Virginia Commonwealth University Health System Research Articles

Knowledge, attitudes, and practices of bedside nursing staff regarding antibiotic stewardship: A cross-sectional study

Nursing engagement in antibiotic stewardship programs (ASPs) remains suboptimal. The purpose of this study was to determine the knowledge, attitudes, and practices of nursing staff members regarding ASPs and identify barriers to their participation in such programs. This cross-sectional study was conducted at Virginia Commonwealth University Health System, an 860-bed tertiary care academic center located in Richmond, Virginia, where a well-resourced ASP has been in place for 2 decades. A survey consisting of 12 questions was administered to nursing staff via REDCap (Research Electronic Data Capture) in February 2018. A total of 159 survey responses were included in the study. The results demonstrated gaps in knowledge regarding antibiotic stewardship (AS) and highlighted the importance of improving communication between nurses and ASPs. Overall, 102 (64.15%) of the study participants indicated familiarity with AS. Time constraints and concerns over physician pushback were identified as major barriers to participation. Many nurses were unaware of our center's ASP. Nurses identified activities falling within their daily workflow as potential areas for contribution to ASPs. Key barriers to participation were also identified. These data will inform efforts to engage nursing in AS activities at our medical center.

A 25-year retrospective analysis of the American Society of Anesthesiologists physical status classification: did we "up-code" young obese patients when obesity was not yet considered a disease?

The influence of obesity on anesthetic risk remains controversial, and obesity has only recently been specifically identified as a criterion by which a patient can be given a higher American Society of Anesthesiologists-physical status (ASA-PS) score. Nevertheless, we hypothesized that clinicians had assigned obese patients a greater ASA-PS score before obesity became an "official" criterion in 2015. Basic demographic and physical details were collected on patients receiving anesthetics in the Virginia Commonwealth University Health System between 1986 and 2010. The risk ratio (RR) of "up-coding" ASA-PS classification assignments was calculated for patients of varying body mass index (BMI). We specifically focused on the subset of patients aged 20-29 yr in whom the medical sequelae of obesity would not yet likely be manifest. Among a total of 194,698 patients, the percentage who were obese increased from 20% to 39% between 1986 and 2010. Obese patients of all ages were more likely than non-obese patients to be classified as ASA-PS II-IV rather than ASA-PS I. The RR and ratio of RR analyses indicated a consistent pattern of up-coding patients with greater BMI (contingency table Chi-square: P < 0.001). Most notably, relative to patients with a normal BMI, young obese patients aged 20-29 yr had an increased likelihood of up-coding in ASA-PS compared with obese patients in the older cohorts. These findings suggest a consistent and temporally stable practice of up-coding obese patients despite this lack of explicit guidance. The ASA House of Delegates' recent decision to specifically mention obesity reinforces long-existing practices regarding ASA-PS coding and will likely not degrade the validity of data sets collected before the change.

Virginia Children’s Center Represents New Wave in Facility Design

Virginia Children’s Center Represents New Wave in Facility Design

Evaluation of Intravenous Vancomycin Pharmacokinetic Parameters in Patients With Acute Brain Injury

Background: Vancomycin is a glycopeptide antibiotic that is primarily cleared by renal elimination. Patients with acute brain injury often exhibit augmented renal clearance which has been associated with subtherapeutic vancomycin concentrations. Objective: To determine whether population pharmacokinetics accurately predict vancomycin empiric dose frequency in patients with acute brain injury. Methods: This was a single-center, retrospective cohort study conducted following institutional review board approval at Virginia Commonwealth University Health System. Data were collected from patients 18 years of age or older admitted with acute brain injury. The primary outcome was the difference in the elimination rate constant of vancomycin between population predicted pharmacokinetics and patient-specific pharmacokinetics. Results: A total of 158 patients were included in the analysis. A test of the paired differences between the mean population predicted and patient-specific elimination rate constants showed that the mean population predicted elimination rate constant was larger by 0.0211 h−1 (95% confidence interval [CI]: −0.028 to −0.015). The difference between the mean population predicted and patient-specific half-lives showed that the mean population predicted half-life was shorter by 1.01 hours (95% CI: 0.7-1.3). Vancomycin was administered at a mean initial dose of 15.4 mg/kg (standard deviation [SD] = 2.2), with an average frequency of 12 hours (SD = 1.1). The average trough concentration at steady state was 9.9 µg/mL (SD = 4.9). Conclusions: The small clinical difference in population and patient-specific elimination rate constants demonstrates that population pharmacokinetics may be an accurate empiric dosing strategy for determining vancomycin dose frequency in patients with acute brain injury.

