Duration Of Prescription Research Articles

Cost comparison of filgrastim versus pegfilgrastim and pegfilgrastim biosimilars for inpatient prophylaxis of febrile neutropenia.

The Ohio State University Comprehensive Cancer Center (The James) uses daily subcutaneous filgrastim as the inpatient granulocyte colony-stimulating factor of choice. The coordination of care associated with filgrastim can often be a barrier to patient discharge. The purpose of this study was to compare the inpatient cost of daily filgrastim to single dose pegfilgrastim and biosimilars. Adult patients admitted to The James who received at least one dose of filgrastim between June 1, 2021 and August 31, 2021 were retrospectively identified. This study compared the inpatient cost of filgrastim and biosimilars associated with one chemotherapy cycle to the potential inpatient cost of pegfilgrastim and biosimilars based on average sales price (ASP). Additionally, the number and duration of discharge prescriptions for filgrastim was determined. Of the 44 unique patient encounters that met inclusion criteria, 19 received 300-mcg doses of filgrastim and 25 received 480-mcg doses. The median number of doses administered per admission was eight. If each of these patients were to instead receive the most inexpensive biosimilar, pegfilgrastim reference product, the cost would be 216% higher than with filgrastim-sndz. At discharge, 15 patients (34%) received a prescription for filgrastim to be continued for a median duration of 6 days. Based on ASP, pegfilgrastim was more costly than filgrastim. Potential rebates and negotiation power may alter the financial outlook of adding pegfilgrastim to inpatient formulary. Exploration of delays in discharge due to insurance coordination for filgrastim continuation in the outpatient setting may also impact formulary decisions.

2228. Antibiotic Appropriateness for UTI Treatment on Monday vs Friday in a NYC Hospital ED

Abstract Background Urinary tract infections (UTI) are common and often lead to an antibiotic prescription. Prior studies have shown that antibiotic prescriptions can vary between weekdays and weekends. Methods This is a retrospective case series of female patients ≥18 years with simple cystitis presenting to the ED between 2019 to 2021 in a NYC community hospital. Our primary objective was to determine how often the appropriate antibiotic was prescribed and compare this between Monday and Friday. Antibiotic appropriateness was defined using the 2011 Infectious Disease Society of America clinical practice guidelines for acute uncomplicated cystitis. Criteria included antibiotic selection, dose, frequency, and duration. Per the NYC outpatient UTI antibiogram, Amoxicillin, Ampicillin, Ciprofloxacin, and TMP/SMX were not appropriate empiric therapies. Categorical data is reported as counts (%) and compared with Chi-square; age (nonparametric) is reported as median (range) and compared with Mann-Whitney. Sample size calculation estimated that 71 subjects were needed on each day to detect an effect size of 20% difference in our primary outcome (90% antibiotic appropriateness on Monday and 70% on Friday) with 80% power and an alpha error of 0.05. Results 160 subjects were included, 80 seen on Mondays and 80 seen on Fridays. Demographics were similar between groups, except for antibiotic allergies (Table 1). There was no difference between appropriate antibiotics prescribed on Mondays compared to Fridays, 54/80 (67.5%) vs 60/80 (75%) (p-value = 0.29). Failure to meet criteria for appropriateness was due to inappropriate prescription duration (44/160) or selection (14/160). All prescriptions met criteria for dose and frequency. There was no difference in antibiotic selection, dose, frequency, or duration of prescription on Monday vs Friday (Table 2). More urine cultures were collected on Mondays (62/80) vs Fridays (49/80) (p =.03). Conclusion 1 in 3 patients were prescribed inappropriate antibiotics for simple cystitis, though there was no difference between Mondays and Fridays. Inappropriate antibiotic duration and differences in urine culture collection indicate an inconsistent approach to treatment and missed opportunity to course correct in cases of pathogen resistance. Disclosures Cara Grimes, MD, MAS, Johnson and Johnson: Expert Testimony|Provepharm, Inc: Advisor/Consultant.

