Medication Guidelines Research Articles

Lipid Management in the Primary Health Care Settings in China: Results from the China-PEACE Million Persons Project and Primary Health Care Survey

Background: Dyslipidemia, historically rare in China, may be common but has not been well studied. Methods: We used data from the China-PEACE (Patient-Centered Evaluative Assessment of Cardiac Events) Million Persons Project, a national cardiovascular disease screening project that enrolled 2·6 million community residents aged 35-75 in all 31 provinces from September 2014 through November 2018, and the China-PEACE primary health care survey of 3 529 primary care institutions. We assessed the prevalence, treatment, and control of dyslipidemia in community residents and the availability of lipid-lowering medications in primary care institutions. Findings: Among 2 314 858 participants with lipid measurements, one third (782 184; 33·8%) had dyslipidemia. Of 71 793 participants who had established atherosclerotic cardiovascular disease (ASCVD) and were recommended by guidelines for lipid-lowering medications regardless of low-density lipoprotein cholesterol (LDL-C) levels, 10 121 (14 ·1%) were treated and of those treated, 4 535 (44·8%) achieved LDL-C ≤70 mg/dL. Of 236 666 participants who had high risk of ASCVD, 101 511 (42·9%) achieved LDL-C ≤ 100 mg/dL. Advanced age, female sex, non-Han ethnicity, lower income, smoking, alcohol consumption, non-diabetes in participants with established ASCVD and younger age, female sex, non-Han ethnicity in participants with high risk of ASCVD were associated with lower control of LDL-C (all p<0·01). Of 3 529 primary care institutions surveyed, 49·7% stocked statin and 19·2% stocked non-statin lipid-lowering drugs. Village clinics in rural areas had the lowest statin availability. Interpretation: Dyslipidemia has become a major public health problem in China and is often inadequately treated and uncontrolled. Strategies aimed at detection, prevention, and treatment are needed. Funding Statement: The National Key Research and Development Program from the Ministry of Science and Technology of China (2018YFC1312400, 2018YFC1312401, 2018YFC1312404, 2017YFC1310800); the CAMS Innovation Fund for Medical Science (2016-I2M-1-006, 2017- I2M-2-002, 2017-I2M-BR the Major Public Health Service Project from the Ministry of Finance and National Health and Family Planning Commission of China; the 111 Project from the Ministry of Education of China (B16005). Declaration of Interests: HMK discloses that he is a recipient of a research grant, through Yale, from Medtronic and the U.S. Food and Drug Administration to develop methods for post-market surveillance of medical devices; is a recipient of research agreements with Medtronic and Johnson & Johnson (Janssen), through Yale, to develop methods of clinical trial data sharing; works under contract with the Centers for Medicare & Medicaid Services, through Yale, to develop and maintain performance measures that are publicly reported; was a recipient of a research agreement, through Yale, from the Shenzhen Center for Health Information for work to advance intelligent disease prevention and health promotion, and collaborates with the National Center for Cardiovascular Diseases in Beijing; received payment from the Arnold & Porter Law Firm for work related to the Sanofi clopidogrel litigation and from the Ben C. Martin Law Firm for work related to the Cook IVC filter litigation; chairs a Cardiac Scientific Advisory Board for UnitedHealth; is a participant/participant representative of the IBM Watson Health Life Sciences Board; is a member of the Advisory Boards for Element Science and for Facebook, and the Physician Advisory Board for Aetna; and is the founder of Hugo, a personal health information platform. WS is a consultant for Hugo, a personal health information platform. All other authors declare no competing interests. Ethics Approval Statement: The central ethics committee at the China National Center for Cardiovascular Disease and the Institutional Review Board at Yale University approved this project. All enrolled participants provided written informed consent.

A review of a recently published guidelines' "strong recommendation" for therapeutic drug monitoring of olanzapine, haloperidol, perphenazine, and fluphenazine.

IntroductionIn addition to clozapine, there is a growing body of evidence that supports therapeutic drug monitoring (TDM) for additional antipsychotics commonly used in the United States.MethodsThe Arbeitsgemeinschaft für Neuropsychopharmakologie und Pharmakopsychiatrie (AGNP) published TDM guidelines for several psychiatric medications. Sources were identified that the authors used to establish therapeutic reference ranges for haloperidol, fluphenazine, perphenazine, and olanzapine—4 antipsychotics commonly used in the United States with a “strong recommendation” for TDM. The sources were then reviewed for content and appropriateness for utilization in establishing the reference ranges.ResultsOlanzapine had 15 citations, haloperidol had 9, perphenazine had 4, and fluphenazine had 2. The studies' methods were reviewed along with the proposed therapeutic reference ranges.DiscussionSeveral limitations of the guidelines were identified. Reference ranges were suggested based on studies of patients with various diagnoses; some patients had an acute exacerbation, and others were in a maintenance phase. An additional publication was identified that reviewed similar (and additional) TDM studies; those conclusions were in slight contrast with those of the AGNP guidelines. In the future, guidance should be given to those looking to conduct TDM studies to standardize methods and make meta-analysis of this data more feasible.