Development and validation of an instrument to measure collaborative goal setting in the care of patients with diabetes

ObjectiveDespite known benefits of patient-perceived collaborative goal setting, we have a limited ability to monitor this process in practice. We developed the Patient Measure of Collaborative Goal Setting (PM-CGS) to...

Is Treating Oral and Maxillofacial Trauma Profitable? An Analysis of Hospital and Surgeon Reimbursement at an Academic Medical Center

During the past 2decades, there has been a marked decrease in the willingness of community-based oral and maxillofacial surgeons to participate in trauma call. Although many factors can influence the decision not to take trauma call, 1 primary disincentive is the perception that managing facial trauma might be profitable for the hospital, but not profitable for the surgeon. The purpose of this study was to compare the profitability of facial trauma management for the hospital and the surgeon at the Virginia Commonwealth University (VCU) Medical Center (Richmond, VA). In this retrospective cohort study, records were collected for patients who were seen for primary trauma management by the Department of Oral and Maxillofacial Surgery at VCU (VCUOMS) from June 2011 through July 2014. Cost and reimbursement data were analyzed for these patients from the VCU Health System (VCUHS) and the VCUOMS. For the hospital, actual cost data were provided; for the surgeon, cost was calculated based on an average overhead of 50%. For uniformity, patients were excluded if they remained in the hospital for longer than a 23-hour observation period. Patients younger than 18years also were excluded. In total, 169 patients met the inclusion criteria. There was a statistically relevant difference in the percentage of costs recouped and the actual profit. The average percentage of costs recouped was 230% for the VCUHS versus 47% for the VCUOMS. This amounts to an average profit per case of $3,461 for the hospital versus a loss of $1,162 for the surgeon. The results of this study indicate that in the VCU Medical Center, maxillofacial trauma yields a net profit for the hospital and a net loss for the operating surgeon. Although the results are limited to outpatient management at 1 academic institution, they suggest that hospitals in some settings might be in a position to incentivize surgeons for trauma management.

The Access Initiative: Improving Appropriateness of Patient Fit for Resident Case Assignment.

The Virginia Commonwealth University Health System (VCUHS) is an inner-city hospital complex that serves as a “safety net hospital” for a challenging mix of patients and clinical needs. Our health system has traditionally provided care to a large percentage of Medicaid and indigent patients. Virginia Coordinated Care (VCC) is the specially funded program at VCUHS that aids the provision of indigent care. The VCC population represents a high percentage of cases in our residents’ general psychiatry training clinics, as well as in their individual psychotherapy caseloads. Consistent with research on challenges to treatment engagement, our clinic has faced treatment, residency education, and financial challenges resulting in part from our setting [1] and population characteristics [2, 3]. The Residency Education Program at VCUHS includes several distinct components in its outpatient training. Year-long general psychiatric clinics offer trainees a critical continuity experience, working in teams and following approximately 100 patients. Subspecialty clinics, such as geriatrics, schizophrenia, mood disorders, and neuropsychiatry, offer residents the opportunity to conduct detailed assessments and advanced treatment under the aegis of expert faculty. Additionally, a comprehensive psychotherapy training program introduces second year postgraduates (PGY-2 s) to supportive therapy and medication management of the residents’ own cases. These expand and continue into the third year (PGY-3), augmented by assigned cases in psychodynamic therapy, CBT, and group therapy. Residents remaining through PGY-4 continue most of these modalities, and in addition receive training in family and couples therapy. Referrals for our resident training clinics and other outpatient psychiatric services come from primary care providers, community mental health centers, and patient requests. Due to high demand and limited community resources for mental health services, wait times have historically been as long as six months in our clinic. Prior to piloting the Access program, our outpatient services (including our resident training clinics) lacked a coordinated intake system. The centralized scheduling service historically conducted an initial phone screen and placed patients in first-available general psychiatry intake clinics. We had long struggled with several limitations of this scheduling arrangement, often due to “poor fits” for our training clinics. At the time of developing the Access program described herein, impacts of patient “fit” on providing care included those seeking forensic or disability assessments, pursuing court-ordered treatment, wanting primary substance abuse treatment, or seeking refills for untreated prescription medication dependencies. This created a frustrating scenario for many patients who waited an inordinate amount of time to be seen, only to eventually be redirected to more appropriate services elsewhere. Our providers, including psychiatric residents, also felt the reverse complication—the perceived pressure to accommodate patients whose needs or goals were not well-suited to our clinical services and training goals. Residents struggled with many patients who lacked the capacity and/or commitment for treatment, and with those not sufficiently motivated or oriented to psychotherapy and psychopharmacology to be consistent in their attendance. In addition to the issues of patient “fit,” our clinic has struggled with high no-show rates, similar to that often seen in clinics of our setting and population [2]. Our baseline no* William T. Nay wnay@vcu.edu

