Pharmacist Prescribing at Inpatient Discharge in Alberta.

Background: Pharmacists in the province of Alberta may apply for additional prescribing authorization (APA), which allows them to independently prescribe medications. Currently, no literature exists about pharmacist prescribing for inpatients at the time of discharge. Objectives: The primary objective was to report the proportion of patients for whom inpatient pharmacists with APA prescribed at discharge across Alberta, Canada. Secondary objectives were to describe discharge interventions other than prescribing that were provided, enablers of and barriers to discharge prescribing, and differences in discharge prescribing by facility or population type, clinical area, and health care charting system. Methods: A descriptive, cross-sectional web-based survey of inpatient pharmacists with APA across Alberta was conducted over a 6-week period in early 2022. Results: A total of 104 respondents met the inclusion criteria. Under half (45/102, 44.1%) of the participants reported prescribing at discharge. Those that reported prescribing at discharge did so for only a median 14.5% of their patients. The most common enabler of discharge prescribing was a supportive care team, and the most common barrier was the presence of other prescribers. Pharmacists who did not report prescribing at discharge selected "discomfort with being responsible for the prescription" and "fear of professional liability" as barriers more often than those who did report discharge prescribing (51.0% [26/51] vs 33.3% [13/39] and 43.1% [22/51] vs 25.6% [10/39], respectively). The proportion of pharmacists who reported prescribing at discharge was greater with increasing population/facility size (30% [6/20] of pharmacists in settings that served small populations vs 50% [29/58] of those in settings that served large populations). Conclusions: Inpatient pharmacists who use APA at discharge reported prescribing for only a minority of patients, and discharge prescribing practices varied widely across the province. Future areas of research include how pharmacists can overcome barriers to prescribing at discharge.

Contexte: Les pharmaciens de la province de l'Alberta peuvent demander une autorisation supplémentaire de prescrire des médicaments de manière indépendante. À l'heure actuelle, aucune documentation n'existe sur la prescription de médicaments destinés aux patients hospitalisés au moment de leur congé par les pharmaciens. Objectifs: L'objectif principal visait à rendre compte de la proportion de patients à qui les pharmaciens en milieu hospitalier titulaires d'une autorisation supplémentaire de prescrire prescrivaient des médicaments au moment du congé en Alberta, au Canada. Les objectifs secondaires visaient quant à eux à décrire : les interventions au moment du congé, autres que la prescription; les obstacles et les facilitateurs de la prescription au moment du congé; et les différences en matière de prescription au moment du congé par type d'établissement ou de population, domaine clinique et système de dossiers de soins de santé. Méthode: Une enquête en ligne descriptive et transversale a été menée auprès de pharmaciens en milieu hospitalier titulaires d'une autorisation supplémentaire de prescrire en Alberta, sur un intervalle de 6 semaines au début de 2022. Résultats: Au total, 104 répondants satisfaisaient aux critères d'inclusion. Moins de la moitié (45/102, 44,1 %) des participants ont déclaré prescrire au moment du congé. Ceux-ci le faisaient pour seulement une médiane de 14,5 % de leurs patients. Le facteur le plus courant favorisant la prescription au moment du congé était une équipe de soins de soutien; l'obstacle le plus courant était la présence d'autres prescripteurs. Les pharmaciens ayant déclaré ne pas prescrire au moment du congé ont plus fréquemment indiqué comme obstacle le fait d'être « mal à l'aise à l'idée d'être responsable de la prescription ¼ et la « crainte de la responsabilité professionnelle ¼ que les pharmaciens ayant indiqué prescrire au moment du congé (51,0 % [26/51] contre 33,3 % [13/39] et 43,1 % [22/51] contre 25,6 % [10/39], respectivement). La proportion de pharmaciens ayant déclaré prescrire au moment du congé était plus élevée lorsque la taille de la population/de l'établissement était plus importante (30% [6/20] des pharmaciens dans des milieux desservant de petites populations contre 50 % [29/58] de ceux dans des milieux desservant de grandes populations). Conclusions: Les pharmaciens en milieu hospitalier titulaires d'une autorisation supplémentaire de prescrire ont déclaré prescrire pour seulement une minorité de patients au moment du congé, et les pratiques en la matière variaient largement dans la province. Les futurs domaines de recherche comprennent la manière dont les pharmaciens peuvent surmonter les obstacles les empêchant de prescrire au moment du congé.

Prevalence of Venous Thromboembolism and Anticoagulant Use in Patients with COVID-19 in Alberta, Canada.

