Characteristics and Predictors of Patient Care Performed by Clinical Department Chairpersons at U.S. Schools of Pharmacy

Background Clinical pharmacy or pharmacy practice departments at schools of pharmacy are usually composed of practicing pharmacy specialists. There is little known about the requirements for and frequency of patient care provided by clinical department chairpersons. The primary objective of this study was to determine the likelihood that pharmacy practice chairs engage in patient care. A secondary objective was to identify those factors predicting chairperson participation in patient care activities. Methods A brief 22-item adaptive response survey was sent to clinical department chairpersons at schools of pharmacy in the United States. Initial identification of chairs came from the American Association of Colleges of Pharmacy (AACP) with verification by school websites. Surveys from schools without a clinical chairperson (or similar position) were excluded, as were surveys from schools with Ph.D. department chairpersons from blended departments (ie, Clinical with Outcomes/Policy Sciences). Results Of the 128 eligible schools\u27 department chairpersons, 113 completed the surveys (88.3% response rate). Forty-four (38.9%) chairs reported that they maintain an active clinical practice even though 103 (91.1%) report it is not required. Factors that had a significant association with clinical practice were clinical service being an expectation (P = .0004), having a practice prior to becoming chairperson (P = .001), having a higher clinical service expectation (P \u3c .0001), and having a lower administrative percentage (P = .0003). Age, rank, and academic track were not significant predictors. Of those with clinical practice, sites included community (45.4%), acute care (38.6%), primary care (4.5%), and other settings (11.4%). A majority of those with practice reported providing direct patient care (81.8%) or indirectly via supervision of students or other trainees (61.4%). Conclusions Most schools of pharmacy do not require clinical department chairpersons to maintain a patient care practice, but many still choose to practice. Those that practiced before becoming a chairperson and have a lower administrative burden are more likely to continue to provide patient care

Evaluating the Medication Regimen Complexity Score as a Predictor of Clinical Outcomes in the Critically Ill

Background: Medication Regimen Complexity (MRC) refers to the combination of medication classes, dosages, and frequencies. The objective of this study was to examine the relationship between the scores of different MRC tools and the clinical outcomes. Methods: We conducted a retrospective cohort study at Roger William Medical Center, Providence, Rhode Island, which included 317 adult patients admitted to the intensive care unit (ICU) between 1 February 2020 and 30 August 2020. MRC was assessed using the MRC Index (MRCI) and MRC for the Intensive Care Unit (MRC-ICU). A multivariable logistic regression model was used to identify associations among MRC scores, clinical outcomes, and a logistic classifier to predict clinical outcomes. Results: Higher MRC scores were associated with increased mortality, a longer ICU length of stay (LOS), and the need for mechanical ventilation (MV). MRC-ICU scores at 24 h were significantly (p \u3c 0.001) associated with increased ICU mortality, LOS, and MV, with ORs of 1.12 (95% CI: 1.06–1.19), 1.17 (1.1–1.24), and 1.21 (1.14–1.29), respectively. Mortality prediction was similar using both scoring tools (AUC: 0.88 [0.75–0.97] vs. 0.88 [0.76–0.97]. The model with 15 medication classes outperformed others in predicting the ICU LOS and the need for MV with AUCs of 0.82 (0.71–0.93) and 0.87 (0.77–0.96), respectively. Conclusion: Our results demonstrated that both MRC scores were associated with poorer clinical outcomes. The incorporation of MRC scores in real-time therapeutic decision making can aid clinicians to prescribe safer alternatives

Implementation of screening, brief intervention, and referral to treatment (SBIRT) in the emergency department without additional resources