A5056 - Creating An Innovative Staff Training Program to Meet Mbsaqip Standards for Adolescents on A General Care Pediatric Floor

Childhood overweight and obesity affect approximately 1/3 of US children. Many have one or more comorbidities such as abnormal blood pressure, dyslipidemia, non alcoholic fatty liver disease, metabolic syndrome, polycystic ovarian syndrome, pre-diabetes, diabetes, obstructive sleep apnea, psychological problems, impaired quality of life, as well as others. Treatment of childhood obesity can be time consuming, difficult and complex and many pediatric practices have limited resources to offer interventions within an office setting. To provide guidance in the primary care settting Spear and others, created evidenced-based recommendations for obesity treatment and described it as a step or staged approach for weight management. It provides a practical way to address childhood obesity and the staged care is divided into four stages including prevention plus utilizing healthy lifestyle changes, structured weight management, comprehensive multidisciplinary intervention and tertiary care intervention. Our Adolescent Weight Loss Surgery Program is a part of a comprehensive multidisciplinary intervention program through the Healthy Lifestyles Center where the pediatric surgery team evaluates adolescents for surgery during the tertiary care intervention phase. With the new Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program, (MBSAQIP)Standards, only the centers who have achieved this designation may perform bariatric operations. While the Virginia Commonwealth University Health System has been a pioneer in adult bariatric surgery, we only recently received our accreditation as a Comprenhensive Center with Adolescent Qualifications. In order to qualify and maintain accreditation, specific educational training is required for all staff who care for this population.

Postmortem cytology: Alive and well in the practice of autopsy and forensic pathology.

Postmortem cytology: Alive and well in the practice of autopsy and forensic pathology.

Opiod Induced Pruritus: The Need for Palliative Care for a Palliative Medicine (S707)

•Give the prevalence of opioid induced pruritus in a pediatric population.•List at least 3 main risk factors for the development of opioid induced pruritus (OIP). Opioids are frequently utilized in the pediatric hematology and oncology population for pain control. Pruritus from opioids can be as distressing and debilitating as pain. Little is known about opioid-induced pruritus (OIP) in the pediatric population, and even less in the pediatric hematology and oncology population. This study sought to assess the prevalence and characteristics of OIP in the pediatric hematology and oncology population admitted to Virginia Commonwealth University Health System between June 2008 and December 2012. A retrospective chart review was performed. Descriptive statistics were calculated for pruritus, predictor variables, and relevant covariates with Chi-square and Wilcoxon rank-sum tests to detect differences in the covariates and predictor variables by pruritus status. Poisson regression was used to determine the association between the predictor variables and pruritus. SAS version 9.3 was used for all analyses. The incidence of OIP was 5.98% for the final sample size (n=435). Multiple predictors were significant in bivariate analyses. In adjusted Poisson regression: morphine was 12 times more likely to cause OIP compared to those who were in the other opioid group (p=0.005); patients with allergies were almost 3 times more likely to have OIP compared to patients without allergies (p= 0.01); and the risk of pruritus increased by approximately 14% with every one-unit (mg/kg) increase in the dose of opioid (p= 0.007). The incidence of OIP for the pediatric hematology and oncology population was similar to previous studies (mainly in adults). Type of opioid and dose of opioid were also found to be important predictors of OIP in the current study. An unexpected finding was allergies being an independent risk factor for OIP.