Evaluation of Methylphenidate Safety and Maximum-Dose Titration Rationale in Attention-Deficit/Hyperactivity Disorder

Evidence on the titration of stimulant medications for attention-deficit/hyperactivity disorder (ADHD) is lacking. However, this lack of evidence has not prevented medication guidelines from specifying apparently arbitrary dose limitations, which could discourage clinicians from titrating methylphenidate to higher and, perhaps for some patients, more efficacious doses. To determine the evidence on dose titration and adverse events associated with dose titration of stimulants for ADHD. MEDLINE from 1946, Embase from 1974, and PsycINFO from 1806 through April 1, 2019, were searched to identify relevant articles. The inclusion criteria were that (1) the study was conducted on children up to 18 years of age; (2) children had a diagnosis of ADHD according to the Diagnostic and Statistical Manual of Mental Disorders, or hyperkinetic disorder according to the International Classification of Diseases codes; and (3) the dose of methylphenidate was determined by titration. The PRISMA guidelines for abstracting data and assessing data quality and validity were followed. Quality assessment was undertaken using the Jadad scoring system. Statistical analysis was undertaken using a random-effects model. The outcomes of interest were (1) the doses used in published clinical trials, (2) the clinical justification given by researchers for their selected dose range, and (3) the adverse effects associated with methylphenidate when the dose is established by titration. A total of 11 randomized clinical trials and 38 cohort studies were analyzed. The randomized clinical trials involved 1304 participants treated with methylphenidate and 887 controls; the 38 cohort studies included 5524 participants. Maximum doses of methylphenidate ranged from 0.8 to 1.8 mg/kg/d. Some studies detailed their method of titration, including starting dose, titration interval, increment dose, and maximum dose. Not all of these studies reported justification for the chosen dose range. Common adverse effects of methylphenidate included insomnia (odds ratio, 4.66; 95% CI, 1.99-10.92; P < .001), anorexia (5.11 higher than for those who took placebo; 95% CI, 1.99-13.14; P < .001), abdominal pain (1.9 times more likely; 95% CI, 0.77-4.77; P = .16), and headache (14% of participants; 95% CI, 10%-20%; P < .001). A range of maximum doses for methylphenidate was recommended in clinical studies; no discernable scientific justification for any particular dose was given. Reports of life-threatening adverse events were absent; further studies of the efficacy, tolerability, and safety of methylphenidate titrated purely on clinical grounds, without reference to any set maximum dose, are needed.

Inpatient Medication Errors and Pharmacist Intervention at Ministry of Health Public Hospital, Riyadh, Saudi Arabia

Pharmacology, Toxicology and Biomedical Reports,2019,5,1,44-48.DOI:10.5530/PTB.2019.5.8Published:January 2019Type:Research ArticleAuthors:Yousef Ahmed Alomi, Nesreen Alshabaar, Nadia Lubad, and Fatimah Ali Albusalih Author(s) affiliations:Yousef Ahmed Alomi*, The Past General Manager of General Administration of Pharmaceutical Care Head, National Clinical Pharmacy and Pharmacy Practice Head, Pharmacy R & D Administration, Ministry of Health, Riyadh 11392, SAUDI ARABIA. Nesreen Alshabaar, King Salman Hospital, Ministry of Health, Riyadh 11392, SAUDI ARABIA. Nadia Lubad, King Salman Hospital, Ministry of Health, Riyadh 11392, Riyadh, SAUDI ARABIA. Fatimah Ali Albusalih, College of Clinical Pharmacy, Imam Abdulrahman Bin Faisal University (University of Dammam) Dammam, SAUDI ARABIA. Abstract:Objectives: To explore the inpatient medication errors and pharmacist intervention at Ministry of Health Hospital, Riyadh, Saudi Arabia. Methods: This is a 9-month cross-sectional study conducted at a 300-bed public hospital to evaluate pharmacist response and prevention of inpatient medication errors in adult and pediatric patients. There is a medication safety officer in the hospital along with a medication safety committee. The following information on medication errors were documented in the form available at the hospital: patient’s demographic information, sources of medication errors, time of errors, type of errors, description of errors, causes of errors, recommendation to prevent such errors and the outcome of errors. The form was developed by using the National Coordinating Council (NCC) for Medication Error Reporting and Prevention (MERP) system. Results: According to the results, the pharmacist prevented a total of 3089 medication errors within 805 patients. About 3.8 errors per prescription were prevented. Most of the prevention occurred during prescribing stage (705 (99.2%)). Patient-related errors (1564 (50.63%)) and prescriber-related errors (1435 (46.46%)) were the most type of prevented errors. Allergy was the most prevented subtype of errors (560 (91.4%)) followed by patient’s body weight (543 (88.6%)) and prescriber data missing/unclear (347 (56.6%)). Most of the errors that were prevented were near miss (93.3%) followed by 6.3% of the errors that reached the patient but did not cause any harm. The highest percentage with respect to the causes of medication errors was missing clinical information (649 (83.7%)) and miscommunication of drug order (627 (80.9%)). The top 20 medications involved in medication errors were oral and intravenous injections (Paracetamol and enoxaparin injection, respectively). Conclusion: The pharmacist plays a very crucial role in preventing medication errors. In order to prevent medication errors and improve patient outcome, the pharmacist provides education to the healthcare professional about medication safety and establishes the intravenous medication guidelines. Keywords:Inpatient, Intervention, Medication errors, Ministry of Health, Pharmacist, Riyadh, Saudi ArabiaView:PDF (192.53 KB) PDF PDF Images Table 2A: Pharmacist intervention of stage of medication operation.

