Reducing Warfarin ADR’s with a Nurse Led Anticoagulation Clinic: A New Model of Patient Care

Introduction: Warfarin was the leading cause of drug related adverse events at South Miami Hospital, which resulted in 27 hospital admissions in a year. A retrospective chart review revealed that patients were being discharged without a clear plan for follow up and management. Having optimal outcomes as a result of Warfarin therapy depends on maintaining the INR (International Normalized Ratio) in its range. In order to do so, high-quality anticoagulation management (HQACM) is required. Methods: In response to the increased in Warfarin toxicity hospital admissions and community physician’s concern regarding anticoagulation safety, an interdisciplinary team was formed to address the problem. A nurse led clinic was created to provide an outpatient setting staffed with nurse experts to whom physicians can refer their anticoagulation patients for safe, evidence-based clinical warfarin management. Patients are carefully monitored and data regarding ADRs are analyzed and reported to the SMH Pharmacy and Therapeutics committee. Results: Today Warfarin drug related adverse events admissions have decreased significantly to less than 10 admissions per year and this number has been sustained. It is evident that the anticoagulation clinic is a remarkable resource for education, monitoring, and Warfarin management. Discussion: The clinic uses evidence-based guidelines to make dosing adjustments and follow up intervals. This model has been effective of reducing Warfarin toxicity admissions by 74% since its opening. Patients continue to appreciate the timeliness and convenience of their Warfarin management

Implementing a Transcultural Nursing Care Model to Improve Pulmonary Hypertension Medication Compliance

Purpose: The goal of the performance improvement (PI) project was to decrease discontinuation rates of riociguat therapy by using a transcultural nursing model as opposed to a single nurse coordinator model. Background: Pulmonary hypertension (PH) medications have been proven to be effective in improving outcomes for patients suffering from PH. These medications have significant and expected side effects with complex titration regimens which can be confusing to patients which led to poor compliance and high rates of discontinuation. Patients’ race and ethnicity have been associated to poor medication compliance due to varying cultural expectations, language barriers, and socioeconomic status. Evidence also shows that minority groups are less likely to take medications for PH demonstrating the need to eliminate this disparity. Methods: A PI project was initiated to address high discontinuation rates in PH medications, specifically riociguat therapy. It was proposed that due to our highly culturally diverse patient population that we incorporate a transcultural nursing model to improve compliance and drug therapy continuation. The nursing model that was being used prior to the PI project was a single nurse coordinator model. In this model, the PH coordinator was responsible for educating patients on the therapies as well as assessing patients during their initial and follow up visits. The coordinator was primarily an English-speaking nurse that would use interpretation services during PH appointments in the outpatient clinic. Beginning in November of 2016, the clinic implemented the transcultural nursing model where nursing assignments paired according to patients’ language and cultural background in order to facilitate transcultural communication. Results: After implementing the transcultural nursing model, the continuation rate for riociguat went from 55% to 79%. The model was very effective in improving patient compliance and drastically reducing the discontinuation rate of riociguat. The patients were able to converse with their nurse coordinating their care without the need for translation services which greatly improved the understanding of the plan of care. Conclusion: The implementation of a transcultural nursing model is an effective way of increasing the continuation rates of PH medications in a culturally diverse practice setting helping to reduce disparities

Breathing Easier When a Lung-Health Outpatient Team Has Your Back

Purpose: The goal of this program is to improve the quality of life in COPD patients. An outpatient resource center provides post-discharge follow-up in order to facilitate continuum of care. Background: Frequent readmissions are common in the COPD patient population and have become a focus of the CMS value based measures. Research has shown a 7.1% 30-day readmission rate for a principal diagnosis of COPD and a 20.5% for all-cause 30-day readmission. Patients often do not have a resource which guides them through the continuum of care from inpatient to home. Knowledge deficits regarding medication administration and regimen can lead to poor-compliance and therefore worse outcomes. Understanding the disease process and progression is key if patients are to receive the maximum benefit from their medications. Many of these patients suffer from more than one chronic medical condition which leads to complicated medication regimens. The GOLD recommendation for post hospital discharge to lessen exacerbation-related readmissions is an early follow-up process. However, upon discharge, many of these patients are not back to their baseline and often are unclear about their treatment regimen. According to the Institute for Safe Medication Practices (ISMP), 94% of patients with COPD and asthma use their inhalers incorrectly which can lead to a reduction of efficacy and poor outcomes. Intensive outpatient monitoring, evaluation, and education are needed to prevent readmissions. COPD patients often do not have a resource center that follows up within 1 week of discharge to evaluate their condition, provide intervention, and guide them through the continuum of care from inpatient to outpatient status. Methods: A Lung Health Outpatient Resource Center was assembled using the resources of a multidisciplinary team. The team facilitates to progress patients through the continuum of care with the goal of improving the quality of life and decrease readmissions. Prevention strategies are initiated after an exacerbation; both pharmacologic and non-pharmacologic interventions are used to complement the individual’s treatment goals. The multi-disciplinary team was headed by the Respiratory Department and included: a nurse practitioner (ARNP), respiratory therapist (RT), registered nurse (RN), social work (SW), physicians, and pharmacy. Prior to a COPD patient discharge, an appointment is scheduled at the Lung Health Outpatient Resource Center. During the appointment, the ARNP, RT, and RN evaluate the patient and provides treatment as needed. Education about the COPD disease process and self-management are provided by the multidisciplinary team. The team helps identify and reduce exposure to internal and external risk factors. If further interventions are indicated, the patient’s pulmonologist is contacted for further treatment options. Results: The program started in June of 2017 and data was collected until February of 2018, (9 months). A total of 56 patients were seen in the outpatient clinic and out of the 56, 5 were readmitted for all cause diagnosis and zero cases were admitted for COPD exacerbation. Conclusion: A multidisciplinary Lung Health Outpatient Resource Center made a significant impact in the reduction of COPD readmission rates