564. Patient and Prescriber Characteristics Associated with Inappropriately Long Antibiotic Duration for Skin and Soft Tissue Infections

Abstract Background For common infections, previous studies suggest more seasoned prescribers more commonly use inappropriately long antibiotic durations however, there is a paucity of data regarding patient and provider factors associated with antibiotic prescription duration for pediatric skin and soft tissue (SSTI). Methods Retrospective analysis of patients age 0-21 years prescribed enteral antibiotics for cellulitis, abscess, impetigo, or other SSTI in one of 13 Nationwide Children’s Hospital’s primary care clinics in 2020. Encounters for paronychia, facial abscess, and immunocompromised patients were excluded. Based on national and local SSTI guidelines, antibiotic duration was considered inappropriately long if >5 days for cellulitis or drained abscess or >7 days for undrained abscess, impetigo, or other SSTI. Patient and prescriber factors were collected (Table 1) then univariate and multivariable analyses performed to determine which factors were associated with long antibiotic duration. Statistical analyses accounted for within prescriber correlation. Results From 1/1/2020 to 12/31/2020, we identified 1248 encounters for SSTI. After exclusions, 577 encounters with enteral prescriptions written by 89 prescribers were analyzed. Patient age ranged from 11 days to 20 years, 314 (54%) were female, and 497 (86%) had public insurance. The most common diagnosis was impetigo in 165 (29%). Similar rates of long duration were seen across patients of all ages and insurance categories. No difference in prescriber degree type was associated with antibiotic duration. Mean years since completion of medical training for prescribers of long vs guideline concordant prescriptions was 13 vs 10 in univariate analysis (p=.001). In the multivariable analysis, only diagnosis was associated with increased odds of long duration (Table 2). Compared to impetigo, the adjusted odds ratio for inappropriately long duration was 9.36 for cellulitis and 2.03 for abscess. Patient and Prescriber Characteristics for SSTI Antibiotic Prescriptions IQR, interquartile range, MD, Doctor of Medicine, DO, Doctor of Osteopathic Medicine, NP, Nurse Practitioner †Mann Whitney ‡Fisher’s exact *Chi-square ¶N=556 due to missing data for 21 encounters Multivariable Analysis of Patient and Provider Factors and Inappropriately Long Antibiotic Duration for SSTI Multivariable Analysis of Patient and Provider Factors and adjusted odds ratios for inappropriately long antibiotic duration. *Unknown insurance type for 24 encounters †Missing data for 21 encounters Conclusion In this study of antibiotic duration for SSTI, diagnosis of cellulitis was most strongly associated with inappropriately long duration- providing a focus for future stewardship efforts. Contrary to prior studies, no other patient or provider factor was associated with long duration in our pediatric primary care network. Disclosures Jack Stevens, PhD, Colgate Palmolive (although this abstract does not pertain to any products/services of that highly diversified company): Stocks/Bonds|Procter and Gamble (although this abstract does not pertain to any products/services of that highly diversiified company): Stocks/Bonds.

Short-course antibiotic therapy: The next frontier in antimicrobial stewardship.

Ensuring appropriate use of antibiotics is critical to preserving their effectiveness through limiting the development and spread of antimicrobial resistance. Evidence is accumulating that shorter courses of antibiotics are as effective as traditional longer regimens for many common infections and can reduce the risk of adverse events. Despite the availability of evidence and guidelines supporting short-course antibiotic therapy for these conditions, prolonged use of antibiotics remains common. This article will review the origins and evolution of our approach regarding antimicrobial prescription duration, the evidence for the use of short-course therapy for selected infections, barriers to the uptake of this practice and potential approaches that can be taken to reduce inappropriately long antibiotic use.

Changing patterns of opioid initiation for pain management in Ontario, Canada: A population-based cross-sectional study.

The recent publication of a national guideline and quality standards in Canada have provided clinicians with new, evidence-based recommendations on safe, appropriate opioid use. We sought to characterize how well opioid initiation practices aligned with these recommendations before and following their release. We conducted a population-based study among people initiating opioids prior to the release of national guidelines (April 2015-March 2016; fiscal year [FY] 2015) and in the most recent year available (January-December 2019) in Ontario, Canada. We used linked administrative claims data to ascertain the apparent indication for opioid therapy, and characterized the initial daily dose (milligrams morphine or equivalent; MME) and prescription duration for each indication. In FY2015, 653,885 individuals commenced opioids, compared to 571,652 in 2019. Over time, there were small overall reductions in the prevalence of initial daily doses exceeding 50MME (23.9% vs. 20.1%) and durations exceeding 7 days (17.4% vs. 14.8%); but the magnitude of the reductions varied widely by indication. The prevalence of high dose (>50MME) initial prescriptions reduced significantly across all indications, with the exception of dentist-prescribed opioids (13.6% vs. 12.1% above 50MME). In contrast, there was little change in initial durations exceeding 7 days across most indications, with the exception of some surgical indications (e.g. common excision; 9.3% vs. 6.2%) and among those in palliative care (35.2% vs. 29.2%). Despite some modest reductions in initiation of high dose and long duration prescription opioids between 2015 and 2019, clinical practice is highly variable, with opioid prescribing practices influenced by clinical indication. These findings may help identify medical specialties well-suited to targeted interventions to promote safer opioid prescribing.

