Peer Support Specialist Incorporation into Collaborative Patient Centered Care

Peer support specialists (PSS) can deliver recovery care to those suffering with mental health and substance abuse issues; specifically, recuperative care is the fundamental principle in good practice for individuals with mental disease or substance abuse disorders. The goal of this quality improvement project was to improve the referral process to the in-house PSS at one Midwestern Veteran’s Administration Medical Center. Data from May and June 2021 was collected to determine the number of referrals prior to project implementation. The pre-implementation data showed twenty-four referrals from May and June 2021. Implementation occurred during the months of July and August 2021. Data was collected in the two-month period and although there was not an increase in the referrals as the project anticipated, the data did not show a large decrease in referrals either. Referrals were tracked from the initial consult by the provider and whether the patient made the follow up with the PSS. This may be due to multiple variables such the decreased patient visits during the intervention period, poor communication between primary care providers and the mental health team, as well as an influx of new providers to the clinic that did not receive pre-implementation education on the new process. Clinic staff, providers, and PSS provided feedback on the referral process and suggested continuing education to both new providers and LPNs that started in the clinic after implementation

Impact of obesity on acyclovir-induced nephrotoxicity

© 2018 by the authors. Licensee MDPI, Basel, Switzerland. Triamcinolone acetonide (TA), an intermediate acting corticosteroid, is used in the treatment of posterior ocular diseases, such as inflammation, posterior uveitis, and diabetic macular edema. The objective of this investigation was to prepare TA-loaded solid lipid nanoparticles (TA-SLNs) and in situ gel (TA-SLN-IG) formulations for delivery into the deeper ocular tissues through the topical route. TA-SLNs were prepared by hot homogenization and ultrasonication method using glyceryl monostearate and Compritol® 888ATO as solid lipids and Tween®80 and Pluronic® F-68 as surfactants. TA-SLNs were optimized and converted to TA-SLN-IG by the inclusion of gellan gum and evaluated for their rheological properties.In vitro transcorneal permeability and in vivo ocular distribution of the TA-SLNs and TA-SLN-IG were studied using isolated rabbit corneas and New Zealand albino rabbits, respectively, and compared with TA suspension, used as control (TA-C). Particle size, PDI, zeta potential, assay, and entrapment efficiency of TA-SLNs were in the range of 200–350 nm, 0.3–0.45, −52.31 to −64.35 mV, 70–98%, and 97–99%, respectively. TA-SLN-IG with 0.3% gellan gum exhibited better rheological properties. The transcorneal permeability of TA-SLN and TA-SLN-IG was 10.2 and 9.3-folds higher compared to TA-C. TA-SLN-IG showed maximum tear concentration at 2 h, indicating an improved pre-corneal residence time, as well as higher concentrations in aqueous humor, vitreous humor and cornea at 6 h, suggesting sustained delivery of the drug into the anterior and posterior segment ocular tissues, when compared to TA-SLN and TA-C. The results, therefore, demonstrate that the lipid based nanoparticulate system combined with the in situ gelling agents can be a promising drug delivery platform for the deeper ocular tissues

Which pharmacists are performing antimicrobial stewardship: A national survey and a call for collaborative efforts

