasting Model. In general, the conversion from mid-1800s cropland/grassland to forest led to warming, but results were sensitive to physics parameterizations. The 2-m maximum temperature (T2max) was most sensitive to choice of land surface model, 2-m minimum temperature (T2min) was sensitive to radiation scheme, and all ensemble members simulated precipitation poorly. Reforestation experiments suggest that conversion of mid-1800s cropland/grassland to present-day forest warmed T2max +0.5 to +3 K, with weaker warming during a warm, dry winter compared to a cold, snowy winter. Warmer T2max over forests was primarily the result of increased absorbed shortwave radiation and increased sensible heat flux compared to cropland/grassland. At night, T2min warmed +0.2 to +1.5 K where deciduous broadleaf forest replaced cropland/grassland, a result of decreased ground heat flux. By contrast, T2min of evergreen needleleaf forest cooled –0.5 to –2.1 K, primarily owing to increased ground heat flux and decreased sensible heat flux

The On/Off Nature of Star-Planet Interactions

Evidence suggesting an observable magnetic interaction between a star and its hot Jupiter appears as a cyclic variation of stellar activity synchronized to the planet's orbit. In this study, we monitored the chromospheric activity of 7 stars with hot Jupiters using new high-resolution echelle spectra collected with ESPaDOnS over a few nights in 2005 and 2006 from the CFHT. We searched for variability in several stellar activity indicators (Ca II H, K, the Ca II infrared triplet, Halpha, and He I). HD 179949 has been observed almost every year since 2001. Synchronicity of the Ca II H & K emission with the orbit is clearly seen in four out of six epochs, while rotational modulation with P_rot=7 days is apparent in the other two seasons. We observe a similar phenomenon on upsilon And, which displays rotational modulation (P_rot=12 days) in September 2005, in 2002 and 2003 variations appear to correlate with the planet's orbital period. This on/off nature of star-planet interaction (SPI) in the two systems is likely a function of the changing stellar magnetic field structure throughout its activity cycle. Variability in the transiting system HD 189733 is likely associated with an active region rotating with the star, however, the flaring in excess of the rotational modulation may be associated with its hot Jupiter. As for HD 179949, the peak variability as measured by the mean absolute deviation for both HD 189733 and tau Boo leads the sub-planetary longitude by 70 degrees. The tentative correlation between this activity and the ratio of Mpsini to the planet's rotation period, a quantity proportional to the hot Jupiter's magnetic moment, first presented in Shkolnik et al. 2005 remains viable. This work furthers the characterization of SPI, improving its potential as a probe of extrasolar planetary magnetic fields.Comment: Accepted for publication in the Astrophysical Journa

The use of storm fragments and biodegradable replanting methods allows for a low-impact habitat restoration method of seagrass meadows, in the eastern Aegean Sea

Seagrasses are important marine ecosystems but are vulnerable to physical damage from anthropogenic activities such as anchoring and trawling. Replanting damaged areas can represent a viable restoration strategy, yet current methods rely on the removal of plants from existing meadows and in some cases the use of non-sustainable planting materials. In this paper, we present evidence of a sustainable replanting strategy. Storm fragments of the endemic Mediterranean seagrass, neptune grass Posidonia oceanica were collected from the shore and shallow water, both the plagiotropic and orthotropic (horizontal and vertical) growth forms were then replanted using one of two biodegradable materials, coconut fibre pots or bamboo stakes, to secure them to the seafloor. Establishment of plagiotropic fragments were increased by bamboo anchorage (x̅ = 89% SE ± 0%) compared to orthotropic storm fragments (x̅ = 66.5% SE ± 6.5%). By contrast a coconut fibre method resulted in greater establishment of orthotropic fragments (x̅ = 79% SE ± 7%) compared to plagiotropic (x̅ = 51% SE ± 11%). Fragments showed some blade growth, but little shoot growth after 15 months. The fragment shoot and blade growth did not differ between the plagiotropic or orthotropic fragments replanted by bamboo stakes or coconut fibre pot. Our results suggest that the use of storm fragments and biodegradable anchoring materials constitutes a viable, non-destructive replanting technique in seagrass restoration. Furthermore success can be increased by selecting a growth-form appropriate planting method

MOST photometry of the RRd Lyrae variable AQ Leo: Two radial modes, 32 combination frequencies, and beyond

