Remimazolam as a Primary Agent for Brief Invasive and Noninvasive Procedures: A Case Series.

Remimazolam is a novel benzodiazepine with sedative and amnestic properties similar to midazolam. Ester metabolism results in a half-life of 5 - 10 min and a limited context sensitive half-life. We present preliminary retrospective experience with its use as a primary agent for procedural sedation for brief invasive and noninvasive procedures. The study cohort included seven patients, ranging in age from 14 to 51 years. Remimazolam administration included bolus dosing in two patients and a combination of bolus dosing followed by an infusion in the other five patients. The initial bolus dose of remimazolam ranged from 2.5 to 5 mg. Starting doses for the infusion ranged from 10 to 30 µg/kg/min with titration of the continuous infusion during the procedure, ranging from 10 - 30 µg/kg/min. Median dose infusion requirements were 15 - 20 µg/kg/min. One procedure was completed with remimazolam as the sole anesthetic agent while the other six patients received adjunctive agents. Changes in blood pressure or oxygen saturation were noted which resolved with minimal interventions such as a decrease in remimazolam infusion rate or an increase in supplemental oxygen administration. Our anecdotal experience provides further support for the efficacy of remimazolam as an agent for procedural sedation.

Opioid reduction in ambulatory thyroid and parathyroid surgery after implementing enhanced recovery after surgery protocol.

BACKGROUND: Opioid abuse is widespread in the United States and the risk for chronic use is increased in surgical patients, including patients with thyroid and parathyroid. METHODS: Records for 171 patients prior to and 67 patients following implementation of an enhanced recovery after surgery (ERAS) protocol for ambulatory thyroid/parathyroid surgeries were reviewed. The ERAS included superficial cervical plexus block, multimodal premedication, and postoperative reliance on acetaminophen and ibuprofen with judicious prescribing of opioids. RESULTS: Post-ERAS patients were prescribed a mean 72 morphine milligram equivalents (MME); pre-ERAS patients were prescribed a mean 163 MME (p < 0.001). 97.1% of pre-ERAS patients were prescribed opioids with 91.1% filled; 68.7% of post-ERAS study patients were prescribed opioids with 84.8% filled. CONCLUSION: Implementation of ERAS and focus on prescribing practices decreased the MME prescribed and used for ambulatory thyroid and parathyroid surgery. Future steps include increased patient education and tracking pain scores and medication utilization out of hospital.

Review of Metformin Use for Type 2 Diabetes Prevention.

CONTEXT: Prediabetes is prevalent and significantly increases lifetime risk of progression to type 2 diabetes. This review summarizes the evidence surrounding metformin use for type 2 diabetes prevention. EVIDENCE ACQUISITION: Articles published between 1998 and 2017 examining metformin use for the primary indication of diabetes prevention available on MEDLINE. EVIDENCE SYNTHESIS: Forty articles met inclusion criteria and were summarized into four general categories: (1) RCTs of metformin use for diabetes prevention (n=7 and n=2 follow-up analyses); (2) observational analyses examining metformin use in heterogeneous subgroups of patients with prediabetes (n=9 from the Diabetes Prevention Program, n=1 from the biguanides and the prevention of the risk of obesity [BIGPRO] trial); (3) observational analyses examining cost effectiveness of metformin use for diabetes prevention (n=11 from the Diabetes Prevention Program, n=1 from the Indian Diabetes Prevention Program); and (4) real-world assessments of metformin eligibility or use for diabetes prevention (n=9). Metformin was associated with reduced relative risk of incident diabetes, with the strongest evidence for use in those at highest risk (i.e., aged <60 years, BMI ≥35, and women with histories of gestational diabetes). Metformin was also deemed cost effective in 11 economic analyses. Recent studies highlighted low rates of metformin use for diabetes prevention in real-world settings. CONCLUSIONS: Two decades of evidence support metformin use for diabetes prevention among higher-risk patients. However, metformin is not widely used in real-world practice, and enhancing the translation of this evidence to real-world practice has important implications for patients, providers, and payers.

Pinnisterols A-C, New 9,11-Secosterols from a Gorgonian Pinnigorgia sp.

Three new 9,11-secosterols, pinnisterols A-C (1-3), were isolated from a gorgonian coral Pinnigorgia sp., collected off the waters of Taiwan. The structures of these compounds were elucidated on the basis of spectroscopic methods. The new sterols 1 and 3 displayed significant inhibitory effects on the generation of superoxide anions and the release of elastase by human neutrophils, and sterol 1 was found to show moderate cytotoxicity in hepatic stellate cells (HSCs).

Pharmacist- versus physician-initiated admission medication reconciliation: impact on adverse drug events.

BACKGROUND: Medication reconciliation (MR) has proven to be a problematic task for many hospitals to accomplish. It is important to know the clinical impact of physician- versus pharmacist-initiated MR in the resource-limited hospital environment. METHODS: This quasi-experimental study took place from December 2005 to February 2006 at an urban US Veterans Affairs hospital. MR was implemented on 2 similar general medical units: one received physician-initiated MR and the other received pharmacist-initiated MR. Adverse drug events (ADEs) and a 72-hour medication-prescribing risk score were ascertained by research pharmacists for all admitted patients by structured record review. Multivariable models were tested for intervention effect, accounting for quasi-experimental design and clustered observations, and were adjusted for patient and encounter covariates. RESULTS: Pharmacists completed the MR process in 102 admissions and physicians completed the process in 116 admissions. In completing the MR process, pharmacists documented statistically more admission medication changes than physicians (3.6 vs 0.8; P < 0.001). The adjusted odds of an ADE caused by an admission prescribing change with pharmacist-initiated MR compared with a physician-initiated MR were 1.04 with a 95% CI of 0.53 to 2.0. The adjusted odds of an ADE caused by an admission prescribing change that was a prescribing error with pharmacist-initiated MR compared with a physician-initiated MR were 0.38 with a confidence interval of 0.14 to 1.05. No difference was observed in 72-hour prescribing risk score (coefficient = 0.10; 95% CI, -0.54 to 0.75). CONCLUSION: MR performed by pharmacists versus physicians was more comprehensive and was followed by lower odds of ADEs from admission prescribing errors but with similar odds of all types of ADEs. Further research is warranted to examine how MR tasks may be optimally divided among clinicians and the mechanisms by which MR affects the likelihood of subsequent ADEs.