Cognition differences and improvement countermeasures of non-technical medical services based on grey correlation analysis

Purpose The purpose of this paper is to explore the rationality differences of cognition of non-technical medical services in different groups, and to provide countermeasures for improving non-technical medical services. Design/methodology/approach Literature analysis, expert interviews, questionnaire survey and frequency analysis were taken to reveal the influencing factors of non-technical medical services. Grey correlation methods were taken to compare the rationality differences of cognition of non-technical medical services by analysis influencing factors’ scores marked by different groups. Findings A total of 12 influencing factors of non-technical medical services were obtained, including “doctor’s working career”, “doctor’s strict implementation of medical treatment norms and medication guidelines”, “doctor’s service awareness”, etc. And rationality differences of cognition of non-technical medical services were confirmed as follows: the doctors’ cognition was more reasonable compared with patients; the women’s cognition was more reasonable compared with men; the lower aged groups’ cognition was more reasonable compared with higher aged groups; and people with doctoral degree had a less reasonable cognition compared with others. Originality/value The authors systematically discussed the cognition differences of non-technical medical services among different people, and provided some countermeasures reasonably.

IN VIVO STAFF EDUCATION TO USE AN OBJECTIVE MEDICATION GUIDELINE IN THE MANAGEMENT OF BPSD BY THE CONSULTING PSYCHIATRIST IN THE LONG TERM SETTING TO REDUCE UNNECESSARY ANTIPSYCHOTIC MEDICATIONS.

Introduction Antipsychotics have had a history of being prescribed at a high rate in nursing homes(NH). 30% of all newly-admitted NH residents received antipsychotic medications in 2006. In 2012, Centers for Medicare & Medicaid Services (CMS) launched the Partnership to Improve Dementia Care in Nursing Homes to promote comprehensive dementia care and therapeutic interventions for NH residents with dementia-related behaviors in partnership with various national organizations. The appropriate use of the medication is still an uneven practice and clinicians often are unclear when to start, continue or stop the medication. We endeavor to present the outcomes following the implementation of the guidelines at our facility. Methods In an 800 bed facility, the psychiatrists implemented a user-friendly objective medication guideline in the management of BPSD, while concurrently providing staff education to the frontline staff beginning 2011.The elements of the guideline include - a) non-medication interventions, b) when to start, continuation and discontinuation criteria. We reviewed changes in antipsychotic medication rate over the past 7 years at the facility while comparing the commensurate national data available in CMS archives from quarter 1 of 2011 (2011Q1) to quarter 1 of 2018 (2018Q1). Results Point prevalence of antipsychotics at the facility in Q1 of each year were 38%(2011), 25%(2012), 12.9%(2013), 13.6%(2014), 14.1%(2015), 14.55%(2016), 11.67%(2017) and 9.14%(2018). The national point prevalence during the same duration were 23.6%(2011), 23.8%(2012), 21.64%(2013), 19.79%(2014), 18.68%(2015), 16.6%(2016), 15.7%(2017) and 14.8%(2018). The point prevalence for the facility went down from 38% in Q1 of 2011 to 9.14% in Q1 of 2018, a decrease of 76%. The national point prevalence during the same duration of 7 years decreased from 23.6% to 14.8%, a decline of 37%. The prevalence for the facility has registered a faster decline than the national average (76% vs 37%). The prevalence of antipsychotics was higher for the facility in 2011 (38% vs 23.6%) and 2012 (25% vs 23.8%) compared to the national average. We are collecting data for the rate of use of psychotropics other than antipsychotics in the management of BPSD at the facility. Conclusions Psychiatry can play a significant role in implementing appropriate medication use guidelines while providing in-vivo education to the primary care team. The guidelines help provide an objective standardized manner of right-sizing the dose or appropriate usage of the medication. It helps involve all stakeholders, including, the psychiatrist, primary care provider, nursing and family, in providing adequate care to the NH residents. Using an objective behavior assessment tool (Neuropsychiatric Inventory Questionnaire - NPI) may further improve medication prescribing practices. The pattern of prescription of other classes of psychotropics will also help rationalize appropriate behavioral management. This research was funded by None.