Highly precise and nearly uninterrupted optical photometry of the RR Lyrae star AQ Leo was obtained with the MOST (Microvariability & Oscillations of STars) satellite over 34.4 days in February-March 2005. AQ Leo was the first known double-mode RR Lyrae pulsator (RRd star). Three decades after its discovery, MOST observations have revealed that AQ Leo oscillates with at least 42 frequencies, of which 32 are linear combinations (up to the sixth order) of the radial fundamental mode and its first overtone. Evidence for period changes of these modes is found in the data. The other intrinsic frequencies may represent an additional nonradial pulsation mode and its harmonics (plus linear combinations) which warrant theoretical modeling. The unprecedented number of frequencies detected with amplitudes down to millimag precision also presents an opportunity to test nonlinear theories of mode growth and saturation in RR Lyrae pulsators.Comment: accepted for publication in MNRAS; revision v2 : broken references have been fixe

Sustained improvement in vancomycin dosing and monitoring post-implementation of guidelines: Results of a three-year follow-up after a multifaceted intervention in an Australian teaching hospital

Copyright © 2017 Japanese Society of Chemotherapy and The Japanese Association for Infectious Diseases. Published by Elsevier Ltd. All rights reserved. This manuscript version is made available under the CC-BY-NC-ND 4.0 license http://creativecommons.org/licenses/by-nc-nd/4.0/Introduction Despite vancomycin being in use for over half-a-century, it is still not dosed or monitored appropriately in many centers around the world. The objective of this study was to determine the effectiveness of a multifaceted intervention to implement a vancomycin dosing and monitoring guideline across multiple medical and surgical units over time. Methods This was an observational before-and-after interventional cohort study. The pre-intervention period was August to December 2010–2011 and the post-intervention period was September to November 2012–2014. The implementation strategy comprised: face-to-face education, online continuing medical education, dissemination of pocket guideline and email reminder. Outcome measures included: appropriate prescribing of loading and maintenance doses, therapeutic drug monitoring, time to attain target range and nephrotoxicity. Results Post-implementation prescribing of loading doses increased (10.4%–43.6%, P=<0.001), guideline adherent first maintenance dose (44%–68.4% P = 0.04), correct dose adjustment from (53.1%–72.2%, P = 0.009). Beneficial effects pre and post-implementation were observed for adherent timing of initial concentration (43.2%–51.9%, P = 0.01), concentrations in target range (32.6%–44.1%, P = 0.001), time to target range (median 6–4 days, P=<0.001), potentially nephrotoxic concentrations (30.7%–20.9%, P=<0.001) and nephrotoxicity (10.4%–6.8%, P=<0.001). Conclusions A multifaceted intervention to implement a vancomycin dosing and monitoring guideline significantly improved prescribing, monitoring, pharmacokinetic and safety outcomes for patients treated with vancomycin over an extended period. However, increased guideline adoption by clinicians is required to maximize and prolong the utility of this important agent

Interventions Targeting the Prescribing and Monitoring of Vancomycin for Hospitalized Patients: A Systematic Review Protocol

This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/), which permits any noncommercial use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.Introduction Vancomycin remains one of our essential antibiotics after fifty years of treating serious infections such as methicillin-resistant Staphylococcus aureus. Vancomycin, unlike many other antibiotic agents, requires individualized dosing and monitoring of serum drug levels to ensure it is efficacious, to minimize toxicity, and to limit the development of antibiotic resistance. These issues have led to numerous vancomycin clinical practice guidelines being published in recent years including several key national guidelines. Significant resources are invested during the development of such guidelines; however, there is often little or no information about how such guidelines or other vancomycin practice improvement initiatives should be implemented. The aim of this systematic review is to identify and evaluate the effect of interventions using education, guideline implementation, and dissemination of educational resources that have sought to improve therapeutic drug monitoring and dosing of vancomycin. Methods A systematic review of the literature will be conducted for RCTs and observational studies where a vancomycin guideline or practice improvement initiative has been implemented. Electronic databases to be searched are PubMed, Medline, CINAHL, EMBASE and the Cochrane Library of Systematic Reviews. The population will be patients who have had intravenous vancomycin prescribed and monitored in hospital. The interventions will be education, implementation of guidelines or protocols, dissemination of educational materials (printed or electronic) or multifaceted interventions of the above. The comparator will be patients who have had standard-care prescribing and monitoring of vancomycin. Outcomes will be changes in prescribing and ordering of vancomycin serum tests, and serum levels attained in patients as well as reported nephrotoxicity. Two reviewers will be involved in the quality assessment and extraction of data. The Scottish Intercollegiate Guidelines Network checklist for RCTs will be used. Studies that are not randomized will be assessed for quality using the validated ROBINS-I (risk of bias in non-randomized studies of interventions) tool. Discussion This systematic review will identify interventions that have been used to implement guidelines and clinical practice initiatives for vancomycin. The findings of this review may be informative to those involved with the implementation of vancomycin clinical practice guidelines. Systematic review registration: PROSPERO: CRD42016049147

