Protocol for a pilot and feasibility study of nurse practitioner-pharmacist telehealth collaboration to simplify complex medication regimens

IntroductionNew and flexible multidisciplinary workforce models are needed to address unnecessary medication regimen complexity in residential aged care facilities (RACFs). This study will investigate the feasibility of a nurse practitioner-pharmacist telehealth-based collaborative care model to simplify complex medication regimens.MethodsThis is a pragmatic, non-randomized pilot and feasibility study of up to 30 permanent residents from 4 RACFs in Western Australia. Simplification will be conducted in accordance with a validated 5-step implicit process. Nurse practitioners will identify residents potentially interested in and who may benefit from simplification, including any regulatory or safety imperatives that might preclude simplification. Medication regimens will be assessed by an off-site clinical pharmacist to identify opportunities for simplification in terms of drug–drug, drug–food, or drug–time interactions, and the availability of alternative formulations. The pharmacist will communicate simplification opportunities to nurse practitioners via video case conferencing. Nurse practitioners will then discuss simplification opportunities with the resident, caregiver and the health and care team, including any unintended consequences for the resident or RACF. The primary outcome measure will be feasibility (stakeholder acceptability, protocol adherence, recruitment and retention rates). Secondary outcomes include change in the number of medication administration times per day, medication and behavioral incidents, falls and fractures, hospitalization and mortality at 4 months.Ethics and disseminationEthical approval has been obtained from the Monash University Human Research Ethics Committee. Research findings will be disseminated through industry report, lay summaries, conference presentations and peer-reviewed publications.     

Survival among Breast Cancer Patients: Comparison of the U.S. Military Health System with the Surveillance,Epidemiology and End Results Program

IntroductionAccessibility to health care is important to cancer survival. The U.S. military health system (MHS) provides universal health care access. However, whether the universal care has been translated into improved cancer survival is unknown. We compared survival of patients with breast cancer in the MHS with that in the U.S. general population and assessed the differences in cancer stage at diagnosis and treatment receipt between the two populations.MethodsThe MHS patients (n = 31,548) were identified from the Department of Defense's (DoD) Automated Central Tumor Registry (ACTUR). Patients in the U.S. general population (n = 63,096) were identified from the Surveillance, Epidemiology, and End Results (SEER) program. The two populations were matched on age, race, and diagnosis year. Multivariable Cox regression hazard modeling was used to estimate hazard ratios (HRs) comparing ACTUR with SEER. Multivariable logistic regression was used to estimate odds ratios (ORs) comparing stage and treatment receipt.ResultsACTUR patients exhibited a 24% lower overall mortality than the SEER patients (HR = 0.76, 95% CI, 0.71-0.80). They were less likely to present with later stage compared to the SEER patients (OR = 0.61, 95% CI, 0.55-0.67 for stage IV tumors). The ACTUR patients with stages I-III tumors were more likely to receive surgery (OR = 1.35, 95% CI, 1.20-1.52) but less likely to receive radiation (OR = 0.91, 95% CI, 0.88-0.94). The survival advantage of ACTUR patients remained regardless of surgery or radiation receipt.ConclusionsBreast cancer patients with universal health care access had improved survival compared to patients in the general population.     

针药并用治疗书写痉挛症5例

Combined acupuncture and Chinese herb decoction were applied for 5 cases with graphospasm. Acupuncture included scalp acupuncture and body acupuncture. Using transcranial repeated needling, Băihuì (百会GV20), Chorea-trembling controlled area, Emotional area, as well as Dàzhuī (大椎GV14), Fēngchí (风池 GB20), and Yíngxiāng (迎香EX-HN8) etc. were stimulated by proposed by Sun Shentian. Meanwhile, the patients took orally Chinese herb decoction, on the basis of the Sìwù decoction (四物汤four substances decoction) addition and subtraction, relieve symptoms under syndrome differentiation. The treatment was carried out for 4 courses in total. One course consisted of 5 days, with an interval of 2 days between two courses. After treatment of 5 patients, 2 patients were cured, 2 patients achieved markedly effective response, and 1 patient achieved effective response.     