Prescribing of diabetes medications to people with type 2 diabetes and chronic kidney disease: a national cross-sectional study

BackgroundPrevious studies in general practice and hospital settings have identified that prescribing of non-insulin diabetes medications may be sub-optimal in people with type 2 diabetes (T2D) and renal impairment. Since these publications, a number of new medications have become available for the management of T2D. Study aims were to, in a cohort of Australians with T2D and renal impairment attending general practice, (1) investigate whether the prescribing of non-insulin diabetes medications is consistent with dosing adjustments recommended within current Australian Diabetes Society (ADS) guidelines; and (2) identify patient socio-demographic and clinical factors associated with at least one prescription of a non-insulin diabetes medication inconsistent with current ADS guidelines for medication doses.MethodsCross-sectional study using data from the MedicineInsight general practice database managed by NPS MedicineWise. Patients with T2D who were aged 18 years and over, with an average eGFR< 60 ml/min/1.73m2 and at least one prescription of a non-insulin diabetes medication between 1st January 2015 and 30th June 2017 were included. Descriptive statistics were used to summarise patient characteristics and medication use. Marginal logistic regression models were used to estimate associations between sociodemographic and clinical factors and prescribing of ≥1non-insulin diabetes medicine not consistent with ADS guidelines.ResultsThe majority of the 3505 patients included (90.4%) had an average eGFR of 30-59 ml/min/1.73m2. In terms of absolute numbers, metformin was the medication most frequently prescribed at a dose not consistent with current ADS guidelines for dosing in renal impairment (n = 1601 patients), followed by DPP4 inhibitors (n = 611) and sulphonylureas (n = 278). The drug classes with the highest proportion of prescriptions with dosage not consistent with ADS guidelines were SGLT2 inhibitors (83%), followed by biguanides (58%) and DPP4 inhibitors (46%). Higher HbA1c, longer known diabetes duration and diagnosis of retinopathy were associated with receiving ≥1prescription with a dosage not consistent with guidelines.ConclusionsPrescribing of non-insulin diabetes medications at doses inconsistent with current ADS guideline recommendations for dosing adjustments for people with renal impairment was common. Further research is needed to understand how general practitioners access, interpret and apply the ADS guidelines and the impact this may have on patient outcomes.

Significance of Bone Turnover Marker Measurement in the Treatment of Osteoporosis

The bone turnover marker (BTM) measurement in osteoporosis treatment includes evaluation of bone metabolism status or evaluation of bone loss risk level, determination of fracture risk, and evaluation of drug treatment. Currently, by using the BTM, it has become possible to evaluate and select an effective treatment for osteoporosis. The BTM has become widely used as a clinical test item in actual clinical practice. Patients' low adherence to osteoporosis medication regimens increases the risk of vulnerable fractures and affects the cost effectiveness of therapeutics. A joint working group has been established, with International Federation of Clinical Chemistry and Laboratory Medicine (IFCC) and International Osteoporosis Foundation (IOF) in a central role. The joint policy document of the joint working group is intended to increase the international application of BTM in clinical medicine, and to eliminate blood type I procollagen-N-propeptide (P1NP) and type I collagen cross-linked C-telopeptide (CTX) in observational research and intervention studies, in order to eliminate the inherent uncertainty of these measurements in clinical use. Current osteoporotic drug treatment has been proven to prevent bone fractures, but poor adherence to dosage regimens is an ongoing problem in clinical practice; various attempts have been made to improve adherence. Low adherence to an osteoporosis medication regimen increases the risk of fracture, and affects cost effectiveness. The BTM is an effective indicator in monitoring reactivity to osteoporosis drug therapy, and can be used to individually evaluate guidelines for treatment continuity and medication. In addition, providing BTM information to patients has reportedly improved their adherence to therapeutics, thereby potentially improving both the outcome and cost-effectiveness of osteoporosis drug therapy.

Improved outcome with standardized plan for clinical management of acute decompensated chronic heart failure.

BackgroundOur overall goal is to improve clinical care for inpatients with chronic heart failure (CHF). A retrospective assessment of CHF patients admitted to our hospital over the past decade (2005 vs. 2014) indicated a need for better strategies to evaluate clinical treatment, implement best practices and achieve optimal patient outcome. To that purpose, we developed a standardized plan to improve in-hospital treatment of acute decompensated CHF patients.Methods & ResultsRetrospective chart reviews were conducted to compare three cohorts of CHF patients admitted to the University Hospital of Lund at different time points over a 12-year period: 2005 (365 patients), 2014 (172 patients) and 2017–2018 (57 patients). Little improvement was seen between 2005 and 2014 with respect to one-year mortality (35% vs. 34%) and adequate treatment with recommended medications, e.g., use of renin-angiotensin system blockers (45% vs. 51%). A standardized treatment plan was devised to improve outcomes. A third cohort, treated under the plan (2017–2018), was compared with the 2014 cohort. One-year mortality (18% vs. 34%) and 30-day readmission (5% vs. 30%) were dramatically decreased, and adherence to medication guidelines was achieved. Key elements of the plan included well-defined treatment procedures, enhanced communication and teamwork, education, adequate time for treatment (5 days) and post-discharge follow-up as necessary. Natriuretic peptide (NT-proBNP) levels were useful for assessing patient status, prognosis and response to treatment.ConclusionDevelopment of a standard plan for clinical management of acute decompensated CHF patients resulted in significant improvements in patient outcome, as reflected in decreased rates of 30-day readmission and one-year mortality.

