Impact of pharmacist outreach on glucagon prescribing.

BACKGROUND: Hypoglycemia is a major limiting factor in the glycemic management of diabetes. As a method of treating hypoglycemia, the American Diabetes Association recommends glucagon to be prescribed for all individuals at increased risk of clinically impactful hypoglycemia. Glucagon Emergency Kits have been shown to reduce emergency department visits and overall health care costs. Despite these known benefits, glucagon continues to be underprescribed. Previous pharmacist-led interventions embedded in a single clinic have been shown to positively affect the rate of glucagon prescribing in patients with diabetes. OBJECTIVE: This study aimed to compare the rate of glucagon prescribing between quality improvement remote pharmacist outreach to multiple primary care and endocrinology specialty clinics and the control group in 1 month following a pharmacist-led provider outreach. METHODS: This was a single-center, 2-arm study with a simple randomization design. RESULTS: On pharmacist outreach, 61 of 109 patients (56.0%) in the outreach group were prescribed a glucagon product within 1 month of their primary care provider (PCP) or endocrinology appointment compared with 1 of 113 (0.9%) of patients in the control group (P < 0.001). Glucagon prescribing occurred in 25 of 35 Black patients (71.4%) compared with 36 of 73 white patients (49.3%) in the outreach group. Glucagon prescribing was associated with race (P = 0.03; chi-square test). CONCLUSIONS: The pharmacist-led provider outreach before a PCP or endocrinology appointment has a positive and statistically significant impact on glucagon prescribing rates. The pharmacist outreach had a higher impact on Black patients than white patients, possibly because of a lower rate of glucagon prescribing in Black patients before the outreach.

Concomitant Large Loculated Pleural and Pericardial Effusions in a Patient with Rheumatoid Arthritis on Methotrexate.

Rheumatoid arthritis (RA) is the most common multisystemic autoimmune inflammatory joint disorder, affecting nearly 1.3 million adults in the US. RA has high economic and social burdens. Functional disability may arise in RA from the characteristic chronic progressive inflammation and the erosion of multiple joints and cartilage damage. Systemic manifestations of RA include rheumatoid nodules, pleuropulmonary complications, pericarditis, rheumatoid vasculitis, Felty's syndrome (the rare triad of rheumatoid arthritis, splenomegaly, and neutropenia), amyloidosis, and neurological complications. We present the diagnostic challenges of differentiating pleuropulmonary and pericardial complications of rheumatoid arthritis from side effects of therapy (rheumatoid pleural and pericardial effusions vs immune suppression associated side effects and infections). We use the Naranjo score to facilitate this decision-making process. A 52-year-old man with a history of RA, chronic small right pleural effusion, and hypertension on long-term oral methotrexate and corticosteroid therapy presented to the emergency room after 1 week of worsening respiratory symptoms. A chest radiograph demonstrated a large pleural effusion and pneumonia. Intravenous methylprednisolone and antibiotics were administered. A video-assisted thoracoscopic procedure was performed, chest tubes were inserted, and abatacept was eventually initiated as adjunctive therapy to methotrexate and corticosteroid therapy for the rheumatoid arthritis and lung condition. Abatacept is an immunosuppressive fusion protein composed of the Fc region of immunoglobulin G1 fused to the extracellular domain of cytotoxic T-lymphocyte-associated protein 4, which interferes with the immune activity of T cells.

Concurrent Delusions of Ocular Parasitosis and Complex Visual Hallucinations from Charles Bonnet Syndrome Treated Successfully with Aripiprazole in an Elderly Male: A Case Report.

INTRODUCTION: Delusional parasitosis (DP) has been described as among the most challenging diagnosis to manage in dermatology and psychiatry literature. Patients with this perplexing and enigmatic condition present potentially to a wide range of specialties including primary or emergency care, dermatology, infectious diseases, neurology, and psychiatry. DP is probably underdiagnosed from patients' underreporting of symptoms of being infested with parasites, resulting from the associated social stigma. In addition, specialists who most often encounter these patients often possess low familiarity and comfort level in the diagnosis and therapy of this disorder. To our knowledge, we present only the fifth case of delusional parasitosis that was associated with complex visual hallucinations. Both concurrent conditions were treated successfully with aripiprazole. Interestingly, in all of these prior cases including ours, the patients were elderly (age range, 74-95 years). Delusions of ocular parasitosis has been described in fewer than 11 cases. When delusions occur concurrently with hallucinations, the differential diagnosis becomes even more challenging and may include schizophrenia, drug-induced psychosis, Lewy body dementia, and Charles Bonnet syndrome. Our patient's delusions of ocular parasitosis led to ocular damage and severe visual impairment because of his constant need to extract the parasites from his eyes. We speculate that the subsequent complex visual hallucinations that developed can best be understood as Charles Bonnet syndrome. CASE PRESENTATION: A 78-year-old healthy African American male complained of pests and bugs approximately 2 cm in size that infested the skin of his entire body. He also described the life cycle of these parasites, which jumped onto his eyelids and conjunctiva. He developed functional vision blindness from his unwillingness to open his eyelids as a result of his attempts to block the parasites. He was evaluated by dermatology, infectious diseases, ophthalmology, and psychiatry. All specialists agreed with the diagnosis of DP, and recommended antipsychotic therapy. They consistently dismissed the patient's symptoms as anything more than psychiatric, so the patient did not follow-up for further assessments or other therapies. Even months after the diagnosis of DP, he developed complex visual hallucinations. He described new visions in vivid detail: inanimate objects (buildings, jackhammers, torches, planes), animals (bears, doves, sharks), shapes (triangles, rectangles, omega, and mason signs). The objects interacted on high-definition landscapes such as oceans. He refused further psychiatric assessment because he felt strongly that the symptoms were infectious in nature and not psychiatric. However, a therapeutic relationship with his geriatrician was established through empathic communications, goal setting, and shared decision making. He even agreed to start treatment with aripiprazole 2 mg because the shared goal was symptom management of the concurrent delusional parasitosis and complex visual hallucinations. The slow titration of aripiprazole to 6 mg led to a 75% reduction in the delusions and hallucinations. He initially declined higher dosages of the aripiprazole because of sedation and personal wariness of medications in general. However, a therapeutic relationship was nurtured based on respect, careful listening, and provision of options. Eventually, he agreed to a higher dosage of aripiprazole and thus titrate antipsychotic therapy that he rejected when prescribed by the dermatology and psychiatry specialists. We attempted to approximate the 15-mg dosage that led to remission of symptoms in previous case reports.