The Effects of Expanding Primary Care Access for the Uninsured

The Patient Protection and Affordable Care Act seeks to improve health equity in the United States by expanding Medicaid coverage for adults who are uninsured and/or socioeconomically disadvantaged; however, when millions more become eligible for Medicaid in 2014, the health care workforce and care delivery systems will be inadequate to meet the care needs of the U.S. population. To provide high-quality care efficiently to the expanded population of insured individuals, the health care workforce and care delivery structures will need to be tailored to meet the needs of specific groups within the population.To help create a foundation for understanding the use patterns of the newly insured and to recommend possible approaches to care delivery and workforce development, the authors describe the 13-year-old experience of the Virginia Coordinated Care program (VCC). The VCC, developed by Virginia Commonwealth University Health System in Richmond, Virginia, is a health-system-sponsored care coordination program that provides primary and specialty care services to patients who are indigent. The authors have categorized VCC patients from fiscal year 2011 by medical complexity. Then, on the basis of the resulting utilization data for each category over the next fiscal year, the authors describe the medical needs and health behaviors of the four different patient groups. Finally, the authors discuss possible approaches for providing primary, preventive, and specialty care to improve the health of the population while controlling costs and how adoption of the approaches might be shaped by care delivery systems and educational institutions.

Effects of Health Literacy and Polypharmacy on Medication Adherence

To determine if health literacy has an effect on medication adherence in patients taking fewer than five prescriptions (no polypharmacy), and those taking five or more prescriptions (polypharmacy). Retrospective cohort. The Primary Care Residents' Clinic at Virginia Commonwealth University Health System (VCUHS). Those who received a Rapid Estimate of Adult Literacy in Medicine-Revised (REALM-R) assessment at the clinic between June 1, 2009, and June 30, 2010, and utilized the VCUHS outpatient pharmacies to fill their prescriptions. A total of 648 individuals were identified. The degree of health literacy and level of medication adherence were analyzed per patient by accessing the clinic's electronic health records. The number of medications each patient filled was determined using VCUHS outpatient pharmacy databases. To determine if there are any associations among the degree of health literacy, the level of medication adherence, and the amount of medications a patient is taking. There was a significant association found between the level of medication adherence and the degree of polypharmacy. We found no association between the degree of health literacy and the level of adherence to a prescribed medication regimen. Additionally, there was no relationship between the degree of polypharmacy and health literacy. Those patients with more medications were also found to have lower levels of medication adherence and vice versa. Our study does not show an association between health literacy and medication adherence nor between health literacy and polypharmacy. Thus, potential changes to improving health literacy may not have a significant effect on adherence.

Making the (business) case for outpatient and home-based palliative care for cancer patients.

266 Background: Randomized controlled trials by Temel (2010) and Brumley (2003, 2007) have demonstrated the positive clinical, psycho-social, and utilization impact of providing early clinic or home-based palliative care (PC) concurrently with standard disease-focused treatment. Despite clear benefits, the growth of outpatient PC has been constrained by lack of clarity about the “business case” for hospitals or health systems to develop and fund PC services outside the inpatient setting. Methods: We will present findings from Virginia Commonwealth University (VCU) that provide a compelling quantification of the risks for hospitals to continue “business as usual” in this changing environment. Our approach measures quality, quantity, and costs of care for patients with cancer over a period of 6-12 months prior to death. Performance on some of these measures impact revenues in the prevailing fee-for-service reimbursement model; others are utilized in national, public ratings of quality; and still others influence organizational ability to compete in the population health management model that rewards quality and efficiency over time. Results: We used these data to highlight VCU Health System’s exposure to financial risks to create a strong business case for outpatient palliative care in which patient-centered and hospital-centered outcomes are aligned. This approach elevated our proposal to be included in a broader strategic initiative by our health system to manage complex care more efficiently, and to manage population health more proactively. Our analytic approach was then replicated by a diverse group of California provider groups who adopted or adapted the VCU model to advance their community-based palliative care programs as part of the California Health Care Foundation’s “Palliative Care Action Community” initiative. Conclusions: Our analytic model and articulation of the business case for community-based palliative care can help others to create and sustain quality-driven, patient-centered, cost-effective PC programs in their own institutions.