Urban diabetes: a cross-sectional study in a ward of Dhaka metropolitan city

A cross-sectional study was conducted among the inhabitants of the Ward 27 (Bashaboo) of Dhaka Metropolitan City. Out of 52000 people (+20 years, according to the voter list), a total of 450 subjects were selected for interview by purposive sampling. Subjects were categorized as nondiabetic, NDM (n=166) and diabetic, DM (n= 284) groups. The DM group was further categorized after data collection into previously diagnosed diabetes mellitus, DMPD (n= 117) and newly diagnosed diabetes mellitus, DMND (167). Sociodemogrphic, clinical, anthropometric, biochemical, and dietary data were collected using standardized protocols. The findings showed that majority of the respondents were female (60.3%) and belonged to middle income group (Tk 5000-14999) (62.4%). The main clinical complications of the respondents were hypertension (DMPD=26% and DMND=21%), vertigo (DMPD=22% and DMND=27%), joint pain (DMPD=22% and DMND=21%), back pain (DMPD=18% and DMND=20%) and cataract (DMPD=12% and DMND=12%). The level of plasma triglyceride, plasma cholesterol and urine n-albumin were significantly higher among the newly diagnosed DM subjects. The group of middle aged and middle income subjects had significantly higher level of these parameters. The data, therefore, indicate that diabetic related complications among DMND subjects were relatively higher compared to DMPD subjects thus pointing to the notion of a positive effect of a controlled life-style among DMPD patients as per the medication guideline. Bangladesh J. Nutr. Vol. 28-31, December 2018, P: 47-53

Turning Pain into Gain: Evaluation of a Multidisciplinary Chronic Pain Management Program in Primary Care.

ObjectiveTo measure the impact of the multidisciplinary Turning Pain Into Gain program in people experiencing chronic pain of any etiology.MethodsA mixed-methods observational study of 252 participants was used to explore the impact of Turning Pain Into Gain on medication use; quality of life and functioning, as measured by the Pain Self-Efficacy Questionnaire; and self-reported hospitalizations between 2015 and 2016.ResultsResponses from 178 participants showed an increased alignment with Australian pain medication guidelines (e.g., a 7.3% reduction in paracetamol duplication was reported with a concurrent 5.1% rise in the administration of sustained-release paracetamol formulations); improved Pain Self-Efficacy Questionnaire scores from 23.1 (out of a possible score of 60) preprogram to 35.3 postprogram; and a reduction in self-reported hospitalizations from 50 cases in the 12 months preprogram to 11 cases in the 12 months postprogram.ConclusionsPositive medication, Pain Self-Efficacy Questionnaire, and hospitalization changes provide evidence for the broader implementation of similar patient-centered programs to promote more holistic management of diverse types of chronic pain in primary care. Reduced hospitalization reflects potential for this intervention to be cost-effective, which could be investigated further.

Duffy Antigen Phenotyping Is a Useful and Clinically Available Test for Benign Ethnic Neutropenia

