Samuel K. Peasah

Clostridium difficile Infection in Older Adults: Systematic Review of Efforts to Reduce Occurrence and Improve Outcomes

OBJECTIVEnProvide a systematic review of the primary literature on efforts to reduce Clostridium difficile infection (CDI) occurrence and improve outcomes in older adults.nnnDATA SOURCES, STUDY SELECTION, DATA EXTRACTIONnPubMed and CINAHL databases were searched for research studies using search terms CDI, CDI prevention, reduction, control, management, geriatric, elderly, adults 65 years of age and older. The MeSH categories Aged and Aged, 80 and older, were used. A second search of PubMed, CINAHL, National Guideline Clearinghouse, and TRIP databases was conducted for primary, secondary, and tertiary literature for CDI epidemiology, burden, and management in adults of all ages, and prevention and management guidelines. Of the 2,263 articles located, 105 were selected for full review: 55 primary and 50 secondary, tertiary. Primary literature selected for full review included studies of interventions to prevent, reduce occurrence, control, manage, or improve outcomes in adults 65 years of age and older. Patient settings included the community, assisted living, nursing facility, subacute care, or hospital.nnnDATA SYNTHESISnThe main outcome measures for research studies were whether the studied intervention prevented, reduced occurrence, controlled, managed, or improved outcomes. Studies were conducted in acute or long-term hospitals, with a few in nursing facilities. Interventions that prevented or reduced CDI included antibiotic policy changes, education, procedure changes, infection control, and multi-intervention approaches. There were few management studies for adults 65 years of age and older or for all adults with results stratified by age. Treatments studied included efficacy of fidaxomicin, metronidazole, vancomycin, and fecal microbiota transplant. Though clinical outcomes were slightly less robust in those 65 years of age and older, age was not an independent predictor of success or failure. The current prevention and management guidelines for adults of all ages, as well as special considerations in skilled nursing facilities, extracted from the secondary/tertiary literature selected, are summarized.nnnCONCLUSIONnThere are a limited number of studies designed for older adults. Our findings suggest that guideline recommendations for adults are adequate and appropriate for older adults. Exposure to antibiotics and Clostridium difficile remain the two major risk factors for CDI, reinforcing the importance of antibiotic stewardship and infection control.

The use of debates as an active learning tool in a college of pharmacy healthcare delivery course

n Abstractn n Background and purposen To describe the use of debates, and to evaluate student performance and perceptions, when student debates are incorporated as an active learning tool in a required pharmacy healthcare delivery course.n n n Educational activity and settingn Student live debates replaced 15% of a traditional lecture-based course. Twelve healthcare controversies were debated by student teams each year. Student perception of debate utility and opinion on topics, pre- and post-debate, were measured via a voluntary survey. Both peer and instructors assessments of team performances, as well as individual student performance on the debate-based questions on course exams, contributed to course grade.n n n Findingsn The average survey response rates were 76% (2014) and 86% (2015). Fifteen-54% of student respondents changed their opinion on individual debate topics due to the debates. Although exam performance on debate-based questions was no better than on lecture-based questions, respondents who found the debates useful or very useful in mastering course material increased by 19% post versus pre-debate surveys.n n n Summaryn Debates are an effective active learning tool for engaging students in controversial subjects. Assessment of student performance should include student and instructor evaluations, and can be incorporated into the course grade.n n

Review of the Role of the Pharmacist in Reducing Hospital Readmissions

Hospital readmissions remain a public health concern despite progress in reducing and preventing its occurrence. Among strategies that have been implemented to reduce readmission most involves medication management. Our objective was to evaluate the effectiveness of interventions involving pharmacists to reduce hospital readmissions. PubMed and Google Scholar were searched for primary literature from January 1990 to July 2016 with search terms such as “hospital readmission,” and “Pharmacist,” or “Pharmacy,” or “medications.” Studies with an abstract in English which highlighted a pharmacist involvement based on the type of intervention, country of origin, type of study, and findings were summarized. The outcomes of these interventions to reduce hospital readmissions were mixed. Of the 29 studies, 16 (55%) showed a statistically significant reduction in readmissions ranging from 3.3% to 30%. Most of the interventions focused mainly on patient education postdischarge (8) or in addition to medication reconciliation predischarge (9). There were no studies from Africa or Asia but mainly from the United States (72%). Although multiple factors contribute to hospital readmission, this review highlights the important role pharmacists can play singularly and as part of interdisciplinary teams. Most effective interventions often involved medication review and patient education postdischarge.