Interprofessional Team-Based Learning Module: Anticoagulation

OPEN ACCESSJanuary 31, 2013Interprofessional Team-Based Learning Module: Anticoagulation Dave L. Dixon, PharmD, Adraine Lyles, PharmD, Brigitte Luong Sicat, PharmD, Bennett Lee, MD, Bruce Rybarczyk, PhD, Benjamin Lord Dave L. Dixon, PharmD Virginia Commonwealth University School of Medicine Google Scholar More articles by this author , Adraine Lyles, PharmD Virginia Commonwealth University School of Medicine Google Scholar More articles by this author , Brigitte Luong Sicat, PharmD Virginia Commonwealth University School of Medicine Google Scholar More articles by this author , Bennett Lee, MD Virginia Commonwealth University School of Medicine Google Scholar More articles by this author , Bruce Rybarczyk, PhD Virginia Commonwealth University School of Medicine Google Scholar More articles by this author , Benjamin Lord Virginia Commonwealth University School of Medicine Google Scholar More articles by this author https://doi.org/10.15766/mep_2374-8265.9334 SectionsAbout ToolsDownload Citations ShareFacebookTwitterEmail AbstractThis resource is an interprofessional education (IPE) module, which uses team-based learning (TBL), as an instructional strategy, to teach learners about providing collaborative care to patients receiving anticoagulation therapy in the primary care setting. The case used in this module was based on an actual patient case from this interprofessional primary care practice. This TBL module was used in a two-hour interprofessional education session with approximately 36 internal medicine residents, eight pharmacy residents, and 12 psychology graduate students at the Virginia Commonwealth University Health System. Participants were divided into seven teams of approximately six to eight, the majority of whom were internal medicine residents, with usually one to two members of each of the other disciplines. An individual readiness assurance test was given to each member of a team at the beginning of the module. The RAT was then re-administered in the form of a team RAT (TRAT) whereby participants answered the questions together as a team. The questions were then reviewed with all participants after the T-RAT was finished in order to clarify and answer questions. After the T-RAT discussion, the teams engaged in case-based application exercises. Team members worked together and utilized each discipline's knowledge and skills to discuss and answer the case questions. The participants completed two evaluation surveys at the end so facilitators could determine the module's effectiveness. Using a 4-point scale (0 = no gain, 4 = great gain), all participants reported a “moderate gain” to “good gain.” Furthermore, participants responded with a mean score of 3.8 when asked what degree of impact this TBL session would have on their approach to patient care (1 = no impact to 5 = large impact). There was a nonsignificant trend toward a lower level of impact for medical residents compared to pharmacy and psychology. Educational Objectives By the end of this module, the learner will be able to: Appreciate the contributions of physicians, psychologists, and pharmacists in the care of individuals receiving anticoagulation therapy.Determine when anticoagulation should be initiated, continued, or discontinued.Determine a patient's appropriate duration of anticoagulant therapy.Assess a patient's risk for thromboembolism and complications of anticoagulant therapy including bleeding.Effectively interview a patient receiving anticoagulant therapy to monitor for efficacy and safety.Discuss management considerations when adjusting warfarin therapy.Identify alternatives to pain medications that may interfere with anticoagulant therapy.Summarize efficacy and safety issues of newer anticoagulants and explain their current role in therapy.Describe key clinic resources and processes in managing patients receiving anticoagulant therapy.Discuss the value of cognitive screening tests in caring for patients receiving anticoagulation therapy.Apply principles of motivational interviewing in caring for patients receiving anticoagulation therapy and possible alcohol abuse.Explain how the stages of change model helps clinicians to understand where to focus their efforts on helping individuals with alcohol abuse.Describe the harm reduction versus abstinence approaches of behavioral treatment of substance abuse. Sign up for the latest publications from MedEdPORTAL Add your email below FILES INCLUDEDReferencesRelatedDetails FILES INCLUDED Included in this publication: Anticoagulation Facilitator's Guide.doc Anticoagulation Readiness Assurance Test.doc Anticoagulation TBL Case.doc Anticoagulation TBL Syllabus.doc To view all publication components, extract (i.e., unzip) them from the downloaded .zip file. Download editor’s noteThis publication may contain technology or a display format that is no longer in use. CitationDixon DL, Lyles A, Sicat BL, Lee B, Rybarczyk B, Lord B. Interprofessional Team-Based Learning Module: Anticoagulation. MedEdPORTAL. 2013;9:9334. https://doi.org/10.15766/mep_2374-8265.9334 Related Interprofessional Team-Based Learning Module: Depression Interprofessional Team-Based Learning Module: Anticoagulation Copyright & Permissions© 2013 Dixon et al. This is an open-access article distributed under the terms of the Creative Commons Attribution license.KeywordsAnticoagulationTeamworkTBLWarfarinInterprofessional Education Collaboration (IPEC)Alcohol UseTeam-based LearningThromboembolism Disclosures None to report. Funding/Support None to report. Loading ...