Patients who misuse substances present in inordinate numbers for emergency department (ED) services. Therefore, EDs are an important environment for identifying, intervening and connecting patients with treatment and recovery support to improve patient health and reduce healthcare utilization. EDs have largely depended on external funding or additional personnel to execute SBIRT. Our aim was to integrate SBIRT into the ED workflow and coordinate transfer to treatment and community support programs without added monetary/staff resources. Beginning in 2010, we worked cooperatively with a local ED to integrate SBIRT into the normal ED workflow. This program of screening, brief interventions and warm-handoff referral is dubbed “Safe Landing.” Efforts have focused on: training staff; embedding SBIRT tools into existing data systems; nurturing relationships with community treatment and recovery providers; developing protocols for a “warm-handoff” that would ensure patients who, in the context of a health crisis, express an immediate interest in following a road to recovery; and securing reimbursement for services. Over one-and-a-half years since implementation, 45,770 patients have been screened, with 7,996 assessed, 2,058 receiving a brief intervention, and 137 referred to treatment or recovery support. Multiple staff trainings have resulted in a palpable culture shift to patient advocacy and increasing compliance with SBIRT protocols. Screening and BI tracking tools embedded in the ED data systems continue to be enhanced. ED reimbursement for SBIRT began 10/2012, and cooperative relationships with treatment and recovery providers have diversified. We will discuss the implementation strategies employed to overcome challenges in operationalizing SBIRT in the ED. Challenges to be discussed include changes in key personnel, embedding SBIRT into the labyrinth of data systems, initial staff scepticism and evolving area treatment and recovery services organizations. Regardless, Safe Landing perseveres, and commitment by the local ED is stronger than ever

Impact of a Multimodal Antimicrobial Stewardship Program on Pseudomonas aeruginosa Susceptibility and Antimicrobial Use in the Intensive Care Unit Setting

Objective. To study the impact of our multimodal antibiotic stewardship program on Pseudomonas aeruginosa susceptibility and antibiotic use in the intensive care unit (ICU) setting. Methods. Our stewardship program employed the key tenants of published antimicrobial stewardship guidelines. These included prospective audits with intervention and feedback, formulary restriction with preauthorization, educational conferences, guidelines for use, antimicrobial cycling, and de-escalation of therapy. ICU antibiotic use was measured and expressed as defined daily doses (DDD) per 1,000 patient-days. Results. Certain temporal relationships between antibiotic use and ICU resistance patterns appeared to be affected by our antibiotic stewardship program. In particular, the ICU use of intravenous ciprofloxacin and ceftazidime declined from 148 and 62.5 DDD/1,000 patient-days to 40.0 and 24.5, respectively, during 2004 to 2007. An increase in the use of these agents and resistance to these agents was witnessed during 2008–2010. Despite variability in antibiotic usage from the stewardship efforts, we were overall unable to show statistical relationships with P. aeruginosa resistance rate. Conclusion. Antibiotic resistance in the ICU setting is complex. Multimodal stewardship efforts attempt to prevent resistance, but such programs clearly have their limits

Clinical Practice Guidelines for Antimicrobial Prophylaxis in Surgery

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/140217/1/sur.2013.9999.pd

Risk-shifting Through Issuer Liability and Corporate Monitoring

This article explores how issuer liability re-allocates fraud risk and how risk allocation may reduce the incidence of fraud. In the US, the apparent absence of individual liability of officeholders and insufficient monitoring by insurers under-mine the potential deterrent effect of securities litigation. The underlying reasons why both mechanisms remain ineffective are collective action problems under the prevailing dispersed ownership structure, which eliminates the incentives to moni-tor set by issuer liability. This article suggests that issuer liability could potentially have a stronger deterrent effect when it shifts risk to individuals or entities holding a larger financial stake. Thus, it would enlist large shareholders in monitoring in much of Europe. The same risk-shifting effect also has implications for the debate about the relationship between securities litigation and creditor interests. Credi-tors’ claims should not be given precedence over claims of defrauded investors (e.g., because of the capital maintenance principle), since bearing some of the fraud risk will more strongly incentivise large creditors, such as banks, to monitor the firm in jurisdictions where corporate debt is relatively concentrated

Engineering adeno-associated viral vectors to evade innate immune and inflammatory responses