Abstract Objectives: To determine how pharmacists with formal antimicrobial stewardship program (ASP) responsibilities prioritize their time and pharmacists without formal antimicrobial stewardship program responsibilities contribute to ASP activities. Design: A nationwide survey. Respondents: Members of the American College of Clinical Pharmacy who subscribe to the following practice and research network e-mail listservs: infectious diseases, adult medicine, cardiology, critical care, hematology-oncology, immunology and transplantation, and pediatrics. Methods: A survey was distributed via listservs. Respondents were asked about their personal and institutional demographics and ASP activities. Results: In total, 245 pharmacists responded: 135 pharmacists with formal antimicrobial stewardship program responsibilities; 110 pharmacists without formal antimicrobial stewardship program responsibilities. Although most respondents had completed a general pharmacy residency (85%), only 20% had completed an infectious diseases (ID) specialty residency. Among pharmacists with formal antimicrobial stewardship program responsibilities, one-third had no formal training or certification in ID or ASP. Pharmacists without formal antimicrobial stewardship program responsibilities spent ∼12.5% of their time per week on ASP activities, whereas pharmacists with formal antimicrobial stewardship program responsibilities spent 28% of their time performing non-ASP activities. Pharmacists with formal antimicrobial stewardship program responsibilities were more likely than pharmacists without formal antimicrobial stewardship program responsibilities to perform antibiotic guideline development (P \u3c.001), antibiotic-related education (P =.002), and direct notification of rapid diagnostic results (P =.018). Pharmacists with formal antimicrobial stewardship program responsibilities without formal ID training or certification spent less time on ASP activities and were more likely to perform lower-level interventions. Conclusions: Many ASP activities are being performed by pharmacists without formal ID training. To ensure the future success of ASPs, pharmacists with formal antimicrobial stewardship program responsibilities should have adequate training to meet more advanced metrics, and more pharmacists without formal antimicrobial stewardship program responsibilities should be included in basic interventions

Fluoroquinolone versus nonfluoroquinolone treatment of bloodstream infections caused by chromosomally mediated ampc‐producing enterobacteriaceae

Objectives: Chromosomally mediated AmpC-producing Enterobacteriaceae (CAE) display high susceptibility to fluoroquinolones; minimal clinical data exist supporting comparative clinical outcomes. The objective of this study was to compare treatment outcomes between fluoroquinolone and nonfluoroquinolone definitive therapy of bloodstream infections caused by CAE. Methods: This retrospective cohort assessed adult patients with positive blood cultures for CAE that received inpatient treatment for 48 hours. The primary outcome was difference in clinical failure between patients who received fluoroquinolone (FQ) versus non‐FQ treatment. Secondary endpoints included microbiological cure, infection‐related length of stay, 90‐day readmission, and all‐cause inpatient mortality. Results: 56 patients were included in the study (31 (55%) received a FQ as definitive therapy; 25 (45%) received non‐FQ). All non‐FQ patients received a beta‐lactam (BL). Clinical failure occurred in 10 (18%) patients, with 4 (13%) in the FQ group and 6 (24%) in the BL group (p = 0.315). Microbiological cure occurred in 55 (98%) patients. Median infection‐related length of stay was 10 (6–20) days, with a significantly longer stay occurring in the BL group (p = 0.002). There was no statistical difference in 90‐day readmissions between groups (7% FQ vs. 17% BL; p = 0.387); one patient expired. Conclusion: These results suggest that fluoroquinolones do not adversely impact clinical outcomes in patients with CAE. When alternatives to beta‐lactam therapy are needed, fluoroquinolones may provide an effective option

Real-world, multicentre evaluation of the incidence and risk factors for non-susceptible Stenotrophomonas maltophilia isolates

Background: Stenotrophomonas maltophilia is a cause of infection most commonly in the opportunistic host. Trimethoprim-sulfamethoxazole and levofloxacin are considered first-line treatment agents. With reports of increasing resistance to these first-line agents, it is important to determine risk factors associated with a non-susceptible isolate. Methods: This was a real-world, multicentre, retrospective case-control study from five centres in the southeast United States evaluating S. maltophilia. The primary outcome was risk factors associated with non-susceptibility of S. maltophilia isolates to ≥1 antimicrobial agents. Secondary outcomes include incidence of S. maltophilia non-susceptibility, all-cause mortality, and 30-day readmission rates. Results: There were 325 patients included in the study. For the primary outcome, the only factor associated with non-susceptibility per univariate analysis was isolation from urine culture (13.3% vs. 5.4%; P = 0.014), whereas the presence of mechanical ventilation (37.7% vs. 21.5%) and intensive care unit admission (35.3% vs. 18.4%) were associated with susceptibility (P \u3c 0.001). For the secondary outcomes, non-susceptibility was present in 49% of isolates with 43 of 325 (13.2%), 53 of 324 (16.4%), and 105 of 172 (61%) to TMP-SMX, levofloxacin, and ceftazidime, respectively. Resistance to chloramphenicol and tigecycline was observed among 5/26 and 11/16 of tested isolates, respectively. Sixty-six patients (20%) experienced all-cause, inpatient mortality (18% susceptible vs. 23% non-susceptible; P = 0.280) and 44 patients (17%) were readmitted within 30 days of discharge (16% susceptible vs. 18% non-susceptible; P = 0.673). Conclusion: S. maltophilia non-susceptibility had a prevalence of ∼50% to at least one first-line or commonly used agent. More research is needed to delineate risk factors for non-susceptible isolates