Risks of complicated acute appendicitis in patients with psychiatric disorders

BackgroundAcute appendicitis often presents with vague abdominal pain, which fosters diagnostic challenges to clinicians regarding early detection and proper intervention. This is even more problematic with individuals with severe psychiatric disorders who have reduced sensitivity to pain due to long-term or excessive medication use or disturbed bodily sensation perceptions. This study aimed to determine whether psychiatric disorder, psychotropic prescription, and treatment compliance increase the risks of complicated acute appendicitis.MethodsThe diagnosis records of acute appendicitis from four university hospitals in Korea were investigated from 2002 to 2020. A total of 47,500 acute appendicitis-affected participants were divided into groups with complicated and uncomplicated appendicitis to determine whether any of the groups had more cases of psychiatric disorder diagnoses. Further, the ratio of complicated compared to uncomplicated appendicitis in the mentally ill group was calculated regarding psychotropic dose, prescription duration, and treatment compliance.ResultsAfter adjusting for age and sex, presence of psychotic disorder (odds ratio [OR]: 1.951; 95% confidence interval [CI]: 1.218–3.125), and bipolar disorder (OR: 2.323; 95% CI: 1.194–4.520) was associated with a higher risk of having complicated appendicitis compared with absence of psychiatric disorders. Patients who are taking high-daily-dose antipsychotics, regardless of prescription duration, show high complicated appendicitis risks; High-dose antipsychotics for < 1 year (OR: 1.896, 95% CI: 1.077–3.338), high-dose antipsychotics for 1–5 years (OR: 1.930, 95% CI: 1.144–3.256). Poor psychiatric outpatient compliance was associated with a high risk of complicated appendicitis (OR: 1.664, 95% CI: 1.014–2.732).ConclusionsThis study revealed a close relationship in the possibility of complicated appendicitis in patients with severe psychiatric disorders, including psychotic and bipolar disorders. The effect on complicated appendicitis was more remarkable by the psychiatric disease entity itself than by psychotropic prescription patterns. Good treatment compliance and regular visit may reduce the morbidity of complicated appendicitis in patients with psychiatric disorders.

Probiotics in Periodontal and Peri-Implant Health Management: Biofilm Control, Dysbiosis Reversal, and Host Modulation.

Periodontitis and peri-implantitis are microbially associated diseases of the tissues supporting the teeth and dental implants that are mediated by host inflammation and eventually lead to tooth and dental implant loss. Given the probiotics' role in biofilm control, dysbiosis reversal, and host modulation, their potential beneficial effects on the improvement of periodontitis and peri-implantitis have been recently investigated. Moreover, probiotics use has also been proposed in periodontal health management in patients undergoing fixed orthodontic therapy. Therefore, the present study aimed to review, considering the periodontal microbiome composition around teeth and dental implants in healthy and pathological conditions, the putative favorable effects of probiotics on gingivitis, periodontitis, and peri-implantitis. The secondary aim of the present narrative review was to synthesize the supporting evidence and proposed protocols for probiotics use as adjuncts in periodontitis and peri-implantitis treatment and the periodontal health management of orthodontic patients with fixed appliances. Contrasting findings from the literature may be due to the different methods, posology, and duration of probiotics prescriptions and due to the heterogeneous biological and clinical measurement methods employed. Thus, no definitive conclusions could be drawn about the effectiveness of probiotics in periodontal management, both in healthy and pathological conditions. Further studies are needed to validate probiotics for periodontal management and provide recommended protocols.

Improving Duration of Antibiotics for Skin and Soft-tissue Infections in Pediatric Urgent Cares.

