Paul C. Walker

Impact of a pharmacist-facilitated hospital discharge program: a quasi-experimental study.

BACKGROUND Medication discrepancies are common at hospital discharge and can result in adverse events, hospital readmissions, and emergency department visits. Our objectives were to characterize medication discrepancies at hospital discharge and test the effects of a pharmacist intervention on health care utilization following discharge. METHODS We used a prospective, alternating month quasi-experimental design to compare outcomes of patients receiving the intervention (n = 358) with controls (n = 366). All patients were discharged to home and were at high risk for medication-related problems following discharge because of the number or types of medications they were prescribed, multiple medication changes during hospitalization, or problems managing medications. The intervention consisted of medication therapy assessment, medication reconciliation, screening for adherence concerns, patient counseling and education, and postdischarge telephone follow-up. The primary outcomes were 14-day and 30-day readmission rates and emergency department visits within 72 hours of discharge. Medication discrepancies occurring at discharge were also characterized. RESULTS Medication discrepancies at discharge were identified in 33.5% of intervention patients and 59.6% of control patients (P < .001). Although all discrepancies were resolved in the intervention group prior to discharge, readmission rates did not differ significantly between groups at 14 days (12.6% vs 11.5%; P = .65) and 30 days (22.1% vs 18%; P = .17), nor did emergency department visits (2.8% vs 2.2%, respectively; P = .60). CONCLUSION While our intervention improved the quality of patient discharge by identifying and reconciling medication discrepancies at discharge, there was no effect on postdischarge health care resource utilization.

Serotonergic Regulation of Membrane Potential in Developing Rat Prefrontal Cortex: Coordinated Expression of 5-Hydroxytryptamine (5-HT)1A, 5-HT2A, and 5-HT7 Receptors

The developing prefrontal cortex receives a dense serotonergic innervation, yet little is known about the actions of serotonin [5-Hydroxytryptamine (5-HT)] in this region during development. Here, we examined the developmental regulation of 5-HT receptors controlling the excitability of pyramidal neurons of this region. Using whole-cell recordings in in vitro brain slices, we identified a dramatic shift in the effects of 5-HT on membrane potential during the postnatal developmental period. In slices derived from young animals [postnatal day (P) 6 to P19], administration of 5-HT elicits a robust depolarization of layer V pyramidal neurons, which gradually shifts to a hyperpolarization commencing during the third postnatal week. This progression is the result of coordinated changes in the function of 5-HT7 and 5-HT2A receptors, which mediate different aspects of the depolarization, and of 5-HT1A receptors, which signal the late developing hyperpolarization. The loss of the 5-HT7 receptor-mediated depolarization and the appearance of the 5-HT1A receptor-mediated hyperpolarization appears to reflect changes in receptor expression. In contrast, the decline in the 5-HT2A receptor depolarization with increasing age was associated with changes in the effectiveness with which these receptors could elicit a membrane depolarization, rather than loss of the receptors per se. Together, these results outline coordinated changes in the serotonergic regulation of cortical excitability at a time of extensive synaptic development and thus suggest a key role for these receptor subtypes in the postnatal development of the prefrontal cortex.

Overutilization of proton-pump inhibitors: what the clinician needs to know.

Proton-pump inhibitors (PPIs) remain the leading evidence-based therapy for upper gastrointestinal disorders, including gastroesophageal reflux disease, dyspepsia, and peptic ulcer disease. The effectiveness of PPIs has led to overutilization in multiple treatment arenas, exposing patients to an increasing number of potential risks. The overutilization of PPIs in ambulatory care settings is often a result of failure to re-evaluate the need for continuation of therapy, or insufficient use of on-demand and step-down therapy. PPI overutilization in the inpatient setting is often a result of inappropriate stress ulcer prophylaxis (SUP) in nonintensive care unit patients, and failure to discontinue SUP prior to hospital discharge. Potential consequences of prolonged PPI therapy include hypergastrinemia, enterochromaffin-like cell hyperplasia, and parietal cell hypertrophy, leading to rebound acid hypersecretion. PPIs have been linked via retrospective studies to increased risk of enteric infections including Clostridium difficile-associated diarrhea, community-acquired pneumonia, bone fracture, nutritional deficiencies, and interference with metabolism of antiplatelet agents. Reducing inappropriate prescribing of PPIs in the inpatient and outpatient settings can minimize potential for adverse events, and foster controllable cost expenditure.

Neonatal Bilirubin Toxicity: A Review of Kernicterus and the Implications of Drug-Induced Bilirubin Displacement

SummaryKernicterus, the primary manifestation of neonatal bilirubin toxicity, remains an important complication of unconjugated hyperbilirubinaemia despite advances made with phototherapy and exchange transfusions. It results from the penetration of bilirubin into neuronal tissues of the CNS with subsequent damage to the mitochondrion. A number of factors may modify or potentiate bilirubin toxicity, including drugs administered to the infant. The importance of drug-bilirubin interactions in the pathogenesis of kernicterus was first realised quite inadvertently in the 1950s, and the potential risk for significant drug-bilirubin interactions has since become an important consideration in neonatal drug therapy. All drugs intended for use in newborn infants should be evaluated for their capacity to displace bilirubin. A number of techniques have been developed which have facilitated investigation of the mechanisms mediating the bilirubin-displacing effects of drugs and the pharmacokinetics of drug-bilirubin interactions. Further, the clinical risk for inducing kernicterus has been investigated for many of the drugs to which neonates may be exposed by direct administration, transplacentally, or through breast milk. This review summarises the available knowledge concerning the physicochemical properties and toxicities of bilirubin, reviews the methodologies used in evaluating drug-bilirubin interactions, and focuses on the mechanisms, pharmacokinetics and clinical significance of the bilirubin displacing effects of antibiotics, anticonvulsants, diuretics, and other important drug classes used in the treatment of neonates.