Commentary on “Differences in Function Among Children With Sensory Processing Disorders, Physical Disabilities, and Typical Development”

“How could I apply this information?” This study highlights the importance of choosing assessments based on International Classification of Functioning, Disability and Health concepts to inform diagnosis and document functional skill performance in children who have a sensory processing disorder (SPD) or a physical disability (PD). Clinically, the Pediatric Evaluation of Disabilities Inventory (PEDI) could be used to document functional limitations, which may qualify a child for therapy services. The mean age of the children in this study was almost 4 years. A subanalysis of children younger than 3 years is needed to determine whether the PEDI can identify functional skill differences between young children with SPD and those with typical development (TD) to determine eligibility for early intervention services. However, the results from this study support the likelihood of similar results for this younger age group. The PEDI also quantified the additional burden of caregiver assistance that is required of families with children with SPD and those with PD. A meaningful outcome of intervention may be a reduction of caregiver assistance. “What should I be mindful about when applying this information?” The children in this study were not assessed using a standard protocol or definition of SPD or PD. The therapist's impression of the child was the primary factor used to determine group assignment. The training and experiences of the individual therapists likely influenced their impression and could have affected reliability of group assignment. The inclusion of children with unspecified developmental delay in both SPD and the PD groups may have reduced PEDI scores of both groups. The result of this study must be interpreted with caution as this limitation may inflate group differences when comparing either the SPD or the PD group with the TD group. Stacey C. Dusing, PT, PhD Theresa A. Izzo, PT, DPT, PCS Virginia Commonwealth University Health System Richmond, Virginia

122 Pre Implant Noncompliance Does Not Predict Social Success in LVAD Recipients

Pre Implant Noncompliance Does Not Predict Social Success in LVAD Recipients M. Maltby, M. Flattery, A. Barclay, V. Kasirajan, D. Tang, M. Hess, S. Harton, M.E. Olbrisch, K. Shah. Department of Social Work, Virginia Commonwealth University Health System, Richond, VA; Pauley Heart Center, Virginia Commonwealth University Health System, Richmond, VA; Department of Psychiatry, Virginia Commonwealth University, Richmond, VA.

Management of Intracranial Hypertension: Focus on Pharmacologic Strategies

Drug Update| July 01 2011 Management of Intracranial Hypertension: Focus on Pharmacologic Strategies CE Article Kelly M. Ennis, PharmD; Kelly M. Ennis, PharmD Kelly M. Ennis is PGY2 Critical Care Pharmacy Resident, Department of Pharmacy Services, Virginia Commonwealth University Health System, 401 N 12th St, PO Box 980042, Richmond, VA 23298 (kennis2@mcvh-vcu.edu). Gretchen M. Brophy is Professor of Pharmacotherapy & Outcomes Science and Neurosurgery, Virginia Commonwealth University, Medical College of Virginia Campus, Richmond, VA. Search for other works by this author on: This Site PubMed Google Scholar Gretchen M. Brophy, PharmD, BCPS Gretchen M. Brophy, PharmD, BCPS Kelly M. Ennis is PGY2 Critical Care Pharmacy Resident, Department of Pharmacy Services, Virginia Commonwealth University Health System, 401 N 12th St, PO Box 980042, Richmond, VA 23298 (kennis2@mcvh-vcu.edu). Gretchen M. Brophy is Professor of Pharmacotherapy & Outcomes Science and Neurosurgery, Virginia Commonwealth University, Medical College of Virginia Campus, Richmond, VA. Search for other works by this author on: This Site PubMed Google Scholar AACN Adv Crit Care (2011) 22 (3): 177–182. https://doi.org/10.4037/NCI.0b013e318214564b Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Facebook Twitter LinkedIn MailTo Tools Icon Tools Cite Icon Cite Get Permissions Citation Kelly M. Ennis, Gretchen M. Brophy; Management of Intracranial Hypertension: Focus on Pharmacologic Strategies. AACN Adv Crit Care 1 July 2011; 22 (3): 177–182. doi: https://doi.org/10.4037/NCI.0b013e318214564b Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search Search Dropdown Menu toolbar search search input Search input auto suggest filter your search All ContentAACN Advanced Critical Care Search Advanced Search This content is only available as a PDF. ©2011 American Association of Critical-Care Nurses2011 Article PDF first page preview Close Modal You do not currently have access to this content.

