Clinical decision rules and measuring renal function in community pharmacy: what do we get out of it?

OBJECTIVE To investigate the frequency and management of drug therapy alerts about drug use in patients with (potential) renal impairment, to investigate the contribution of point-of-care testing (PoCT) of renal function in community pharmacy to the availability of information on renal function, and to investigate pharmacists’ experiences with drug therapy alerts and PoCT. DESIGN AND METHODS A clinical decision support system with clinical decision rules for eleven drugs (seven antibiotics, sotalol, digoxin, allopurinol and spironolactone) and PoCT of renal function were implemented in community pharmacies. The clinical decision rules generated an alert when dose adjustment was advised based on a registered impaired renal function, and when information on the renal function was lacking for patients over 70 years of age with a prescription for one of the selected drugs. Data registered in the clinical decision support system regarding generated alerts, renal functions and alert management were analysed retrospectively. In addition, the participating pharmacists filled out a questionnaire about their experiences. RESULTS 336 pharmacists managed 27.307 alerts for 21.494 patients, leading to 362 dose adjustments and 65 drug replacements. For 16.208 of these patients, renal function has been registered in the clinical decision support system, including over 400 PoCT measurements. Based on PoCT, 25 cases of impaired renal function have been registered, leading to two therapy adjustments. The participating pharmacists were positive about the project. CONCLUSION Advanced clinical decision rules on renal function led to over 400 therapy adjustments. PoCT is a potentially useful source of information on renal function in a limited number of cases, when this information is urgently needed and not available from other sources

Clinical decision rules and measuring renal function in community pharmacy: what do we get out of it?

OBJECTIVE To investigate the frequency and management of drug therapy alerts about drug use in patients with (potential) renal impairment, to investigate the contribution of point- of-care testing (PoCT) of renal function in community pharmacy to the availability of information on renal function, and to investigate pharmacists' experiences with drug therapy alerts and PoCT. DESIGN AND METHODS A clinical decision support system with clinical decision rules for eleven drugs (seven antibiotics, sotalol, digoxin, allopurinol and spironolactone) and PoCT of renal function were implemented in community pharmacies. The clinical decision rules generated an alert when dose adjustment was advised based on a registered impaired renal function, and when information on the renal function was lacking for patients over 70 years of age with a prescription for one of the selected drugs. Data registered in the clinical decision support system regarding generated alerts, renal functions and alert management were analysed retrospectively. In addition, the participating pharmacists filled out a questionnaire about their experiences. RESULTS 336 pharmacists managed 27.307 alerts for 21.494 patients, leading to 362 dose adjustments and 65 drug replacements. For 16.208 of these patients, renal function has been registered in the clinical decision support system, including over 400 PoCT measurements. Based on PoCT, 25 cases of impaired renal function have been registered, leading to two therapy adjustments. The participating pharmacists were positive about the project. CONCLUSION Advanced clinical decision rules on renal function led to over 400 therapy adjustments. PoCT is a potentially useful source of information on renal function in a limited number of cases, when this information is urgently needed and not available from other sources

Anatomical Step-by-Step Dissection of Complex Skull Base Approaches for Trainees: Surgical Anatomy of the Endoscopic Endonasal Approach to the Sellar and Parasellar Regions

Introduction Surgery of the sellar and parasellar regions can be challenging due to the complexity of neurovascular relationships. The main goal of this study is to develop an educational resource to help trainees understand the pertinent anatomy and procedural steps of the endoscopic endonasal approaches (EEAs) to the sellar and parasellar regions. Methods Ten formalin-fixed latex-injected specimens were dissected. Endoscopic endonasal transsphenoidal transsellar, transtuberculum-transplanum, and transcavernous approaches were performed by a neurosurgery trainee, under supervision from the senior authors and a PhD in anatomy with advanced neuroanatomy experience. Dissections were supplemented with representative case applications. Results Endoscopic endonasal transsphenoidal approaches afford excellent direct access to sellar and parasellar regions. After a wide sphenoidotomy, a limited sellar osteotomy opens the space to sellar region and medial portion of the cavernous sinus. To reach the suprasellar space (infrachiasmatic and suprachiasmatic corridors), a transplanum-prechiasmatic sulcus-transtuberculum adjunct is needed. The transcavernous approach gains access to the contents of the cavernous sinus and both medial (posterior clinoid and interpeduncular cistern) and lateral structures of the retrosellar region. Conclusion The anatomical understanding and technical skills required to confidently remove skull base lesions with EEAs are traditionally gained after years of specialized training. We comprehensively describe EEAs to sellar and parasellar regions for trainees to build knowledge and improve familiarity with these approaches and facilitate comprehension and learning in both the surgical anatomy laboratory and the operating room

Automated motion analysis of bony joint structures from dynamic computer tomography images: A multi-atlas approach