Aspirin in a diabetic retinopathy setting: Insights from NO BLIND study

Background and aimsDiabetic retinopathy (DR) is the most common microvascular complication of diabetes. Diabetic macroangiopathies, particularly cardiovascular (CV) diseases, seem closely related to diabetes microvascular complications. Aspirin represents the most prescribed compound in CV prevention. Aspirin impact on DR is still object of debate. As it is already recommended among diabetics at high CV risk, aim of this study was to assess a potential relationship between DR and aspirin therapy, in a type 2 diabetes cohort of patients screened through telemedicine.Methods and resultsNO Blind is a cross-sectional, multicenter, observational study, which involved nine Italian outpatient clinics. Primary endpoint was the assessment of the relationship between aspirin treatment and DR. 2068 patients were enrolled in the study, subsequently split in two subpopulations according to either the presence or absence of DR. Overall, 995 subjects were under aspirin therapy. After adjusting for most common potential confounders, age and gender, aspirin reveals significantly associated with DR (OR: 1.72, 95%CI: 1.58–2.89, p = 0.002) and proliferative DR (PDR) (OR: 1.89, 95%CI: 1.24–2.84, p = 0.003). Association comes lost further adjusting for MACEs (OR: 1.28, 95%CI: 0.85–1.42, p = 0.157) (Model 4) and eGFR (OR: 0.93; 95%CI: 0.71–1.22; p = 0.591) (Model 5).ConclusionIn this multicenter cross-sectional study including a large sample of outpatients with T2DM, we showed that aspirin was not associated with DR after adjustment for several cardio-metabolic confounders. However, as partially confirmed by our findings, and related to the well-known pro-hemorrhagic effect of aspirin, its use should be individually tailored, even by telemedicine tools.     

Maternal and neonatal outcomes with the addition of intrathecal midazolam as an adjuvant to spinal anesthesia in cesarean delivery: A systematic review and meta-analysis of randomized controlled trials

Study objectiveTo determine the efficacy and safety, in terms of maternal and neonatal outcomes, of adding intrathecal midazolam to spinal anesthesia for cesarean delivery in healthy pregnant women.DesignA meta-analysis of randomized controlled trials was conducted. PubMed, Cochrane Library, Embase, and Web of Science were searched manually, and citation screening was completed on May 20, 2021.SettingMost of the included data were collected in the operating room and postoperative recovery area.PatientsA total of 1382 healthy parturients undergoing cesarean delivery with single-shot spinal anesthesia were recruited in 19 eligible randomized controlled trials.InterventionsSingle intrathecal midazolam adjuvant was compared to a control, with the local anesthetic dose in spinal anesthesia identical between the intervention and control groups.MeasurementsThe primary outcomes were time to first analgesic use, maternal adverse effects, and neonatal Apgar scores at 1 and 5 min. The secondary outcomes were the onset and duration of the sensory and motor blocks.Main resultsAdjuvant intrathecal midazolam prolonged the time to the first analgesic (mean difference [MD]: 59.96 min, 95% confidence interval [CI]: [23.12, 96.79]) and decreased perioperative maternal nausea and/or vomiting (odds ratio [OR], 0.28; 95% CI: [0.17, 0.45]). However, more sedation events were observed with midazolam (OR, 3.93; 95% CI: [1.12, 13.78]). There was no significant difference in the neonatal Apgar scores at 1 or 5 min (MD: -0.29, 95% CI: [−0.61, 0.03]; MD: -0.00, 95% CI: [−0.11, 0.1], respectively). Intrathecal midazolam also shortened sensory and motor block onset by less than 1 min and prolonged sensory block duration but had no significant effect on motor block duration.ConclusionsCurrent evidence indicates that intrathecal midazolam, as an adjuvant to spinal anesthesia, provides modest analgesic and significant antiemetic effects at the cost of more sedation events in cesarean delivery patients. The neonatal Apgar score was not affected by intrathecal midazolam administration. However, more objective, sensitive, and long-term measurements of neonatal safety and maternal neurological effects should be performed in the future.     

JCL roundtable: South Asian atherosclerotic risk

South Asian risk for atherosclerotic cardiovascular disease (ASCVD) has received special emphasis in the 2018 US AHA/ACC/Multisociety Cholesterol Guidelines. The term “South Asian” refers specifically to the countries of India, Pakistan, Nepal, Bhutan, Bangladesh, Sri Lanka, and Maldives and to the worldwide diaspora of families from these countries. With this definition, approximately 25% of the world's population is South Asian, but about 50% of ASCVD occurs in this group. In this JCL Roundtable, we discuss the roles of visceral adiposity, diabetes, and features of the metabolic syndrome; lipoprotein(a); and diet and lifestyle, including the transition of both diet and lifestyle over the past 40 to 50 years. Genetic and/or hidden risk is an area of ongoing research. Individual patient assessment and intervention should recognize the earlier onset of ASCVD and the value of screening for traditional risk factors as well as waist circumference, coronary artery calcium scoring, and lipoprotein(a) assay. Culturally acceptable dietary strategies are available, although not widely implemented or evaluated as yet. In very-high-risk cases of secondary prevention, one should consider combining medications to drive low-density lipoprotein cholesterol much lower than 70 mg/dL. Our discussion concludes by insisting that the signal of alarm must be accompanied by decisive action.     