National guidelines recommend a 5- to 7-day course of antibiotics for most skin and soft-tissue infections (SSTIs). Our aim was to increase the percentage of pediatric patients receiving 5 to 7 days of oral antibiotics for SSTIs in our pediatric urgent care clinics (UCCs) from 60% to 75% by December 31, 2021. We performed cause-and-effect analysis and surveyed UCC providers to uncover reasons for hesitation with short antibiotic courses for SSTIs. Plan- Do-Study-Act (PDSA) cycle 1 provided an update on current guidelines for UCC providers and addressed providers' concerns. PDSA cycle 2 modified the electronic health record to display antimicrobial prescription sentences from shortest to longest duration. PDSA cycle 3 provided project outcome and balancing measure updates to UCC providers at regular intervals. We created a monthly report of patients 90 days and older in UCCs with a final diagnosis of SSTIs. We used a Shewhart control chart to identify special cause variations. After completing our PDSA cycles, we found that the percentage of children receiving 5 to 7 days of oral antibiotics for SSTIs exceeded 85%. The improvement was sustained over multiple months. There was no increase in the proportion of patients returning to the UCCs with an SSTI diagnosis within 14 days. By addressing primary drivers uncovered through quality improvement methodology, we shortened the antibiotic course for children seen in our UCCs with SSTIs. Outpatient antimicrobial stewardship programs may apply similar methods to other diagnoses to further improve duration of antibiotic prescriptions.

Prescribing Pattern of Benzodiazepine Receptor Agonists (BZRA) and Factors Associated With Duration of BZRA Use in a Malaysian Psychiatry Outpatient Clinic

Introduction: Benzodiazepine receptor agonist (BZRA) are among the most frequently used psychotropic medications worldwide. We aim to understand the pattern of prescription of BZRA in the government healthcare facilities and identify factors affecting the likelihood of BZRA prescription and duration of use. Method: This is a retrospective study. Data was obtained from record of outpatient clinical notes. Medications studied were midazolam, alprazolam, lorazepam, bromazepam, clonazepam, diazepam and zolpidem. Mean duration per prescription, mean dosage per prescription and duration per patient per year were calculated for each sedative hypnotic. The likelihood of factors affecting duration of prescription were also analysed. Results: The prevalence of sedative hypnotic use in psychiatry outpatient clinic was 12.16%. Clonazepam was found to have the longest duration per patient per year (306.5 days). Insomnia and anxiety are the two most common reasons for sedative hypnotic prescription. Factors found to affect duration of prescription were unemployment, borderline personality disorder, alcohol and substance use disorders. Conclusion: Implementation of effective monitoring system on sedative hypnotic prescribing and increase use of non-pharmacological interventions for insomnia and anxiety are necessary to curb prolonged use of sedative hypnotic.

Evaluation of the prescription pattern of ferrous sulfate as a therapy for preventing iron deficiency anemia in infants.

Iron deficiency prevalence in infants is high. Therefore, iron supplementation has been recommended and specified as a program. This study aimed to determine the characteristics of the prescription of ferrous sulfate as a preventive therapy for iron deficiency anemia in young infants. We conducted a descriptive cross-sectional study of clinical records of young infants with eight visits per year. We analyzed a total of 287 records. The prescription characteristics included five criteria prescription indication, age at prescription, dosage, periodicity, and time. These characteristics were scored as follows 1 point when it was considered adequate and 0 when it was considered inadequate; the minimum possible score was 0, and the maximum possible score was 5 points. Statistical analysis included percentages and 95% confidence intervals (CI). The prescription pattern of ferrous sulfate as preventive therapy in infants under one year of age was indicated in 100% of the records reviewed. All five criteria were met in 18.1% of the reviewed records (95%CI 13.6-22.6). The lowest compliance corresponded to adequate dosage (29.2%; 95%CI 23.9-34.5). Age at prescription was correct in 75.9% (95%CI 70.9-80.9); duration of prescription was correct in 44.2% (95%CI 38.4-50.0), and periodicity was proper in 31.1% (95%CI 25.9-36.7) of the files reviewed. Compliance with the prescription of ferrous sulfate as a preventive measure for anemia in infants was not as expected; interventions are needed to reverse this behavior.

CDC Clinical Practice Guideline for Prescribing Opioids for Pain - United States, 2022.