An Advanced Pharmacy Practice Experience in Transitional Care

Objectives. To implement and assess a 4-week advanced pharmacy practice experience in transitional care. Design. Students participated in the transitional care planning of patients being discharged from 4 general medicine services. Students interviewed patients; assessed discharge medications; reconciled preadmission and discharge medications; provided medication counseling; and conducted postdischarge follow-up by phone to assist patients with medication-related problems and identify additional concerns. Assessment. Student involvement increased the number of patients who could be assessed and interviewed by the pharmacist preceptor from 10 patients/day to 15 to 20 patients/day. Students strengthened their provider-patient and provider-provider communication skills and developed skills in identifying and resolving barriers to medication adherence. Conclusion. This transitional care APPE provided students an opportunity to gain experience and self-confidence in the application of pharmaceutical care skills in a transitional care setting, while also providing valuable patient care services to the hospital.

Quality of life as a treatment outcome in patients with cystic fibrosis

We attempted to determine the responsiveness and validity of the Quality of Well‐Being (QWB) scale in 20 consecutive children and adolescents with cystic fibrosis. The QWB score was determined for 6‐day periods immediately before and after hospital admission, and at 6‐ and 12‐month follow‐up. With the instruments scale of zero‐1, responsiveness was indicated by significant changes in QWB score (0.09), physical (0.019), social (0.021), and symptom‐problem complexes (0.04) domains, and all pulmonary function tests from before to after treatment of an acute exacerbation. Only the symptom‐problem complex domain significantly changed from after treatment to 6‐ and 12‐month follow‐up. Validity was shown by significant correlations between before and after QWB scores and forced vital capacity (r=0.476), residual volume total lung capacity ratio (r=0.452), forced expiratory volume in 1 second (r=0.358), and forced expiratory flow between 25% and 75% of vital capacity (r=0.35).

Surgical infection prophylaxis for left ventricular assist device implantation.

Abstract  Background: Antimicrobial prophylaxis is commonly administered to patients undergoing left ventricular assist device (LVAD) surgeries to prevent infectious complications. However, optimal surgical infection prophylaxis (SIP) for LVAD surgeries is not well defined. Methods: We conducted an electronic survey to characterize LVAD SIP used at different centers performing LVAD implantation. Results: Responses were received from 23 of 85 centers (27%). Of 21 centers that provided usable data about their LVAD SIP regimens for nonpenicillin allergic patients, 42.9% reported using a four‐drug regimen (three antibiotics plus fluconazole), 23.8% reported using a three‐drug regimen (three antibiotics or two antibiotics plus fluconazole), 23.8% reported using a regimen of two antibiotics, and 9.5% reported using vancomycin alone. A similar pattern was observed among SIP regimens for penicillin‐allergic patients. Criteria for discontinuation of SIP and use of decolonization strategies also varied widely across centers. Conclusions: Our results demonstrate wide variability in LVAD SIP regimens and underscore the lack of consensus regarding best practice. (J Card Surg 2011;26:440‐443)

Improving student education and patient care through an innovative introductory pharmacy practice experience

![Figure][1] The standards of the Accreditation Council for Pharmacy Education (ACPE) for doctor of pharmacy programs require pharmacy curricula to provide students with introductory pharmacy practice experiences (IPPEs), which are defined as “practice experiences offered in various

Vancomycin use during left ventricular assist device support.

We reviewed the frequency and duration of vancomycin use during 93 left ventricular assist device placements. Vancomycin prophylaxis was administered for a mean duration (+/- standard deviation) of 10.5 +/- 11 days. Empirical vancomycin use was frequent, with a mean duration (+/- standard deviation) of therapy of 9.8 +/- 9 days (median, 8 days) given during 81 (87%) of the implantations. The most common indications for empirical vancomycin treatment were isolated leukocytosis or driveline drainage. Strategies to improve vancomycin use during left ventricular assist device support should be considered.

Treatment of Pain in Pediatric Patients

A growing body of evidence demonstrates that untreated pain is associated with adverse consequences that can compromise clinical and developmental outcomes in children but that these adverse consequences can be prevented or attenuated by appropriate analgesic therapy. Thus, effective treatment of acute pain must be a clinical priority for children of all ages. Over the past 20 years, extensive pediatric research exploring pain assessment, developmental pharmacology of analgesics, and the clinical use of analgesics has dispelled many myths and misconceptions about pain management in pediatric patients; proven that analgesics can be used safely in neonates, infants, and children; and provided a framework for the development of pediatric pain management guidelines. This article reviews guidelines recommended for managing acute pain in pediatric patients and the treatment options for children experiencing acute pain. Contemporary issues regarding acetaminophen, nonsteroidal anti-inflammatory agents, and opioids are discussed.