Postoperative Pain Management With Liposomal Bupivacaine in Patients Undergoing Orthopedic Knee and Hip Arthroplasty at a Community Hospital

Objective: The objective of this study was to assess the association between liposomal bupivacaine use in patients undergoing knee or hip arthroplasty and concurrent pain control, length of hospitalization, and physical therapy milestones. Methods: This was a retrospective chart review. Patients receiving liposomal bupivacaine during a 1-year period (study group) were compared with patients seen by the same surgeon in the previous year who did not receive liposomal bupivacaine (control group). Clinical outcomes included concurrent opioid use, average pain scores, length of stay, ambulation, and range of motion. Results: A total of 357 patients were included in the study. Knee study group patients received lower amounts of opioid (209 vs 248 mg; P = .02) and had a delayed time to first rescue medication (6.3 ± 4.7 vs 5.0 ± 4.4 hours; P = .02). Hip study group patients had a delay in time to first rescue medication (7.1 ± 6.3 vs 4.9 ± 4.0 hours; P = .046). Both knee and hip study group patients had higher average pain score during the 72-hour postoperative period (6.38 vs 6.06; P = .01, and 6.32 vs 5.80; P = .02, respectively) but decreased median length of stay (2.0 vs 3.0 days; P < .0001, and 2.0 vs 3.0 days; P = .04, respectively). Conclusions: Use of liposomal bupivacaine produced a modest decrease in opioid use among knee patients and a decreased length of stay in both knee and hip patients; however, this was accompanied by a non-clinically significant increase in pain scores for knee and hip patients suggesting limited utility for orthopedic procedures.

Hypoglycemia Associated With Insulin Use During Treatment of Hyperkalemia Among Emergency Department Patients

Purpose: Hypoglycemia is a common adverse event associated with insulin during treatment of hyperkalemia in hospitalized patients; however, limited data exist regarding hypoglycemia incidence and appropriate dosing strategies for treatment of patients in the emergency department. The study objective was to determine the incidence of hypoglycemia associated with insulin use during treatment of hyperkalemia among patients seen in the emergency department. Methods: This was an Institutional Review Board (IRB)–approved retrospective, chart-review study. All adult patients who received intravenous regular insulin as a result of an order from the emergency department hyperkalemia order set were eligible for inclusion. The main clinical outcomes were incidence of hypoglycemia (blood glucose <70 mg/dL) and severe hypoglycemia (blood glucose <40 mg/dL). Blood glucose was checked within 24 hours of insulin administration. Results: A total of 172 patients were included. The incidence of hypoglycemia was 19.8% (n = 34) and the incidence of severe hypoglycemia was 5.2% (n = 9). Hypoglycemic patients had a significantly lower median blood glucose at baseline compared to those who did not develop hypoglycemia (83.5 [72.0-112.0] mg/dL vs 123.0 [96.0-167.0] mg/dL, P < .0001); however, no difference was noted between groups in the average insulin dose administered (0.11 ± 0.04 units/kg vs 0.12 ± 0.05 units/kg, P = .6175). Conclusion: There is a concerning risk of hypoglycemia associated with insulin use during treatment of hyperkalemia in the emergency department. Standard insulin doses may not be appropriate in some cases like patients with lower baseline blood glucose. Further research is warranted to develop safer hyperkalemia treatment protocols that mitigate this high risk of hypoglycemia associated with insulin use.