This guideline provides recommendations for clinicians providing pain care, including those prescribing opioids, for outpatients aged ≥18 years. It updates the CDC Guideline for Prescribing Opioids for Chronic Pain - United States, 2016 (MMWR Recomm Rep 2016;65[No. RR-1]:1-49) and includes recommendations for managing acute (duration of <1 month), subacute (duration of 1-3 months), and chronic (duration of >3 months) pain. The recommendations do not apply to pain related to sickle cell disease or cancer or to patients receiving palliative or end-of-life care. The guideline addresses the following four areas: 1) determining whether or not to initiate opioids for pain, 2) selecting opioids and determining opioid dosages, 3) deciding duration of initial opioid prescription and conducting follow-up, and 4) assessing risk and addressing potential harms of opioid use. CDC developed the guideline using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework. Recommendations are based on systematic reviews of the scientific evidence and reflect considerations of benefits and harms, patient and clinician values and preferences, and resource allocation. CDC obtained input from the Board of Scientific Counselors of the National Center for Injury Prevention and Control (a federally chartered advisory committee), the public, and peer reviewers. CDC recommends that persons with pain receive appropriate pain treatment, with careful consideration of the benefits and risks of all treatment options in the context of the patient's circumstances. Recommendations should not be applied as inflexible standards of care across patient populations. This clinical practice guideline is intended to improve communication between clinicians and patients about the benefits and risks of pain treatments, including opioid therapy; improve the effectiveness and safety of pain treatment; mitigate pain; improve function and quality of life for patients with pain; and reduce risks associated with opioid pain therapy, including opioid use disorder, overdose, and death.

Naltrexone for alcohol use disorder: Hepatic safety in patients with and without liver disease.

Naltrexone is an approved drug for management of alcohol use disorder (AUD), but data in patients with liver disease (LD) are limited. We aimed to evaluate the safety of naltrexone in those with LD. This is a retrospective cohort of adults with and without LD who were prescribed naltrexone for AUD from 2015 to 2019 in a safety-net setting. Naltrexone hepatic safety was determined by liver enzyme changes during and after compared to before naltrexone prescription as well as rates of subsequent hospitalization and death by Kaplan-Meier methods. Factors associated with hospitalization were examined by Cox regression. Of 160 patients prescribed naltrexone for AUD, 100 (63%) had LD and 47 (47%) of those with LD had cirrhosis (47% decompensated). The total cohort, LD, and cirrhosis groups had lower adjusted mean aspartate aminotransferase and alanine aminotransferase levels after versus before naltrexone prescription (p < 0.001). Two-year survival was 97.7% (95% confidence interval [CI], 84.6-99.7), 95.4% (95% CI, 82.8-98.8), 90.8% (95% CI, 73.5-97.0), and 81.3% (95% CI, 41.2-93.8) in those without LD, LD without cirrhosis, cirrhosis, and decompensated cirrhosis groups (p=0.46), respectively. Alcohol-related 2-year hospitalization rates were 8.2% (95% CI, 2.7-24), 27.7% (95% CI, 16.6-44.0), 40.5% (95% CI, 24.8-61.6), and 41.7% (95% CI, 23.3-66.6) for the groups without LD, LD without cirrhosis, cirrhosis, and decompensated cirrhosis (p=0.007), respectively. Independent predictors of subsequent hospitalization were LD, (hazard ratio [HR], 3.70; 95% CI, 1.19-11.51; p=0.02), cirrhosis (HR, 5.16; 95% CI, 1.69-15.75), and shorter duration (≤30 days) of naltrexone prescription (HR, 2.50; 95% CI, 1.l2-5.20; p=0.01). Conclusion: Naltrexone is safe to use in patients with underlying LD, including those with compensated cirrhosis. Although encouraging, more safety data are needed for those with decompensated cirrhosis.

Effects of Opioid Prescribing Cap Laws on Opioid and Other Pain Treatments Among Persons with Chronic Pain.

Many states have adopted laws that limit the amount or duration of opioid prescriptions. These limits often focus on prescriptions for acute pain, but there may be unintended consequences for those diagnosed with chronic pain, including reduced opioid prescribing without substitution of appropriate non-opioid treatments. To evaluate the effects of state opioid prescribing cap laws on opioid and non-opioid treatment among those diagnosed with chronic pain. We used a difference-in-differences approach that accounts for staggered policy adoption. Treated states included 32 states that implemented a prescribing cap law between 2017 and 2019. A total of 480,856 adults in the USA who were continuously enrolled in medical and pharmacy coverage from 2013 to 2019 and diagnosed with a chronic pain condition between 2013 and 2016. Among individuals with chronic pain in each state: proportion with at least one opioid prescription and with prescriptions of a specific duration or dose, average number of opioid prescriptions, average opioid prescription duration and dose, proportion with at least one non-opioid chronic pain prescription, average number of such prescriptions, proportion with at least one chronic pain procedure, and average number of such procedures. State laws limiting opioid prescriptions were not associated with changes in opioid prescribing, non-opioid medication prescribing, or non-opioid chronic pain procedures among patients with chronic pain diagnoses. These findings do not support an association between state opioid prescribing cap laws and changes in the treatment of chronic non-cancer pain.

