Effect of Pharmacist Counseling Intervention on Health Care Utilization Following Hospital Discharge: A Randomized Control Trial

Background

Reduction in 30-day readmission rates following hospitalization for acute coronary syndrome (ACS) and acute decompensated heart failure (ADHF) is a national goal.

Objective

The aim of this study was to determine the effect of a tailored, pharmacist-delivered, health literacy intervention on unplanned health care utilization, including hospital readmission or emergency room (ER) visit, following discharge.

Design

Randomized, controlled trial with concealed allocation and blinded outcome assessors

Setting

Two tertiary care academic medical centers

Participants

Adults hospitalized with a diagnosis of ACS and/or ADHF

Intervention

Pharmacist-assisted medication reconciliation, inpatient pharmacist counseling, low-literacy adherence aids, and individualized telephone follow-up after discharge

Main Measures

The primary outcome was time to first unplanned health care event, defined as hospital readmission or an ER visit within 30 days of discharge. Pre-specified analyses were conducted to evaluate the effects of the intervention by academic site, health literacy status (inadequate versus adequate), and cognition (impaired versus not impaired). Adjusted hazard ratios (aHR) and 95 % confidence intervals (CI) are reported.

Key Results

A total of 851 participants enrolled in the study at Vanderbilt University Hospital (VUH) and Brigham and Women’s Hospital (BWH). The primary analysis showed no statistically significant effect on time to first unplanned hospital readmission or ER visit among patients who received interventions compared to controls (aHR?=?1.04, 95 % CI 0.78-1.39). There was an interaction of treatment effect by site (p?=?0.04 for interaction); VUH aHR?=?0.77, 95 % CI 0.51-1.15; BWH aHR?=?1.44 (95 % CI 0.95-2.12). The intervention reduced early unplanned health care utilization among patients with inadequate health literacy (aHR 0.41, 95 % CI 0.17-1.00). There was no difference in treatment effect by patient cognition.

Conclusion

A tailored, pharmacist-delivered health literacy-sensitive intervention did not reduce post-discharge unplanned health care utilization overall. The intervention was effective among patients with inadequate health literacy, suggesting that targeted practice of pharmacist intervention in this population may be advantageous.

     

Thermal mapping of right ventricular outflow tract tachycardia

BACKGROUND: Acute and long-term success of catheter ablation of right ventricular outflow tract tachycardia (RVOT VT) may be limited by the inability to reproduce the arrhythmia at the time of activation (AM) and pace mapping (PM). We have observed early initiation of the clinical VT when subtherapeutic radiofrequency (RF) energy was applied to the target area (TA), defined as a 2-cm(2) area around a pace match. We describe a novel approach using thermal mapping (TM) to guide the ablation of RVOT VT. METHODS: Thirteen patients (10 female, mean age 46.2 +/- 13.7 years) with symptomatic VT of left bundle branch block (LBBB) inferior axis morphology and no structural heart disease underwent standard electrophysiologic evaluation with PM (n = 13), AM (n = 13), and 3D noncontact mapping (n = 4). Thermal mapping was performed after standard techniques failed to induce stable sustained VT for mapping in all 13 patients: RF was applied for 5-10 seconds in the TA to achieve a tip temperature of 45-50 degrees C. At sites where morphologically consistent with the clinical VT was induced, RF was applied at target temperature between 50 and 60 degrees C for 30-60 seconds. TM was repeated before and after intravenous Isoproterenol infusion until no further VT could be induced by low temperature application. RESULTS: Noninducibility was achieved in all 13 patients. During a mean follow-up of 29 months (9-69 months), all patients remain arrhythmia-free, off antiarrhythmic medications. CONCLUSION: Thermal mapping is a safe and effective adjunctive technique for the mapping and ablation of RVOT VT when sustained tolerated clinical VT cannot be induced.     

Alleviation of Pancoast's Tumor Pain by Ultrasound-Guided Percutaneous Ablation of Cervical Nerve Roots

▪ Abstract:   The case report describes use of real-time ultrasound guidance to facilitate percutaneous ablation of cervical nerve roots in a patient with Pancoast's syndrome. Distortion of anatomy by the tumor made it difficult to perform the procedure safely using fluoroscopy. A 64-year-old right-handed male patient with carcinoma of the left lung presented with severe pain in the left shoulder and the arm. A clinical diagnosis of the left brachial plexopathy secondary to tumor involvement of C5 to C8 nerve roots was made. Radiological appearance of the cervical spine revealed distorted anatomy because of severe degeneration of the cervical spine and guarding torticollis. Diagnostic prognostic block of the C4 to C7 exiting nerve roots was done under ultrasound guidance and resulted in more than 75% reduction in pain intensity for 4 hours. Ultrasound-guided percutaneous cervical rhizotomy was performed later. At 3-month follow-up, the patient still had complete pain relief as well as improvement in quality of sleep. Ultrasound-guided cervical nerve roots ablation is a feasible approach for patients with intractable neuropathic pain secondary to Pancoast's tumor. It can be a useful alternative to fluoroscopy in patients in whom a fluoroscopy-guided approach is deemed difficult and hazardous. ▪     