Dynamic computer tomography (CT) is an emerging modality to analyze in-vivo joint kinematics at the bone level, but it requires manual bone segmentation and, in some instances, landmark identification. The objective of this study is to present an automated workflow for the assessment of three-dimensional in vivo joint kinematics from dynamic musculoskeletal CT images. The proposed method relies on a multi-atlas, multi-label segmentation and landmark propagation framework to extract bony structures and detect anatomical landmarks on the CT dataset. The segmented structures serve as regions of interest for the subsequent motion estimation across the dynamic sequence. The landmarks are propagated across the dynamic sequence for the construction of bone embedded reference frames from which kinematic parameters are estimated. We applied our workflow on dynamic CT images obtained from 15 healthy subjects on two different joints: thumb base (n = 5) and knee (n = 10). The proposed method resulted in segmentation accuracies of 0.90 ± 0.01 for the thumb dataset and 0.94 ± 0.02 for the knee as measured by the Dice score coefficient. In terms of motion estimation, mean differences in cardan angles between the automated algorithm and manual segmentation, and landmark identification performed by an expert were below 1◦. Intraclass correlation (ICC) between cardan angles from the algorithm and results from expert manual landmarks ranged from 0.72 to 0.99 for all joints across all axes. The proposed automated method resulted in reproducible and reliable measurements, enabling the assessment of joint kinematics using 4DCT in clinical routine

Clinical, Pathological, and Surgical Outcomes for Adult Pineoblastomas

Introduction Pineoblastomas are uncommon primitive neuroectodermal tumors that occur mostly in children; they are exceedingly rare in adults. Few published reports have compared the various aspects of these tumors between adults and children. Methods The authors report a series of 12 pineoblastomas in adults from 2 institutions over 24 years. The clinical, radiologic, and pathologic features and clinical outcomes were compared with previously reported cases in children and adults. Results Patient age ranged from 24 to 81 years, and all but 1 patient exhibited symptoms of obstructive hydrocephalus. Three patients underwent gross total resection, and subtotal resection was performed in 3 patients. Diagnostic biopsy specimens were obtained in an additional 6 patients. Pathologically, the tumors had the classical morphologic and immunohistochemical features of pineoblastomas. Postoperatively, 10 patients received radiotherapy, and 5 patients received chemotherapy. Compared with previously reported cases, several differences were noted in clinical outcomes. Of the 12 patients, only 5 (42%) died of their disease (average length of survival, 118 months); 5 patients (42%) are alive with no evidence of disease (average length of follow-up, 92 months). One patient died of unrelated causes, and one was lost to follow-up. Patients with subtotal resections or diagnostic biopsies did not suffer a worse prognosis. Of the 9 patients with biopsy or subtotal resection, 4 are alive, 4 died of their disease, and 1 died of an unrelated hemorrhagic cerebral infarction. Conclusions Although this series is small, the data suggest that pineoblastomas in adults have a less aggressive clinical course than in children

Antimicrobial usage and resistance in companion animals: A cross-sectional study in three european countries

Companion animals have been described as potential reservoirs of antimicrobial resistance (AMR), however data remain scarce. Therefore, the objectives were to describe antimicrobial usage (AMU) in dogs and cats in three European countries (Belgium, Italy, and The Netherlands) and to investigate phenotypic AMR. A questionnaire and one fecal sample per animal (n = 303) were collected over one year and AMU was quantified using treatment incidence (TI). Phenotypic resistance profiles of 282 Escherichia coli isolates were determined. Nineteen percent of the animals received at least one antimicrobial treatment six months preceding sampling. On average, cats and dogs were treated with a standard daily dose of antimicrobials for 1.8 and 3.3 days over one year, respectively. The most frequently used antimicrobial was amoxicillin-clavulanate (27%). Broad-spectrum antimicrobials and critically important antimicrobials for human medicine represented 83% and 71% of the total number of treatments, respectively. Resistance of E. coli to at least one antimicrobial agent was found in 27% of the isolates. The most common resistance was to ampicillin (18%). Thirteen percent was identified as multidrug resistant isolates. No association between AMU and AMR was found in the investigated samples. The issue to address, regarding AMU in companion animal, lies within the quality of use, not the quantity. Especially from a One-Health perspective, companion animals might be a source of transmission of resistance genes and/or resistant bacteria to humans.</p

A comparison of passive and active dust sampling methods for measuring airborne methicillin-resistant Staphylococcus aureus in pig farms

Methicillin-resistant strains of Staphylococcus aureus (MRSA) are resistant to most β-lactam antibiotics. Pigs are an important reservoir of livestock-associated MRSA (LA-MRSA), which is genetically distinct from both hospital and community-acquired MRSA. Occupational exposure to pigs on farms can lead to LA-MRSA carriage by workers. There is a growing body of research on MRSA found in the farm environment, the airborne route of transmission, and its implication on human health. This study aims to directly compare two sampling methods used to measure airborne MRSA in the farm environment; passive dust sampling with electrostatic dust fall collectors (EDCs), and active inhalable dust sampling using stationary air pumps with Gesamtstaubprobenahme (GSP) sampling heads containing Teflon filters. Paired dust samples using EDCs and GSP samplers, totaling 87 samples, were taken from 7 Dutch pig farms, in multiple compartments housing pigs of varying ages. Total nucleic acids of both types of dust samples were extracted and targets indicating MRSA (femA, nuc, mecA) and total bacterial count (16S rRNA) were quantified using quantitative real-time PCRs. MRSA could be measured from all GSP samples and in 94% of the EDCs, additionally MRSA was present on every farm sampled. There was a strong positive relationship between the paired MRSA levels found in EDCs and those measured on filters (Normalized by 16S rRNA; Pearson's correlation coefficient r = 0.94, Not Normalized; Pearson's correlation coefficient r = 0.84). This study suggests that EDCs can be used as an affordable and easily standardized method for quantifying airborne MRSA levels in the pig farm setting