Evaluation of first year student pharmacists’ perceptions of the pharmaceutical industry

BACKGROUND AND PURPOSEnThere are a limited number of pedagogical studies evaluating student pharmacists perceptions of the pharmaceutical industry. The objective of this two year prospective study was to evaluate changes in student pharmacists perceptions of the pharmaceutical industry during the first year of enrollment in the doctor of pharmacy curriculum.nnnEDUCATIONAL ACTIVITY AND SETTINGnAn online survey was developed and offered to all first-year student pharmacists during the 2014 and 2015 Fall semesters prior to didactic instruction on the pharmaceutical industry and then again at the end of the respective academic years. Descriptive and inferential statistics were used to analyze the data.nnnFINDINGSnA majority of students had a positive impression of the pharmaceutical industry in both the fall (75%) and spring semesters (78%). Over the course of the year, significantly greater numbers of student pharmacists reported favorable impressions of the pharmaceutical industry with respect to research innovation, drug safety, and the provision of drug information. On the other hand, findings suggest that many students remain skeptical regarding the benefits of prescription medications relative to cost and there were significant increases in the number of students who perceived pharmaceutical industry-based marketing practices to have a negative impact on patients and society.nnnDISCUSSION AND SUMMARYnDidactic education may influence student pharmacists perceptions of the pharmaceutical industry. Further research is warranted to evaluate the role of pharmacy curricula and extra-curricular activities in influencing changes in student pharmacists perceptions and the potential implications of these changes to pharmacy practice.

Time–Motion Analysis of Nurses Utilizing Insulin Pen Devices Compared to Vial and Syringe in an Inpatient Setting:

Objective: To compare the time taken and steps completed by nurses in the process of insulin preparation and administration using the pen device compared to the vial and syringe method. Methods: Observational and exploratory study utilizing a time–motion analysis of nurses’ administration of insulin using the pen versus vial and syringe delivery methods. Nurses were observed, video-recorded, and timed during insulin preparation and administration using each delivery method. The steps performed by nurses were observed against recommended processes for preparing and administering insulin, and the percentage of nurses completing each step was noted. Results: A total of 137 (94%) nurses participated. Nurses took less time preparing and administering insulin with the pen device compared with the vial and syringe method (79 ± 18 seconds vs 88 ± 20 seconds, respectively, P < .001). The overall average completion rate of steps with the pen device was 90% ± 7% compared to 88% ± 7% with the vial and syringe method. Conclusion: The time taken by nurses to prepare and administer insulin was lower with the pen device compared with vial and syringe. Furthermore, areas were identified for potential nursing education to enhance safe and appropriate use of insulin with both delivery methods.

School‐Based Influenza Vaccination: Health and Economic Impact of Maine's 2009 Influenza Vaccination Program

OBJECTIVEnTo estimate the societal economic and health impacts of Maines school-based influenza vaccination (SIV) program during the 2009 A(H1N1) influenza pandemic.nnnDATA SOURCESnPrimary and secondary data covering the 2008-09 and 2009-10 influenza seasons.nnnSTUDY DESIGNnWe estimated weekly monovalent influenza vaccine uptake in Maine and 15 other states, using difference-in-difference-in-differences analysis to assess the programs impact on immunization among six age groups. We also developed a health and economic Markov microsimulation model and conducted Monte Carlo sensitivity analysis.nnnDATA COLLECTIONnWe used national survey data to estimate the impact of the SIV program on vaccine coverage. We used primary data and published studies to develop the microsimulation model.nnnPRINCIPAL FINDINGSnThe program was associated with higher immunization among children and lower immunization among adults aged 18-49xa0years and 65 and older. The program prevented 4,600 influenza infections and generated

Evaluation of a Once/Day Tobramycin Regimen to Achieve Target Concentrations in Adult Patients with Cystic Fibrosis

4.9xa0million in net economic benefits. Cost savings from lower adult vaccination accounted for 54 percent of the economic gain. Economic benefits were positive in 98 percent of Monte Carlo simulations.nnnCONCLUSIONSnSIV may be a cost-beneficial approach to increase immunization during pandemics, but programs should be designed to prevent lower immunization among nontargeted groups.

An Elective Course for Student Pharmacists on Pharmaceutical Industry Practice

To evaluate the success of an initial tobramycin dosing regimen to achieve target peak and trough concentrations in adult patients with pulmonary exacerbations of cystic fibrosis (CF).