Heart rate reduces when stroke patients are touched . . . And??

McFadden KL, Hernández TD. Cardiovascular benefits of acupressure (Jin Shin) following stroke. Complement Ther Med 2010; 18: 42–8.     

Adherence to amiodarone monitoring recommendations before and after implementation of a centralized pharmacy service: a cohort study

The objective of this study was to determine whether patients enrolled in a centralized amiodarone monitoring service (AMS) were more adherent to amiodarone surveillance and whether the incidence of amiodarone-related toxicity differed for patients who were enrolled in the AMS. Amiodarone therapy was initiated in 917 patients in an integrated health care delivery system between October 1998 and December 2006. Electronic records were queried to establish the proportion of patients completing recommended amiodarone monitoring during the first year of therapy; specifically, thyroid stimulating hormone (TSH), alanine aminotransferase (ALT), electrocardiogram (ECG), and chest radiograph (CXR). Patients were assigned to the AMS or control cohort based on when amiodarone was initiated. Patients assigned to the AMS cohort were more likely to receive ALT monitoring at baseline, 6 months, and 1 year (68% vs 44%, P < .001; 86% vs 76%, P = .002; 84% vs 69%, P < .001; respectively) and ECG monitoring at baseline and 1 year (76% vs 58%; 96% vs 75%, P < .001, respectively). There was no difference in TSH monitoring at baseline, 6 months, and 1 year (55% vs 49%, P = not significant [NS]; 74% vs 70%, P = NS; 68% vs 64%, P = NS; respectively).     

The Role of Glial Glutamate Transporters in Maintaining the Independent Operation of Juvenile Mouse Cerebellar Parallel Fibre Synapses

There is controversy over the extent to which glutamate released at one synapse can escape from the synaptic cleft and affect receptors at other synapses nearby, thereby compromising the synapse-specificity of information transmission. Here we show that the glial glutamate transporters GLAST and GLT-1 limit the activation of Purkinje cell AMPA receptors produced by glutamate diffusion between parallel fibre synapses in the cerebellar cortex of juvenile mice. For a single stimulus to the cerebellar molecular layer of wild-type mice, increasing the number of activated parallel fibres prolonged the parallel fibre EPSC, demonstrating an interaction between different synapses. Knocking out GLAST, or blocking GLT-1 in the absence of GLAST, prolonged the EPSC when many parallel fibres were stimulated but not when few were stimulated. When spatially separated parallel fibres were activated by granular layer stimulation, the EPSC prolongation produced by stimulating more fibres or reducing glutamate transport was greatly reduced. Thus, GLAST and GLT-1 curtail the EPSC produced by a single stimulus only when many nearby fibres are simultaneously activated. However when trains of stimuli were applied, even to a small number of parallel fibres, knocking out GLAST or blocking GLT-1 in the absence of GLAST greatly prolonged and enhanced the AMPA receptor-mediated current. These results show that glial cell glutamate transporters allow neighbouring synapses to operate more independently, and control the postsynaptic response to high frequency bursts of action potentials.     

Managing community acquired pneumonia in the elderly – the next generation of pharmacotherapy on the horizon

Introduction: Community acquired pneumonia (CAP) is associated with high rates of morbidity and mortality, especially among the elderly. Antibiotic treatment for CAP in the elderly is particularly challenging for many reasons, including compliance issues, immunosuppression, polypharmacy and antimicrobial resistance. There are few available antibiotics that are able to address these concerns.

Areas covered: After a systematic review of the current literature, we describe seven novel antibiotics that are currently in advanced stages of development (phase 3 and beyond) and show promise for the treatment of CAP in those over the age of 65. These antibiotics are: Solithromycin, Pristinamycin, Nemonaxacin, Lefamulin, Omadacycline, Ceftobiprole and Delafloxacin. Using a novel conceptual framework designed by the present authors, known as the ‘San Antonio NIPS model’, we evaluate their strengths and weaknesses based on their ability to address the unique challenges that face the elderly.

Expert opinion: All seven antibiotics have potential value for effective utilization in the elderly, but to varying degrees based on their NIPS model score. The goal of this model is to reorganize a clinician’s focus on antibiotic choices in the elderly and bring attention to a seldom discussed topic that may potentially become a health-care crisis in the next decade.     