Impact of Obesity in Patients with Candida Bloodstream Infections: A Retrospective Cohort Study

© 2020, The Author(s). Background: Candida species are responsible for 15% of bloodstream infections, leading to prolonged hospitalizations and increased mortality. With the rise in obesity, antifungal dosing is unclear. The purpose of this study was to determine differences in clinical outcomes between obese versus non-obese patients with Candida bloodstream infections. Methods: This retrospective cohort included adult patient’s first episode of Candida bloodstream infection treated with ≥ 48 h of antifungal therapy between 1 June 2013 and 31 August 2019. Patients were excluded for: dual systemic antifungal therapy, polymicrobial infections, or chronic candidiasis. The primary outcome was infection-related length of stay. Secondary outcomes included: time to candidemia resolution, 30-day readmission rates, and in-hospital mortality. Results: Eighty patients were included (28 obese; 52 non-obese). Most were male (55%); median age was 54 years. Median BMI and weight were 36.3 kg/m2 and 103 kg versus 20.4 kg/m2 and 61 kg, respectively (p \u3c 0.01). Baseline characteristics were comparable. C. albicans was isolated in 37.5% of cultures and C. glabrata in 30%. Micafungin was utilized empirically in 72.5% of patients; obese patients received definitive micafungin more frequently (57.1% vs. 21.2%; p \u3c 0.01) and were treated longer (13 versus 10 days; p = 0.04). Infection-related length of stay was 19 days in the obese patients and 13 days in the non-obese patients (p = 0.05). Non-obese patients had a shorter duration of candidemia (5 versus 6 days; p = 0.02). In-hospital mortality was numerically higher in obese patients (21.4% versus 13.5%; p = 0.36). There were no differences in 30-day readmissions between groups. Conclusions: Worse clinical outcomes were observed for obese versus non-obese patients. Further clinical research is warranted

The transcriptomic evolution of mammalian pregnancy:gene expression innovations in endometrial stromal fibroblasts

The endometrial stromal fibroblast (ESF) is a cell type present in the uterine lining of therian mammals. In the stem lineage of eutherian mammals, ESF acquired the ability to differentiate into decidual cells in order to allow embryo implantation. We call the latter cell type “neo-ESF” in contrast to “paleo-ESF” which is homologous to eutherian ESF but is not able to decidualize. In this study, we compare the transcriptomes of ESF from six therian species: Opossum (Monodelphis domestica; paleo-ESF), mink, rat, rabbit, human (all neo-ESF), and cow (secondarily nondecidualizing neo-ESF). We find evidence for strong stabilizing selection on transcriptome composition suggesting that the expression of approximately 5,600 genes is maintained by natural selection. The evolution of neo-ESF from paleo-ESF involved the following gene expression changes: Loss of expression of genes related to inflammation and immune response, lower expression of genes opposing tissue invasion, increased markers for proliferation as well as the recruitment of FOXM1, a key gene transiently expressed during decidualization. Signaling pathways also evolve rapidly and continue to evolve within eutherian lineages. In the bovine lineage, where invasiveness and decidualization were secondarily lost, we see a re-expression of genes found in opossum, most prominently WISP2, and a loss of gene expression related to angiogenesis. The data from this and previous studies support a scenario, where the proinflammatory paleo-ESF was reprogrammed to express anti-inflammatory genes in response to the inflammatory stimulus coming from the implanting conceptus and thus paving the way for extended, trans-cyclic gestation

Financial Analysis of Dalbavancin for Acute Bacterial Skin and Skin Structure Infections for Self-Pay Patients