Introduction:Benign Ethnic Neutropenia (BEN) is the most common form of neutropenia worldwide and is usually defined as a neutrophil count under 1.5x103/uL without increased infection risk. BEN has been observed predominantly in individuals of African ancestry as well as in certain Middle Eastern ethnic groups. The discovery of neutropenia during routine laboratory testing, however, may prompt extensive workup for infectious, autoimmune, and hematologic disorders. Identifying a readily available test to diagnose BEN in the appropriate ethnic and clinical setting could preempt unnecessary and invasive testing such as a bone marrow aspiration and biopsy and minimize patient anxiety. The absence of the red blood cell (RBC) Duffy antigen, Fy (a- b-), is thought to be responsible for BEN. As the Duffy antigen is utilized by the parasite Plasmodium vivax to enter the RBC, it has been hypothesized that in West Africa, positive selection for the null allele enabled individuals to be protected against infection and have a survival advantage.Aim:Our study examined whether testing for the Fy phenotype could reliably be used as a clinical assay to identify patients with BEN.Methods:Our cases included patients at the VA CT Healthcare System clinically diagnosed with BEN and controls that were chosen randomly from the pools of patients for whom a CBC and type and screen were checked for any other reason. Both probable BEN cases and controls were tested for the Fy phenotype using standard serologic methods in the blood bank. The Fy phenotype, absolute neutrophil count (ANC), white blood cell count (WBC), hemoglobin level, platelet count, and medical diagnoses were extracted from the medical record. Applicable data were compared statistically using the Mann-Whitney U Test with significance set at p < 0.05.Results:Our study included 32 patients (mean age 54, range 21 to 90) who were clinically identified as probable BEN cases and 50 patients (mean age 68, range 38 to 97) chosen as controls. In the probable BEN group, 28 patients self-identified as African American or Black and 3 declined self-identification. In the control group, 11 patients self-identified as African American or Black, 34 self-identified as White, 2 self-identified as Hispanic, 2 declined self-identification, and 1 self-identified as Native Hawaiian. The majority of probable BEN patients (31 of 32) and only a minority of control patients (6 of 50) were Fy (a- b-). Most study patients were male: 30 of 32 probable BEN patients and all control patients were male. The mean ANC count for Fy(a- b-) probable BEN patients was significantly lower than controls (1.68x103/uL versus 5.46x103/uL, p < 0.0001). Similarly, the mean WBC count for Fy (a- b-) probable BEN patients was significantly lower than the mean WBC for controls (3.72 x 103/uL versus 8.14 x 103/uL, p < 0.0001). Hemoglobin was comparable between Fy(a- b-) probable BEN patients and controls (12.91 g/dL versus 11.68 g/dL, p = 0.0673) as were platelets between Fy(a- b-) probable BEN patients and controls (194x103/uL versus 213x103/uL, p = 0.4354). The only African American patient presumed to have BEN that was not confirmed by Fy testing was found to have concurrent diagnoses that could otherwise explain his neutropenia (HIV/HCV). The remaining confirmed BEN cases did not have an accompanying marrow suppressive hematologic disorder. Five control group patients had potentially marrow suppressive hematologic disorders including myelodysplastic syndrome and acute myeloid leukemia.Conclusions:Readily available serologic testing in the blood bank for Duffy antigen phenotyping can be used to confirm suspected BEN in patients with high clinical suspicion. Further testing is in progress of Fy phenotyping comparing controls with neutropenia for any reason to our proposed BEN population to better determine the positive predictive value. Fy phenotyping to confirm BEN suspicion may help avoid unnecessary and invasive neutropenia testing. In addition, since BEN affects certain ethnic groups (primarily those of African ancestry), these individuals may be unfairly excluded from possible treatment including cytopenia-inducing psychiatric medications like clozapine, myelosuppressive chemotherapy, and clinical trials due to ANC eligibility requirements. Fy phenotyping to confirm clinical suspicion of BEN could be a useful tool to help develop modified guidelines for neutropenia-inducing medication. DisclosuresNo relevant conflicts of interest to declare.

Guideline-based medicine grading on the basis of the guidelines of care for ambulatory atopic dermatitis treatment in the United States

This study was designed to assess the adherence to evidence-based guidelines of care for atopic dermatitis (AD). To characterize AD treatment in the United States, ambulatory visits from the 2006-2015 National Ambulatory Medical Care Survey were analyzed. For each medication prescribed, a grade was assigned on the basis of the American Academy of Dermatology treatment guidelines for topical and systemic medications. Considering all visit prescriptions, I calculated a composite grade, analogous to the US academic grading system (scores A-F). I noted prescribing differences across specialty groups. Systemic corticosteroids were more likely to be prescribed by family and general physicians and less likely by pediatricians. Dermatologists were more likely than other specialties to prescribe nonsedating antihistamines, which lack a guideline base supporting their use. Depending upon modeling of care assumptions, all physician specialty visits earned mean guideline-based grades of B or C in their care of AD patients. The clinical, social, and demographic factors influencing prescribing behavior cannot be completely assessed by using extant data. This preliminary study demonstrates that physicians might benefit from reviewing guidelines of care; there might be an educational gap in the implementation of these guidelines.

Implementation of a Standardized Preoperative Diabetes Medication Guideline and its Effect on Day of Procedure Blood Glucose Levels

The purpose of this project was to determine the effect of implementation of a preoperative diabetes medication management guideline on day of procedure blood glucose (BG) levels. This project was designed as pre- and postimplementation process improvement project based on the Iowa Model of evidence-based practice. Anesthesia providers were surveyed for knowledge and confidence before and following education. Surgical patients with diabetes were provided instructions for all classes of prescribed diabetes medications. Day of procedure BG levels were compared prior to and following the guideline implementation. Provider knowledge scores increased 4.5 points (95% confidence interval [CI] 3.2, 5.8) and confidence improved 31.3 percentage points (95% CI 20.8, 41.7). Mean BG level was 132.3 (SD 37.5) before implementation and 130.4 (SD 44.7) after implementation. The project resulted in significant gains in provider knowledge and confidence, but no significant difference in preoperative BG levels following implementation of the guideline.

Commentary on Liang et al. (2018): The potential impact of medical cannabis on public health with respect to reducing prescription opioid use and associated harm.