Navigating a Difficult Transition in Pulmonary Arterial Hypertension: A Clinical Case Study

Over the past 20 years, Pulmonary Arterial Hypertension (PAH) patients and providers have seen an increase in options to treat PAH. Currently, there are choices for the delivery of medications approved to treat patients with PAH where at one point the only option was intravenous (IV) therapy. This case study details the transition from IV Epoprostenol to oral Treprostinil for the treatment of a 53 year old female diagnosed with severe Pulmonary Arterial Hypertension whose quality of life became unbearable by the IV medication delivery route. This patient was a synchronized swimmer in her youth and her passion for water activities continued throughout her short life. After her diagnosis of severe PAH, her life abruptly changed as she was placed on triple therapy, which consisted of an endothelin receptor antagonist (ERA), a phosphodiesterase-5 inhibitor (pde-5), and the IV epoprostenol. The patient experienced severe side effects that negatively impacted her ability to resume her activities of daily life and swimming. Although she remained hemodynamically stable on IV therapy, her poor quality of life and severe depression convinced her cardiologist that transitioning to an oral treprostinil would be the only option for her survival. At the time, there was a lack of clinical trials or guidelines to support the transition from IV to oral prostacyclins to follow, so an interdisciplinary team approach needed to be taken to ensure that the safety and efficacy of the transition would be maintained

A MTA2-SATB2 chromatin complex restrains colonic plasticity toward small intestine by retaining HNF4A at colonic chromatin.

Plasticity among cell lineages is a fundamental, but poorly understood, property of regenerative tissues. In the gut tube, the small intestine absorbs nutrients, whereas the colon absorbs electrolytes. In a striking display of inherent plasticity, adult colonic mucosa lacking the chromatin factor SATB2 is converted to small intestine. Using proteomics and CRISPR-Cas9 screening, we identify MTA2 as a crucial component of the molecular machinery that, together with SATB2, restrains colonic plasticity. MTA2 loss in the adult mouse colon activated lipid absorptive genes and functional lipid uptake. Mechanistically, MTA2 co-occupies DNA with HNF4A, an activating pan-intestinal transcription factor (TF), on colonic chromatin. MTA2 loss leads to HNF4A release from colonic chromatin, and accumulation on small intestinal chromatin. SATB2 similarly restrains colonic plasticity through an HNF4A-dependent mechanism. Our study provides a generalizable model of lineage plasticity in which broadly-expressed TFs are retained on tissue-specific enhancers to maintain cell identity and prevent activation of alternative lineages, and their release unleashes plasticity

Transcription factor induction of vascular blood stem cell niches in vivo

The hematopoietic niche is a supportive microenvironment composed of distinct cell types, including specialized vascular endothelial cells that directly interact with hematopoietic stem and progenitor cells (HSPCs). The molecular factors that specify niche endothelial cells and orchestrate HSPC homeostasis remain largely unknown. Using multi-dimensional gene expression and chromatin accessibility analyses in zebrafish, we define a conserved gene expression signature and cis-regulatory landscape that are unique to sinusoidal endothelial cells in the HSPC niche. Using enhancer mutagenesis and transcription factor overexpression, we elucidate a transcriptional code that involves members of the Ets, Sox, and nuclear hormone receptor families and is sufficient to induce ectopic niche endothelial cells that associate with mesenchymal stromal cells and support the recruitment, maintenance, and division of HSPCs in vivo. These studies set forth an approach for generating synthetic HSPC niches, in vitro or in vivo, and for effective therapies to modulate the endogenous niche

Isolated effects of caffeine and sodium bicarbonate ingestion on performance in the Yo-Yo test: A systematic review and meta-analysis

To conduct a systematic review and a meta-analysis of studies exploring the effects of caffeine and/or sodium bicarbonate on performance in the Yo-Yo test. Systematic review and meta-analysis. A total of six databases were searched, and random-effects meta-analyses were performed examining the isolated effects of caffeine and sodium bicarbonate on performance in the Yo-Yo test. After reviewing 988 search records, 15 studies were included. For the effects of caffeine on performance in the Yo-Yo test, the meta-analysis indicated a significant favoring of caffeine as compared with the placebo conditions (p=0.022; standardized mean difference [SMD]=0.17; 95% CI: 0.08, 0.32; +7.5%). Subgroup analyses indicated that the effects of caffeine were significant for the level 2 version of the Yo-Yo test, but not level 1. Four out of the five studies that explored the effects of sodium bicarbonate used the level 2 version of the Yo-Yo test. The pooled SMD favored the sodium bicarbonate condition as compared with the placebo/control conditions (p=0.007; SMD: 0.36; 95% CI: 0.10, 0.63; +16.0%). This review demonstrates that isolated ingestion of caffeine and sodium bicarbonate enhances performance in the Yo-Yo test. Given these ergogenic effects, the intake of caffeine and sodium bicarbonate before the Yo-Yo test needs to be standardized (i.e., either restricted or used in the same way before each testing session). Furthermore, the results suggest that individuals competing in sports involving intermittent exercise may consider supplementing with caffeine or sodium bicarbonate for acute improvements in performance. [Abstract copyright: Copyright © 2019 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.