Elevated pretransplant ferritin is associated with a lower incidence of chronic graft-versus-host disease and inferior survival after myeloablative allogeneic haematopoietic stem cell transplantation

Elevated pretransplant serum ferritin levels have been associated with an increased incidence of morbidity and mortality after allogeneic haematopoietic stem cell transplantation (HCT). We studied 222 patients who underwent myeloablative allogeneic HCT in whom pretransplantation serum ferritin levels were available. Pretransplantation ferritin > 1910 μg/l was associated with lower overall survival ( P  = 0·003), lower relapse-free survival ( P  = 0·003), decreased chronic graft- versus -host disease (GVHD) ( P  = 0·019) and increased non-relapse mortality (NRM) ( P  = 0·042). Similar results were obtained when pretransplantation ferritin was analysed as a continuous variable and by quartiles. Our results indicate that an elevated pretransplant ferritin level adversely impacts transplantation outcomes. The adverse impact of elevated ferritin on NRM and survival was despite its association with lower incidences of acute and chronic GVHD, which are major causes of NRM. The association of ferritin with iron overload and its influence on HCT outcomes requires further prospective validation.     

Intestinal Dysbiosis and Depletion of Butyrogenic Bacteria in Clostridium difficile Infection and Nosocomial Diarrhea

Clostridium difficile infection (CDI) causes nearly half a million cases of diarrhea and colitis in the United States each year. Although the importance of the gut microbiota in C. difficile pathogenesis is well recognized, components of the human gut flora critical for colonization resistance are not known. Culture-independent high-density Roche 454 pyrosequencing was used to survey the distal gut microbiota for 39 individuals with CDI, 36 subjects with C. difficile-negative nosocomial diarrhea (CDN), and 40 healthy control subjects. A total of 526,071 partial 16S rRNA sequence reads of the V1 to V3 regions were aligned with 16S databases, identifying 3,531 bacterial phylotypes from 115 fecal samples. Genomic analysis revealed significant alterations of organism lineages in both the CDI and CDN groups, which were accompanied by marked decreases in microbial diversity and species richness driven primarily by a paucity of phylotypes within the Firmicutes phylum. Normally abundant gut commensal organisms, including the Ruminococcaceae and Lachnospiraceae families and butyrate-producing C2 to C4 anaerobic fermenters, were significantly depleted in the CDI and CDN groups. These data demonstrate associations between the depletion of Ruminococcaceae, Lachnospiraceae, and butyrogenic bacteria in the gut microbiota and nosocomial diarrhea, including C. difficile infection. Mechanistic studies focusing on the functional roles of these organisms in diarrheal diseases and resistance against C. difficile colonization are warranted.     

β‐Cell subcellular localization of glucose‐stimulated Mn uptake by X‐ray fluorescence microscopy: implications for pancreatic MRI

Manganese (Mn) is a calcium (Ca) analog that has long been used as a magnetic resonance imaging (MRI) contrast agent for investigating cardiac tissue functionality, for brain mapping and for neuronal tract tracing studies. Recently, we have extended its use to investigate pancreatic β‐cells and showed that, in the presence of MnCl₂, glucose‐activated pancreatic islets yield significant signal enhancement in T₁‐weigheted MR images. In this study, we exploited for the first time the unique capabilities of X‐ray fluorescence microscopy (XFM) to both visualize and quantify the metal in pancreatic β‐cells at cellular and subcellular levels. MIN‐6 insulinoma cells grown in standard tissue culture conditions had only a trace amount of Mn, 1.14 ± 0.03 × 10^?11 µg/µm², homogenously distributed across the cell. Exposure to 2 m m glucose and 50 µ m MnCl₂ for 20 min resulted in nonglucose‐dependent Mn uptake and the overall cell concentration increased to 8.99 ± 2.69 × 10^?11 µg/µm². When cells were activated by incubation in 16 m m glucose in the presence of 50 µ m MnCl₂, a significant increase in cytoplasmic Mn was measured, reaching 2.57 ± 1.34 × 10^?10 µg/µm². A further rise in intracellular concentration was measured following KCl‐induced depolarization, with concentrations totaling 1.25 ± 0.33 × 10^?9 and 4.02 ± 0.71 × 10^?10 µg/µm² in the cytoplasm and nuclei, respectively. In both activated conditions Mn was prevalent in the cytoplasm and localized primarily in a perinuclear region, possibly corresponding to the Golgi apparatus and involving the secretory pathway. These data are consistent with our previous MRI findings, confirming that Mn can be used as a functional imaging reporter of pancreatic β‐cell activation and also provide a basis for understanding how subcellular localization of Mn will impact MRI contrast. Copyright © 2011 John Wiley & Sons, Ltd.