State prescribing cap laws’ association with opioid analgesic prescribing and opioid overdose

IntroductionIn response to the role of opioid prescribing in the U.S. opioid crisis, states have enacted laws intended to curb high risk opioid prescribing practices. This study assessed the effects of state prescribing cap laws that limit the dose and/or duration of dispensed opioid prescriptions on opioid prescribing patterns and opioid overdose. MethodsWe identified 1,414,908 adults from a large U.S. administrative insurance claims database. Treatment states included 32 states that implemented a prescribing cap law between 2017 and 2019. Comparison states included 16 states and DC without a prescribing cap law by 2019. A difference-in-differences approach with staggered policy adoption was used to assess effects of these laws on opioid analgesic prescribing and opioid overdose. ResultsState opioid prescribing cap laws were not associated with changes in the proportion of people receiving opioid analgesic prescriptions, the dose or duration of opioid prescriptions, or opioid overdose. States with laws that imposed days’ supply limits only versus days’ supply and dosage limits, as well as with specific law provisions also showed no association with opioid prescribing or opioid overdose outcomes. ConclusionsState opioid prescribing cap laws did not appear to impact outcomes related to opioid analgesic prescribing or opioid overdose. These findings are potentially due to the limited scope of these laws, which often apply only to a subset of opioid prescriptions and include professional judgment exemptions.

Appropriateness of surgical antimicrobial prophylaxis in a teaching hospital in Ghana: findings and implications.

BackgroundSurgical site infections (SSIs) are among the most common infections seen in hospitalized patients in low- and middle-income countries (LMICs), accounting for up to 60% of hospital-acquired infections. Surgical antimicrobial prophylaxis (SAP) has shown to be an effective intervention for reducing SSIs and their impact. There are concerns of inappropriate use of SAP in Ghana and therefore our audit in this teaching hospital.MethodsA retrospective cross sectional clinical audit of medical records of patients undergoing surgery over a 5 month duration from January to May 2021 in Ho Teaching Hospital. A data collection form was designed to collect key information including the age and gender of patients, type and duration of surgery, choice and duration of SAP. The collected data was assessed for the proportion of SAP compliance with Ghana Standard Treatment Guidelines (STGs) and any association with various patient, surgical wound and drug characteristics.ResultsOf the 597 medical records assessed, the mean age of patients was 35.6 ± 12.2 years with 86.8% (n = 518) female. Overall SAP compliance with the STG was 2.5% (n = 15). SAP compliance due to appropriate choice of antimicrobials was 67.0% (n = 400) and duration at 8.7% (n = 52). SAP compliance was predicted by duration of SAP (P < 0.000) and postoperative hospitalization duration (P = 0.005).ConclusionsSAP compliance rate was suboptimal, principally due to a longer duration of prescription. Quality improvement measures such as education of front-line staff on guideline compliance, coupled with clinical audit and regular updates, are urgently needed to combat inappropriate prescribing and rising resistance rates.

35185 Impact of telehealth on duration of tetracycline prescription during COVID-19

The impact of the COVID-19 pandemic caused more dermatology providers than ever before to turn to telemedicine and virtual visits to safely arrange clinic appointments during lockdowns. Doxycycline and minocycline are two commonly used tetracycline antibiotics that are frequently prescribed by dermatologists for their effective anti-inflammatory properties and good safety profile. This study aimed to evaluate whether virtual visits during COVID-19 impacted duration of doxycycline prescription and determine whether provider type (physician assistant, resident, fellow, or staff attending) affected duration of doxycycline prescription. A retrospective cohort was designed using all documented pharmaceutical prescriptions of doxycycline in 2019 and 2020 prescribed by dermatology providers at the University of Iowa Hospitals. Preliminary results show an overall increase in telemedicine visits from 13.73%, in 2019 compared with 38.13% in 2020 (P < .0001). Analysis also demonstrates that only 25.42% of total in-person dermatology visits resulted in a doxycycline prescription of less than 31 days vs. 47.49% of total virtual visits (P < .0001). However, despite demonstrated increase in virtual visits in 2020, year did not seem to play a factor in the duration of antibiotic prescription with instances of duration being almost equal between 2019 and 2020 (P < .0001). In this era of increasing telehealth, the demonstrated decrease in duration of doxycycline prescription in virtual visits is perhaps indicative of increased accessibility afforded by teledermatology. Future studies might explore factors related to provider decision-making in virtual visits compared with in-person visits and holds implications for how televisits may play an increasingly greater role in acne management.