Substitution of prescription opioid use by medical cannabis is not public health relevant, as it is restricted to substitution of a small subset of less potent opioids such as codeine. In addition, it substitutes one substance with abuse potential by another, and there are better alternatives available. Liang and colleagues 1 have presented a time–series analysis based on 21 years of state-level data of Medicaid records, in which they found that medical cannabis legalization was associated with substantial reductions in the number of Schedule III opioid prescriptions in the United States (−30%), their dosage (30%) and related Medicaid spending (−29%). Prescription opioids in Schedule III are characterized by lower abuse potential compared to opioids in Schedule II, with abuse of these opioids potentially leading to moderate or low physical dependence and/or high psychological dependence 2. In the analyses of Liang and colleagues 1, the Schedule III prescriptions made up only approximately 5% of all opioid prescriptions for the last year of analysis (2014), with codeine prescriptions comprising 99% of all Schedule III prescriptions. Codeine is used in the United States to treat mild to moderate pain and as a cough suppressant. Cannabis has been in use for both of these indications, and thus a substitution effect may be plausible. What would be the public health implications of a partial substitution? First, the overall substitution was not found to be affecting a large portion of the overall opioid prescription use. Secondly, however, codeine has an abuse potential. Although this abuse potential was evaluated to be lower compared to Schedule II opioids, abuse has been documented with both prescribed and over-the-counter codeine 3. Furthermore, codeine use may contribute as a gateway to other opioids, both prescription and illicit opioids, with high overdose potential 4, 5. Overall, the United States has, by far, globally the highest prescription opioid use per capita 6, and probably also the highest overall opioid use per capita in the world (i.e. combining prescription and illicit use), at least if indirectly inferred by opioid use disorders 7. The overall culture of medically overusing opioids has contributed markedly to this situation 8. What about cannabis? Its scheduling currently seems to be in flux, with many US states starting medical marijuana programs 9. However, while its consequences are not as detrimental as those of other drugs, in particular in terms of mortality 10, they are far from benign 11. Finally, the effectiveness of both codeine and cannabis for relieving moderate chronic pain seems to be limited, with no Cochrane Reviews supporting such a claim as primary drug of choice (e.g. 12, 13). Perhaps this judgement about effectiveness is premature for cannabis, with research to collect better evidence only now commencing, but it reflects the current evidence base. However, from a public health point of view, given the abuse potentials of both drugs involved, perhaps solutions should be sought with non-pharmacological therapies or with medications with less abuse potential than opioids or cannabis. The history of opioids in pain medication in North America should be a lesson. Despite limited evidence for effectiveness, prescription opioids were seen as a wonder drug, especially for pain management, with rapidly accelerating use to the point where they contributed markedly to a high level of opioid addiction on the population level and a major public health crisis 14, and decreasing life expectancies 15, 16. As a result, new national guidelines for opioid pain prescription stress non-pharmacological therapies and non-opioid medication as first-line treatment 17. We should not repeat this history with yet another wonder drug installed before proper evidence for effectiveness and well-documented unintentional consequences. Given the current evidence, there is no good reason not to start pain management with non-pharmacological therapies, but there are good reasons to limit the use of drugs with high abuse potential to the highest degree possible. None. The author acknowledges funding from the Canadian Institutes of Health Research, Institute of Neurosciences, Mental Health and Addiction (CRISM Ontario Node grant no. SMN-13950).

Peri-operative Medication Dosing in Adult Obese Elective Surgical Patients: A Systematic Review of Clinical Studies.

Despite the increasing numbers of obese patients undergoing elective surgery, there is a lack of evidence-based dosing guidelines for peri-operative medications in obesity. The objective was to systematically review the dosing and outcomes of peri-operative medications used in obese elective surgical patients. Medical subject headings and general keywords were used to systematically search multiple databases (PubMed, EMBASE, Cochrane Library and CINAHL). Studies of medications in obese surgical patients were included if they had a non-obese control or comparative dosing scalar group. The National Health and Medical Research Council GRADE tool was used to assess quality of evidence for each drug. Thirty-three studies of six drug classes were identified: anaesthetics (n = 6), muscle relaxants (n = 10), neuromuscular reversal agents (n = 3), analgesics (n = 2), antibiotics (n = 5) and anticoagulants (n = 7). A variety of dose scalars and/or recommendations was observed for various medications. Lean body weight was proposed as a suitable weight scalar for induction of anaesthesia with propofol whereas total body weight for maintenance of anaesthesia with propofol and depolarizing muscle relaxants. Ideal body weight was reported as an appropriate dosing scalar for non-depolarizing muscle relaxants and neuromuscular reversal agents. Both corrected body weight 40% and ideal body weight were reported as suitable weight scalars for post-operative analgesia with morphine. The standard 2-g dose of cefazolin appeared effective in the prevention of surgical site infection. Body mass index stratified dosing of enoxaparin was effective for venous thromboembolism prevention. No drug recommendation achieved an "Excellent" quality of evidence. Limited data suggest that clinicians should consider each individual class of medication when selecting a dose for obese surgical patients. Routine use of fixed-dosing regimens is likely to under- or overdose obese patients thus predisposing them to adverse drug events or treatment failure leading to patient harm.

Genotype, phenotype, and medication recommendation agreement among commercial pharmacogenetic-based decision support tools.