Prenatal exposure to perfluoroalkyl substances,immune-related outcomes,and lung function in children from a Spanish birth cohort study

BackgroundPrenatal exposure to perfluoroalkyl substances (PFASs) has been associated with impaired immune and respiratory health during childhood but the evidence is inconsistent and limited for lung function. We studied the association between prenatal PFASs exposure and immune and respiratory health, including lung function, up to age 7 years in the Spanish INMA birth cohort study.MethodsWe assessed four PFASs in maternal plasma samples collected during the 1st trimester of pregnancy (years: 2003–2008): perfluorohexane sulfonate (PFHxS), perfluorooctane sulfonate (PFOS), perfluorooctanoate (PFOA), and perfluorononanoate (PFNA). Mothers reported the occurrence (yes/no) of lower respiratory tract infections, wheezing, asthma, and eczema in the previous 12 months at 1.5 and 4 years of the child (n = 1188) and at 7 years (n = 1071). At ages 4 (n = 503) and 7 (n = 992) years lung function was assessed using spirometry tests.ResultsThe most abundant PFASs were PFOS and PFOA (geometric means: 5.80 and 2.31 ng/mL, respectively). The relative risk of asthma during childhood per each doubling in PFNA concentration was 0.74 (95 CI%: 0.57, 0.96). The relative risk of eczema during childhood per every doubling in PFOS concentration was 0.86 (95 CI%: 0.75, 0.98). Higher PFOA concentrations were associated with lower forced vital capacity and lower forced expiratory volume in 1 s z-scores at 4 years [β (95 CI %): −0.17 (−0.34, −0.01) and −0.13 (−0.29, 0.03), respectively], but not at 7 years.ConclusionThis longitudinal study suggests that different PFASs may affect the developing immune and respiratory systems differently. Prenatal exposure to PFNA and PFOS may be associated with reduced risk of respiratory and immune outcomes, particularly asthma and eczema whereas exposure to PFOA may be associated with reduced lung function in young children. These mixed results need to be replicated in follow-up studies at later ages.     

The association between out of hours burn centre admission and in-hospital outcomes in patients with severe burns

IntroductionPatients with severe burns (≥20 % total body surface area [TBSA]) have specific and time sensitive needs on arrival to the burn centre. Burn care systems in Australia and New Zealand are organised differently during weekday business hours compared to overnight and weekends. The aims of this study were to compare the profile of adult patients with severe burns admitted during business hours with patients admitted out of hours and to quantify the association between time of admission and in-hospital outcomes in the Australian and New Zealand context.MethodsData were extracted from the Burns Registry of Australia and New Zealand for adults (≥18 years) with severe burns admitted to Australian or New Zealand burn centres between July 2016 and June 2020. Differences in patient profiles, clinical management, and in-hospital outcomes were investigated. Univariable and multivariable logistic and linear regression models were used to quantify associations between time of admission and in-hospital outcomes of interest.ResultsWe found 623 patients eligible for inclusion. Most patients were admitted out of hours (69.2 %), their median age was 42 years, and most were male (78 %). The median size burn was 30 % TBSA and 32 % of patients had an inhalation injury. A greater proportion of patients admitted out of hours had alcohol and/or drugs involved with injury compared to patients admitted during business hours. No other differences between groups were observed. Patients in both groups had similar odds of dying in hospital (Odds Ratio [OR], 95 % Confidence Interval [95 %CI] 1.49 [0.64, 3.48]), developing acute kidney injury within 72 h (OR, 95 %CI 0.58 [0.32, 1.07]), or sepsis (OR, 95 %CI 1.04 [0.46, 2.35]). No association was found between time of admission and hospital (%, 95 %CI 1.00 [0.82, 1.23]) nor intensive care length of stay (%, 95 %CI 0.97 [0.73, 1.27]).DiscussionIn this first Australian and/or New Zealand study to explore the association between time of admission and burn patient in-hospital outcomes, out of hours admission was not associated with patient outcomes of interest.ConclusionThese findings support current models of care in Australian and New Zealand burn centres, however further investigation is required. Nonetheless, given most severe burns patients arrive out of hours to burn the centre, it is plausible that out of hours availability of senior burn clinicians will improve patient care and safety resilience within burn care systems.