Therapeutic drug monitoring of teriflunomide: do plasma concentrations predict response to leflunomide in patients with rheumatoid arthritis?

Leflunomide is a commonly used treatment for rheumatoid arthritis. It acts by inhibiting dihydroorotate dehydrogenase through its active metabolite teriflunomide. The objective of the study was to investigate the relation between plasma-concentration of teriflunomide and disease-activity in rheumatoid arthritis. Data were collected from patients with rheumatoid arthritis on a stable leflunomide dose for at least 2months. Socio-demographic data, disease characteristics and DAS28 score were recorded. Blood samples were taken for determination of teriflunomide concentration. A total of 32 serum concentration-time measurements were collected. The concentration of teriflunomide was positively correlated with disease duration of RA (r2=0.2264) and the number of swollen joints (r2=0.2413). There was a trend towards a positive correlation between Health Assessment Questionnaire (HAQ) and plasma teriflunomide concentration (r2=0.1699). Weight was negatively correlated with the residual plasma concentration of teriflunomide (r2=0.2483). However, there was no significant correlation between residual-plasma-concentration of teriflunomide and the following parameters: age, sex,number of tender painful joints, patient-global-assessment, C-reactive protein (CRP) and duration of prescription of leflunomide. We did not find association between disease-activity and residual-plasma-concentration of teriflunomide (r2=0.0021) and haven't been able to define the threshold value of residual-plasma-concentration of leflunomide predictive of a good-response. We did not find a concentration-effect-relationship. However, therapeutic drug monitoring of teriflunomide may be useful to ensure adherence and evaluate toxic-levels in case of adverse-events.

Evaluation of factors associated with medication adherence in patients with bipolar disorder using a medication event monitoring system: a 6‐month follow‐up prospective study

BackgroundNon-adherence in patients with bipolar disorder (BD) results in symptoms, such as aggravation, BD recurrence, emergency room visits, re-hospitalization, and poor psychosocial outcomes. Though non-adherence rates have been reported to range between 30–50% in patients with BD, the problem of adherence is often either overlooked by the physician or denied by the patient. An essential first step to enhancing medication adherence is to objectively estimate adherence. The Medication Event Monitoring System (MEMS), which is a pill bottle cap with a microprocessor, is an accurate device for assessing medication adherence. Using the MEMS, we aimed to measure medication adherence in patients with BD and evaluate the factors associated with and 6-month changes in medication adherence.MethodsParticipants with BD were recruited from the psychiatric outpatient clinic of the Korea University Guro Hospital. The medication adherence of each participant was assessed using the MEMS, a self-report, pill count, and clinician rating. MEMS-measured adherence was reassessed after 6 months. Patient demographics were recorded and clinical assessments were conducted. Data were analyzed using Kappa statistics and Pearson’s correlation analysis.ResultsOf the 59 participants, 50 records were included in the analysis. Patient adherence and adherence rate assessed by the MEMS were lower than those assessed by the other measures. MEMS-measured adherence was correlated more closely with pill counts than with self-reports or clinician ratings. MEMS-measured adherence was negatively associated with prescription duration and the Brief Psychiatric Rating Scale—Affect Subscale Score. Six-month changes in MEMS-measured adherence were positively associated with attitude toward drugs and negatively associated with weight gain assessed by the Udvalg for Kliniske Undersøgelser Side Effect Rating Scale.ConclusionsClinicians may have to consider the limited accuracy of self-reporting and clinician rating methods and exercise caution when assessing the medication adherence of patients with BD using these methods. Our findings may assist clinicians in the assessment and improvement of medication adherence in patients with BD and, consequently, may be useful for the treatment and prevention of BD recurrence.