Drug Combinations in the Treatment of Hypertension

Not uncommonly, to effectively treat hypertension, multiple drugs must be given. Multidrug combinations that dominate clinical practice typically include a thiazide-type diuretic together with either an angiotensin-converting enzyme inhibitor, an angiotensin-receptor blocker, or less so a β-blocker. On the other hand, there are several approaches that can also incrementally reduce blood pressure (BP) but are used less regularly and, as such, go underappreciated as to their effectiveness. Such approaches may include within-class switching of diuretics, combining a thiazide-type diuretic with a calcium-channel blocker (CCB), using 2 CCBs from different subclasses, adding a peripheral α-blocker to an angiotensin-converting enzyme inhibitor, or tacking on an aldosterone receptor antagonist or nitrate therapy to any of several other drug classes. All of these presumably novel approaches offer useful options for treatment in the otherwise difficult-to-control hypertensive patient.1 These aforementioned fresh therapeutic approaches succeed in lowering BP based on the nature of the pharmacokinetic and pharmacodynamic interplay between select drug classes. A pharmacokinetic interaction that can be exploited clinically in the patient with difficult-to-treat hypertension is that of combining a dihydropyridine CCB, such as nifedipine, with a nondihydropyridine CCB, such as diltiazem or verapamil. The latter 2 compounds are known inhibitors of the cytochrome CYP3A4 isozyme. The dihydropyridine CCB nifedipine, as is the case for all CCBs, is extensively metabolized by CYP3A4 with little inhibitory effect on this isozyme itself. When nifedipine is combined with diltiazem or verapamil, the latter dose-dependently inhibits the clearance of nifedipine. This interaction occurs quickly, relates to the relatively steep dose-response relationship for nifedipine plasma levels and BP reduction when nifedipine is given in submaximal doses, and is nearly optimized within 3 days of …

Mammography Screening after Risk-Tailored Messages: The Women Improving Screening through Education and Risk Assessment (WISER) Randomized, Controlled Trial

A randomized trial investigated the impact of risk-tailored messages on mammography in diverse women in the Virginia Commonwealth University Health System's gynecology clinics. From 2003 to 2005, 899 patients > or =40 years of age were randomized to receive risk-tailored information or general information about breast health. Multiple logistic regression analyses summarize their breast health practices at 18 months. At baseline, 576 (64%) women reported having a mammogram in the past year. At 18-month follow-up, mammography rates were 72.6% in the intervention group and 74.2% in the control group (N.S.). Women (n = 123) who reported worrying about breast cancer "often" or "all the time" had significantly higher mammography rates with the intervention (85.0%) vs. the controls (63.5%). No significant differences existed in clinical breast examination, self-examination, or mammography intentions between the two study arms. However, intervention women with lower education reported significantly fewer clinical breast examinations at follow-up. The brief intervention with a risk-tailored message did not have a significant effect overall on screening at 18 months. However, among those who worried, mammography rates in the intervention group were higher. Individual characteristics, such as worry about breast cancer and education status, may impact interventions to improve breast cancer prevention practices.

A Surgical Telemedicine Clinic in a Correctional Setting

The telemedicine network between Virginia Commonwealth University Health System (VCUHS) and the Department of Corrections in Virginia has seen a steady increase in the number of disciplines involved in consultation. Hardware integration and methodologies between VCUHS and correctional facilities were supported by Polycom videoconferencing technology. During consults, a VCUHS-based surgeon was provided with patient records, picture archiving and communication system images, and laboratory data or text reports sent by fax. A registered nurse at the correctional site assisted the surgeon at VCUHS. Electronic stethoscope and dermascope were also used for physical examination of inmates. Preoperative encounters included physical examination and informed consent from video. Electronic scheduling and preoperative orders were issued at the time of consultation. Of the 55 consultations completed this past year, 27 were followed by surgical procedures. In one case, the referral diagnosis was corrected and one case required minor change in diagnosis at an in-person examination on the day of surgery. Twenty patients had postoperative examination by telemedicine, and five of these required a second follow-up telemedicine visit. All patients confirmed their informed consent and acknowledged their surgeon upon first meeting face to face at the hospital. Telemedicine consultation for general surgery is an effective asset and can limit patient transfer.