Nucleic acids are used in many therapeutic modalities, including gene therapy, but their ability to trigger host immune responses in vivo can lead to decreased safety and efficacy. In the case of adeno-associated viral (AAV) vectors, studies have shown that the genome of the vector activates Toll-like receptor 9 (TLR9), a pattern recognition receptor that senses foreign DNA. Here, we engineered AAV vectors to be intrinsically less immunogenic by incorporating short DNA oligonucleotides that antagonize TLR9 activation directly into the vector genome. The engineered vectors elicited markedly reduced innate immune and T cell responses and enhanced gene expression in clinically relevant mouse and pig models across different tissues, including liver, muscle, and retina. Subretinal administration of higher-dose AAV in pigs resulted in photoreceptor pathology with microglia and T cell infiltration. These adverse findings were avoided in the contralateral eyes of the same animals that were injected with the engineered vectors. However, intravitreal injection of higher-dose AAV in macaques, a more immunogenic route of administration, showed that the engineered vector delayed but did not prevent clinical uveitis, suggesting that other immune factors in addition to TLR9 may contribute to intraocular inflammation in this model. Our results demonstrate that linking specific immunomodulatory noncoding sequences to much longer therapeutic nucleic acids can “cloak” the vector from inducing unwanted immune responses in multiple, but not all, models. This “coupled immunomodulation” strategy may widen the therapeutic window for AAV therapies as well as other DNA-based gene transfer methods

Impact of the Herbal Medicine Sophora flavescens on the Oral Pharmacokinetics of Indinavir in Rats: The Involvement of CYP3A and P-Glycoprotein

Sophora flavescens is a Chinese medicinal herb used for the treatment of gastrointestinal hemorrhage, skin diseases, pyretic stranguria and viral hepatitis. In this study the herb-drug interactions between S. flavescens and indinavir, a protease inhibitor for HIV treatment, were evaluated in rats. Concomitant oral administration of Sophora extract (0.158 g/kg or 0.63 g/kg, p.o.) and indinavir (40 mg/kg, p.o.) in rats twice a day for 7 days resulted in a dose-dependent decrease of plasma indinavir concentrations, with 55%–83% decrease in AUC0-∞ and 38%–78% reduction in Cmax. The CL (Clearance)/F (fraction of dose available in the systemic circulation) increased up to 7.4-fold in Sophora-treated rats. Oxymatrine treatment (45 mg/kg, p.o.) also decreased indinavir concentrations, while the ethyl acetate fraction of Sophora extract had no effect. Urinary indinavir (24-h) was reduced, while the fraction of indinavir in faeces was increased after Sophora treatment. Compared to the controls, multiple dosing of Sophora extract elevated both mRNA and protein levels of P-gp in the small intestine and liver. In addition, Sophora treatment increased intestinal and hepatic mRNA expression of CYP3A1, but had less effect on CYP3A2 expression. Although protein levels of CYP3A1 and CYP3A2 were not altered by Sophora treatment, hepatic CYP3A activity increased in the Sophora-treated rats. All available data demonstrated that Sophora flavescens reduced plasma indinavir concentration after multiple concomitant doses, possibly through hepatic CYP3A activity and induction of intestinal and hepatic P-gp. The animal study would be useful for predicting potential interactions between natural products and oral pharmaceutics and understanding the mechanisms prior to human studies. Results in the current study suggest that patients using indinavir might be cautioned in the use of S. flavescens extract or Sophora-derived products

Reconciling conflicting clinical studies of antioxidant supplementation as HIV therapy: a mathematical approach

<p>Abstract</p> <p>Background</p> <p>Small, highly reactive molecules called reactive oxygen species (ROS) play a crucial role in cell signalling and infection control. However, high levels of ROS can cause significant damage to cell structure and function. Studies have shown that infection with the human immunodeficiency virus (HIV) results in increased ROS concentrations, which can in turn lead to faster progression of HIV infection, and cause CD4⁺T-cell apoptosis. To counteract these effects, clinical studies have explored the possibility of raising antioxidant levels, with mixed results.</p> <p>Methods</p> <p>In this paper, a mathematical model is used to explore this potential therapy, both analytically and numerically. For the numerical work, we use clinical data from both HIV-negative and HIV-positive injection drug users (IDUs) to estimate model parameters; these groups have lower baseline concentrations of antioxidants than non-IDU controls.</p> <p>Results</p> <p>Our model suggests that increases in CD4⁺T cell concentrations can result from moderate levels of daily antioxidant supplementation, while excessive supplementation has the potential to cause periods of immunosuppression.</p> <p>Conclusion</p> <p>We discuss implications for HIV therapy in IDUs and other populations which may have low baseline concentrations of antioxidants.</p