Interventions targeting the prescribing and monitoring of vancomycin for hospitalized patients: a systematic review with meta-analysis

Copyright © 2018 Phillips et al. This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution - Non Commercial (unported, v3.0) License. By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed.Purpose: Vancomycin prescribing requires individualized dosing and monitoring to ensure efficacy, limit toxicity, and minimize resistance. Although there are nationally endorsed guidelines from several countries addressing the complexities of vancomycin dosing and monitoring, there is limited consideration of how to implement these recommendations effectively. Methods: We conducted a systematic search of multiple databases to identify relevant comparative studies describing the impact of interventions of educational meetings, implementation of guidelines, and dissemination of educational material on vancomycin dosing, monitoring, and nephrotoxicity. Effect size was assessed using ORs and pooled data analyzed using forest plots to provide overall effect measures. Results: Six studies were included. All studies included educational meetings. Two studies used implementation of guidance, educational meetings, and dissemination of educational materials, one used guidance and educational meetings, one educational meetings and dissemination of educational materials, and two used educational meetings solely. Effect sizes for individual studies were more likely to be significant for multifaceted interventions. In meta-analysis, the overall effect of interventions on outcome measures of vancomycin dosing was OR 2.50 (95% CI 1.29–4.84); P< 0.01. A higher proportion of sampling at steady-state concentration was seen following intervention (OR 1.95, 95% CI 1.26–3.02; P<0.01). Interventions had no effect on appropriate timing of trough sample (OR 2.02, 95% CI 0.72–5.72; P=0.18), attaining target concentration in patients (OR 1.50, 95% CI 0.49–4.63; P=0.48, or nephrotoxicity (OR 0.75, 95% CI 0.42–1.34; P=0.33). Conclusion: Multifaceted interventions are effective overall in improving the complex task of dosing vancomycin, as well as some vancomycin-monitoring outcome measures. However, the resulting impact of these interventions on efficacy and toxicity requires further investigation. These findings may be helpful to those charged with designing implementation strategies for vancomycin guidelines or complex prescribing processes in hospitals

Spectroscopy, MOST Photometry, and Interferometry of MWC 314: Is it an LBV or an interacting binary?

MWC 314 is a bright candidate luminous blue variable that resides in a fairly close binary system, with an orbital period of 60.753$\pm$0.003 d. We observed MWC 314 with a combination of optical spectroscopy, broad-band ground- and space-based photometry, as well as with long baseline, near-infrared interferometry. We have revised the single-lined spectroscopic orbit and explored the photometric variability. The orbital light curve displays two minima each orbit that can be partially explained in terms of the tidal distortion of the primary that occurs around the time of periastron. The emission lines in the system are often double-peaked and stationary in their kinematics, indicative of a circumbinary disc. We find that the stellar wind or circumbinary disc is partially resolved in the K\prime-band with the longest baselines of the CHARA Array. From this analysis, we provide a simple, qualitative model in an attempt to explain the observations. From the assumption of Roche Lobe overflow and tidal synchronisation at periastron, we estimate the component masses to be M1 $\approx 5$ M$_\odot$ and M2$\approx 15$ M$_\odot$, which indicates a mass of the LBV that is extremely low. In addition to the orbital modulation, we discovered two pulsational modes with the MOST satellite. These modes are easily supported by a low-mass hydrogen-poor star, but cannot be easily supported by a star with the parameters of an LBV. The combination of these results provides evidence that the primary star was likely never a normal LBV, but rather is the product of binary interactions. As such, this system presents opportunities for studying mass-transfer and binary evolution with many observational techniques.Comment: 26 pages, 7 figures, 5 tables, 2 appendices with 7 additional tables and 2 additional figures. Accepted for publication in MNRA

Shakeout in the Early Commercial Airframe Industry

The commercial airframe industry in the US experienced a shakeout from the early 1930s into the post‐Second World War period. Unlike shakeouts in automobiles, tyres, or televisions, the commercial airframe industry\u27s early life cycle was affected by external factors, particularly government demand. Using newly digitized data on all planes introduced in the commercial market between 1926 and 1965, we find that commercial airframe manufacturers with bomber contracts during the Second World War were more likely to have postwar market share than firms without such contracts, controlling for plane characteristics and other forms of government contracting. We attribute the effect of bomber contracts to advantages in R&D learning capacity acquired by firms with military airframe contracts. Despite low (or zero) initial presence in the commercial market, these learning capacity advantages allowed such firms to survive the early period of the shakeout, and later to thrive