75. Opioid-free and awake TLIF surgery with a novel interfascial block

<h3>BACKGROUND CONTEXT</h3> Despite a significant rise in prescription opioid-related overdose deaths in the last decade and the US Department of Health declaring the opioid epidemic a national emergency in 2017, median opioid prescription duration remains the longest for spine surgery with 12.6 days, prompting a demand for alternatives to opioid medication in spine surgery-related analgesia. Thoraco-lumbar interfascial plane (TLIP) block [10, 11] is an ultrasound-guided interfascial block that has shown promising results in reducing opioid consumption in non-instrumented spine surgery procedures. <h3>PURPOSE</h3> The aim of this study was to evaluate the efficacy in reducing postoperative pain and opioid analgesia of a novel interdisciplinary strategy combining preoperative thoraco-lumbar interfascial plane (TLIP) block and instrumented percutaneous/endoscopic TLIF surgery. Secondary aims were to determine the time to first postoperative ambulation and hospital length of stay. <h3>STUDY DESIGN/SETTING</h3> This is a prospective study with a retrospective control cohort. <h3>PATIENT SAMPLE</h3> Forty-two patients who underwent elective single-level percutaneous/endoscopic TLIF surgery between 2015 and 2021. A TLIP group with 17 patients prospectively underwent TLIP block before surgery and non-TLIP (control) group with 25 patients obtained standard opioid analgesia. Both groups received the same postoperative analgesia with morphine as patient-controlled rescue medication. <h3>OUTCOME MEASURES</h3> Visual analogic scale (VAS) and Oswestry Disability Index (ODI) scores were evaluated. Statistical evaluation was performed with Student's t-test. <h3>METHODS</h3> For the TLIP group, ultrasound-guided bilateral TLIP was performed in prone position with bupivacaine 0.25% and dexamethasone 8mgrs (20 ml each side) by the anesthesia team. All patients were operated on under general anesthesia (protocol: propofol 2.0-3.0 mcg/ml (TCI) following BIS, ketamine 0.15 mg/Kg/h, rocuronium 0.4 mg/Kg). Percutaneous TLIF was performed by inserting an expandable interbody implant using the facet-sparing, trans-Kambin approach with an endoscopic cannula and complemented with a percutaneous posterior fixation consisting of transpedicular screws and rods. Postoperative analgesia included NSAIDs and acetaminophen. intravenous morphine was administered with a PCA pump consisting of a bolus of 20mcg/kg with interval lock-out of 15 minutes and a maximum of 3 bolus per hour. The use of the PCA pump was monitored. <h3>RESULTS</h3> In contrast to the non-TLIP group, the TLIP group's postoperative, mean VAS back scores as well as mean ODI significantly decreased from 6.6 to 3.3 (P <0.01) and 32.8 to 23.6 (P <0.01) at hospital discharge. No differences were found between both groups at one month. The overall mean follow-up was 29±18 (3–78) months. Non-TLIP group patients were administered a median postoperative 24-hour morphine dose equivalent (MDE) of 23 (range, 8-31) mgr, while TLIP group patients did not require opioid analgesia (P <0.01). TLIP Group patients started postoperative ambulation at a median of 4.1 (range, 2.5–26) hours with a median hospital length-of-stay of 24 [range, 20–48] hours (P=0.112). <h3>CONCLUSIONS</h3> TLIP block significantly improves patient outcome at hospital discharge after TLIF surgery without postoperative administration of opioids. A prospective study is recommended to confirm our preliminary results. <h3>FDA DEVICE/DRUG STATUS</h3> Globus Rise (Approved for this indication), Bupivacaine (Approved for this indication)

EP-3 Quality improvement project analysing the impact on antimicrobial prescribing in a General Surgery department after introducing access to guidelines via a mobile phone app

Abstract Introduction Antimicrobial prescribing forms a central pillar of treatment in surgical admissions. This project aimed to analyse the impact of increasing access to antimicrobial guidelines for doctors in a general surgical department via mobile and laptop apps. Prior to this guidelines were only available in a pdf format accessible via the trusts intranet. Method An initial audit of 238 antimicrobial prescription from 109 patients in the month of October 2020 was performed. The data was collected was compared against the antimicrobial stewardship NICE guidelines (NG 15 1.1.2.4). This showed that only 57% of antibiotic prescriptions were in line with the correct treatment guidelines. After discussion with the lead microbiology consultant and lead pharmacist, trust guidelines were introduced for the first time on the Micro-guide, made accessible to all doctors via the mobile app and laptops. Information was circulated within the surgical department via educational posters and a presentation. 6 months later we closed the audit look. We aimed to review whether increasing access via technological means would lead to greater standards of antimicrobial prescribing. Results Results following the increasing the access to guidelines significantly improved the accuracy of antibiotic prescriptions. Some improvement was also seen in the other parameters such as documentation of indication and duration of antibiotic prescriptions. Conclusion It is evident that improving access to trust guidelines via trusted mobile applications and trust laptops can facilitate improvement in antimicrobial stewardship standards and help slow the emergence of resistance in communities.