Cognitive outcomes among survivors of focal low-grade brainstem tumors diagnosed in childhood

Pediatric focal low-grade brainstem tumors are associated with excellent prognosis. Surgical resection and conformal radiation therapy are front-line treatment options; radiation therapy (RT) serves as an excellent treatment for disease progression. Given high survival rates and limited research regarding functional outcomes, the current study examined neurocognitive outcomes in a group of low-grade brainstem glioma survivors. Forty-three survivors of focal low-grade brainstem gliomas underwent neurocognitive assessment (58?% male; median?=?6.9 years at diagnosis; median?=?14.9 years at latest assessment). Treatment included combinations of surgery, chemotherapy, and RT with 70?% ultimately receiving RT. Neurocognitive outcomes were evaluated through retrospective chart review. Intellectual and academic performance were significantly different from normative expectations (full scale IQ?=?86.5?±?16.8; reading comprehension?=?91.3?±?16.4; math reasoning?=?88.2?±?18.9; reference group?=?100?±?15). Further, the percentage performing below average exceeded the expected 16?% in the normative sample (full scale IQ?=?43?%; reading comprehension?=?37?%; math reasoning?=?50?%). Mean parent ratings did not reflect concerns regarding internalizing and externalizing behaviors or executive functioning (internalizing?=?54.9?±?12.7; externalizing?=?51.6?±?14.6, global executive composite?=?57.1?±?16.0; reference group?=?50?±?10); however, the proportion with clinically elevated scores was higher than the expected 16?% (internalizing?=?42?%; externalizing?=?26?%; global executive composite?=?38?%). Mean performance fell below average for visual-motor coordination (81.8?±?13.2) and parent ratings of adaptive functioning (73.4?±?24.2), with 65 and 62?% falling outside the average range, respectively. There were no significant differences between those receiving and not receiving RT. Multiple cognitive domains were significantly different from normative expectations. Despite focal disease and treatment targeting subcortical brain regions, neurocognitive risks exist that may impact treatment planning and caregiver education.     

Actual versus projected cost avoidance for clinical pharmacy specialist-initiated medication conversions in a primary care setting in an integrated health system

BACKGROUND: Primary care clinical pharmacy specialists (PCCPSs) are positioned to promote effective, safe, and affordable medication use. Documentation of performed interventions is difficult because the diversity of performed interventions in a variety of disease states in some practice settings. Validation of cost-avoidance projections is also difficult because traditional projection methods have several limitations. OBJECTIVE: To (1) compare projected medication cost avoidance (MCA) to actual MCA for medication conversions related to hyperlipidemia, hypertension, depression, and chronic pain initiated by PCCPS, and (2) estimate medication discontinuation that might be attributable to serious adverse drug events (ADEs) possibly associated with medication conversions. METHODS: This was a retrospective, longitudinal study conducted in a not-for-profit, integrated health system comprising approximately 470,000 members. Using a portable documentation tool, PCCPSs recorded projected annual MCA for medication conversions in 4 disease conditions (i.e., hypertension, dyslipidemia, depression, and chronic pain) in the 6-month period from December 1, 2003, through May 31, 2004. Actual annual MCA for these interventions for a 1-year follow-up period was calculated using integrated, electronic data from an administrative pharmacy database. Comparisons were made between projected MCA and actual MCA. Cost was defined as actual drug acquisition cost. In addition, an assessment of serious ADEs potentially related to the conversions was undertaken by reviewing electronic medical records of converted, nonpersistent patients. RESULTS: There were 704 medication conversions for 656 patients, of which 47 (6.7%) were for members who disenrolled in the health plan during the 12 months following the medication conversion date. The total projected MCA was $327,337 in 2004 dollars, or an average of $465 per conversion. For the 657 medication conversions in 609 patients that were evaluable (i.e., the member remained enrolled through 12 months follow-up), 466 (70.9%) persisted at 12 months, 138 (21.0%) discontinued the medication or converted to an alternative therapy, and 53 (8.1%) reverted to the original medication. Drug cost information was not available for some members, leaving approximately half (n = 331, 50.4%) of the 657 evaluable medication conversions with complete cost information available. For these 331 conversions, the overall projected MCA overestimated the actual MCA by 14.1% ($24,888 in aggregate or an average of $75 per conversion, P < 0.001). For persistent medication conversions with complete cost information (n = 278), the projected MCA ($160,225) was not significantly different compared with the actual MCA ($166,546, P = 0.477). For medication conversions that reverted to previous therapy (n = 53), the projected MCA ($41,644) overestimated by 4-fold the actual MCA ($10,435, P < 0.001). There were no emergency department visits or hospital admissions related to nonpersistent medication conversions. Compared with patients who were either nonpersistent or disenrolled at the 12-month follow-up, persistent patients did not significantly differ in chronic disease score but were slightly older (mean = 62.6 years, standard deviation = 13.1 for persistent patients vs. 59.2 [SD = 15.5] for nonpersistent or disenrolled patients). CONCLUSIONS: Projected medication cost avoidance for pharmacistinitiated medication conversions is valid for the 66% of medication conversions that persist but not for nonpersistent conversions or for patients who leave the health care system. The projected medication cost avoidance overestimated the actual cost avoidance by approximately 14%, suggesting that there is opportunity for improvement in the tool used to document medication conversions to more accurately measure cost outcomes from clinical pharmacy interventions.