The degree of agreement between four commercial pharmacogenetic-based decision support tools (DSTs) was examined in five outpatients with major depressive disorder and at least two previous antidepressant failures. Comparisons were made across seven pharmacokinetic (CYP1A2, CYP2B6, CYP2C19, CYP2C9, CYP2D6, CYP3A4, and UGT2B15) and seven pharmacodynamic (BDNF, COMT, HLA-A, HTR2A, HTR2C, OPRM1, and SLC6A4) genes that were included on ≥2 of the four DST testing panels. Among these overlapping genes, genotype (33-100%) and predicted phenotype (20-100%) agreement varied substantially. Medication recommendation agreement was the greatest for mood stabilizers (84%), followed by antidepressants (56%), anxiolytics/hypnotics (56%), and antipsychotics (55%). Approximately one-quarter (26%) of all medication recommendations were jointly flagged by two or more DSTs as "actionable" but 19% of these recommendations provided conflicting advice (e.g., dosing) for the same medication.The level of disagreement in medication recommendations across the pharmacogenetic DSTs indicates that these tests cannot be assumed to be equivalent or interchangeable. Additional efforts to standardize genetic-based phenotyping and to develop medication guidelines are warranted.

Treatment of Cardiovascular Diseases Among Elderly Residents of Long-term Care Facilities

BackgroundThe prevalence of cardiovascular diseases among nursing home residents is high but little is known whether pharmacologic therapy recommended by actual medication guidelines is followed by facility's staff. AimTo evaluate the adherence to actual guidelines for treatment of cardiovascular diseases among older adult residents of long-term care (LTC) facilities. Material and methodsThe cross-sectional study was performed from December 2009 to November 2010 among 189 elderly residents aged ≥60 years in 3 LTC facilities in Poland: 1 long-term care hospital (LTCH) and 2 nursing homes (NHs). The initial evaluation included analysis of medical documentation (all diagnosed diseases and used drugs), blood pressure (BP) measurements and performance of Mini Nutritional Assessment Short-Form (MNA-SF), Abbreviated Mental Test Score (AMTS), Activities of Daily Living (ADL) score, and Barthel Index. Prescribed medication for hypertension (HT), heart failure (HF), and coronary heart disease (CHD) were compared to current European Cardiology Society (ESC), and European Society of Hypertension (ESH) medication guidelines. Residents were divided into 3 subgroups: with HT, HF, and CHD. Results were presented as means and standard deviation. Groups were compared using Mann-Whitney U test for nonparametric data and chi-square test to assess differences in distribution of categorical variables. P values <.05 were considered statistically significant. ResultsCHD was diagnosed among 114 residents (60.3%) but only 60.5% of them were treated with aspirin (ASA), 45.6% with beta-blockers (BBs), 60.5% with angiotensin-converting enzyme inhibitor (ACEI), and 24.6% with statins. HF observed in 75% of cases was treated by using ACEI (54.7%), BBs (45.3%), loop diuretics (LDs, 36%), mineralocorticoid-receptor antagonists (MRAs, 21.3%). HT was diagnosed among 98 study participants (51.9%) and in the majority of cases (76.6%) was well controlled (mean BP: 133.7 ± 17.6/73.8 ± 10.2 mmHg). The most popular antihypertensive drugs were ACEIs (77.6%), BBs (40.8%) and calcium channel blockers (CCBs, 26.5%) whereas thiazides, alpha-blockers (ABs), and angiotensin receptor blockers (ARBs) were used less frequently. ConclusionIn summary, the study showed that insufficient treatment of cardiovascular diseases among elderly residents of LTC facilities could be a potential risk factor of poor prognosis.

Message Encryption in Robot Operating System: Collateral Effects of Hardening Mobile Robots

In human-robot interaction situations, robot sensors collect huge amounts of data from the environment in order to characterize the situation. Some of the gathered data ought to be treated as private, such as medical data (i.e., medication guidelines), personal and safety information (i.e., images of children, home habits, alarm codes, etc.). However, most robotic software development frameworks are not designed for securely managing this information. This paper analyzes the scenario of hardening one of the most widely used robotic middlewares, Robot Operating System (ROS). The study investigates a robot’s performance when ciphering the messages interchanged between ROS nodes under the publish/subscribe paradigm. In particular, this research focuses on the nodes which manage cameras and LIDAR sensors, which are two of the most extended sensing solutions in mobile robotics, and analyzes the collateral effects on the robot's achievement under different computing capabilities and encryption algorithms (3DES, AES and Blowfish) to robot performance. The findings present empirical evidence that simple encryption algorithms are lightweight enough to provide cyber-security even in low-powered robots when carefully designed and implemented. Nevertheless, these techniques come with a number of serious drawbacks regarding robot autonomy and performance if they are applied randomly. To avoid these issues, we define a taxonomy that links the type of ROS message, computational units, and the encryption methods. As a result, we present a model to select the optimal options for hardening a mobile robot using ROS.

Education and Knowledge in Pharmacogenomics: Still a Challenge?

A number of barriers exist for adoption of pharmacogenomics into practice. Physicians, pharmacists, and nurses report limited knowledge about pharmacogenomics and its use in patient care. Lack of pharmacogenomics education curricula as part of professional schools or postgraduate training programs has been reported as a potential cause. Understanding pharmacogenomics is further complicated by a complex and nonstandard lexicon, limited medication guidelines, rapidly changing evidence, and insufficient awareness of test availability and utility.