© 2020, The Author(s). Introduction: Acute bacterial skin and skin structure infections (ABSSSI) are an increasing cause of admission in the self-pay population. We previously reported that patients with ABSSSI discharged to receive dalbavancin showed a decreased length of stay (LOS) and total direct costs without increasing 30-day readmission rate. For patients who are financially eligible, a dalbavancin vial replacement program can offset costs. The objective of this study was to determine cost differences in treating ABSSSI in self-pay inpatients discharged to receive dalbavancin compared to standard of care (SOC). Methods: This retrospective cohort within a community health system compared self-pay adult inpatients with ABSSSI from February 3, 2016 to August 5, 2019 discharged to receive dalbavancin at an outpatient infusion center with SOC intravenous antibiotics. Patients were included with cellulitis, abscess, or postoperative wound infections diagnoses on the basis of International Classification of Disease, Tenth Revision (ICD-10) codes. Excluded populations were patients without dalbavancin vial replacement performed, pregnant, infections caused exclusively by gram-negative bacteria or fungi, or ICD-10 codes not consistent with ABSSSI. The primary outcome was direct cost of hospital stay. Secondary outcomes included length of stay (LOS), 30-day readmission rates, adverse events (AE), and indirect hospital costs. On the basis of previous studies, a one-sided Student’s t test was performed on financial data. Results: Twelve dalbavancin and 263 SOC patients met inclusion criteria. Direct cost ($2758 vs$4010, p = 0.105) and indirect hospital cost ($2913 vs$3646 , p = 0.162) per patient were less in the dalbavancin group. There was no significant difference between median LOS (4 vs 4, p = 0.888), AE (0% vs 14.8%), and 30-day readmission rates for dalbavancin vs SOC group (8.3% vs 7.2%, p = 0.604). Conclusion: Self-pay patients with ABSSSI discharged to receive dalbavancin with vial replacement resulted in decreased direct and indirect costs per patient with similar 30-day readmission rates, AE, and LOS. More studies targeted toward this population are warranted to determine ultimate benefit

Trends in and predictors of carbapenem consumption across North American hospitals: Results from a multicenter survey by the MAD-ID research network

This Special Issue is dedicated to the late Dr. Charles (Charlie) D. Hufford, former Professor of Pharmacognosy and Associate Dean for Research and Graduate Studies at University of Mississippi [...]

Leading change in academic pharmacy: Report of the 2018-2019 aacp academic affairs committee

© 2019 by the authors. Licensee MDPI, Basel, Switzerland. Delivering an effective drug load to the posterior section of the ocular tissues, while using a non-invasive technique, has always been a challenge. In this regard, the goal of the present study was to develop sustained release triamcinolone acetonide (TA) loaded polymeric matrix films for ocular delivery. The TA-films were prepared in two different polymer matrices, with drug loadings of 10% and 20% w/w, and they were evaluated for ocular distribution in vivo in a conscious rabbit model. A 4% w/v TA suspension (TA-C) was used as a control for in vitro and in vivo studies. The TA-films, prepared with melt-cast technology, used polyethylene oxide (PEO) and Soluplus® as the polymer matrix. The films were evaluated with respect to assay, content uniformity, excipient interaction, and permeability across isolated rabbit sclera. The distribution of TA in the ocular tissues, post topical administration, was determined in New Zealand male albino rabbits as a function of dose, and was compared against TA-C. The assay of the 10% and 20% w/w film was in the range from 70–79% and 92–94% for the Soluplus® and PEO films, respectively, and content uniformity was in the range of 95–103% for both the films. The assay of the TA from Soluplus® films was less compared with the PEO films and showed an interaction with TA, as revealed by Differential Scanning Calorimetry (DSC). Hence, Soluplus® films were not selected for further studies. No interaction was observed between the drug and PEO polymer matrix. The enhancement of trans-scleral flux and permeability of TA was about 1.16 and 1.33-folds, respectively, from the 10% w/w PEO and 3.5 and 2.12-folds, respectively, from the 20% w/w PEO films, as compared with TA-C formulations. The in vivo studies demonstrate that significantly higher TA levels were observed in the anterior and posterior segments of the eye at the end of 6h with the PEO films. Therefore, the PEO based polymeric films were able to deliver TA into the back of the eye efficiently and for prolonged periods. View Full-Tex