Background: COVID-19 causes a hypercoagulable state and increases the risk of venous thromboembolism (VTE). Objectives: The primary objective was to identify VTE prevalence among patients with COVID-19 in one Canadian province. Secondary objectives were to identify the prevalence of bleeding, describe anticoagulation prescribing practices, and identify factors contributing to VTE in these patients. Methods: Adult patients admitted to Alberta hospitals between March and December 2020 with COVID-19 who had a length of stay of at least 72 hours were included in this retrospective study. VTE, bleeding events, and comorbidities were defined by International Classification of Diseases and Related Health Problems, 10th Revision codes. Cases of VTE and controls (no VTE) were matched on the basis of age older than 60 years, active cancer, and length of stay for the full cohort, as well as for a subgroup of patients with d-dimer data available, to assess for factors associated with VTE. Results: A total of 2544 patients were included. Median age was 66 years, 1461 patients (57.4%) were male, median weight was 77.7 kg, and median d-dimer level on admission was 1.00 mg/L. The prevalence of VTE was 3.7% (n = 93) and that of major and clinically relevant non-major bleeding was 4.9% (n = 125). Of the total population, 1224 patients (48.1%) had standard prophylactic-dose anticoagulation, 460 (18.1%) received only higher-dose anticoagulation, 248 (9.7%) received both prophylactic- and higher-dose anticoagulation, and 612 (24.1%) had no anticoagulation data. Logistic regression showed that only the presence of d-dimer above 3 mg/L was associated with a significant odds ratio for VTE (7.04, 95% confidence interval 2.43-20.84). Conclusions: VTE prevalence among patients with COVID-19 was higher than baseline prevalence in Alberta. Analysis of prescribing practices demonstrated that a large proportion of patients received higher-dose anticoagulation.

Contexte: La COVID-19 provoque un état d'hypercoagulabilité et augmente le risque de thromboembolie veineuse (TEV). Objectifs: L'objectif principal de cette étude consistait à identifier la prévalence de la TEV chez les patients atteints de COVID-19 dans une province canadienne. Ses objectifs secondaires consistaient, quant à eux, à identifier la prévalence des saignements, décrire les pratiques relatives à la prescription d'anticoagulants et à identifier les facteurs contribuant à la TEV chez ces patients. Méthodes: Cette étude rétrospective a été menée auprès de patients adultes atteints de COVID-19 admis dans les hôpitaux de l'Alberta entre mars et décembre 2020 avec une durée de séjour d'au moins 72 heures. La TEV, les événements hémorragiques et les comorbidités étaient définis par les codes de la Classification internationale des maladies et des problèmes de santé connexes, 10 e révision (CIM-10). Les cas de TEV et les témoins (sans TEV) ont été appariés sur les bases suivantes afin d'évaluer les facteurs associés à la TEV : âge de plus de 60 ans, cancer actif et durée de séjour pour l'ensemble de la cohorte, ainsi que pour un sous-groupe de patients dont les données sur les D-dimères étaient disponibles. Résultats: Au total, 2544 patients ont été inclus. L'âge médian était de 66 ans; 1461 patients (57,4 %) étaient des hommes; leur poids médian était de 77,7 kg et le taux médian de D-dimères à l'admission était de 1,00 mg/L. La prévalence de la TEV était de 3,7 % (n = 93) et celle des saignements majeurs et non majeurs cliniquement pertinents était de 4,9 % (n = 125). Sur la population totale, 1224 patients (48,1 %) ont reçu un anticoagulant à dose prophylactique standard; 460 (18,1 %) n'ont reçu qu'un anticoagulant à dose plus élevée; 248 (9,7 %) ont reçu à la fois un anticoagulant à dose prophylactique et à dose plus élevée; et 612 (24,1 %) ne disposaient pas de données relatives à la prescription d'anticoagualant. La régression logistique a montré que seule la présence de D-dimères au-dessus de 3 mg/L était associée à un rapport de cotes significatif pour la TEV (7,04, intervalle de confiance à 95 % 2,43­20,84). Conclusions: La prévalence de la TEV chez les patients atteints de COVID-19 était plus élevée que la prévalence de référence en Alberta. L'analyse des pratiques de prescription a montré qu'une grande proportion de patients recevait un anticoagulant à plus forte dose.

Three-dimensional assessment of the eruption path of the canine in individuals with bone-grafted alveolar clefts using cone beam computed tomography.

OBJECTIVE: To evaluate the eruption path of the permanent maxillary canine during a 1-year period after secondary alveolar bone grafting and to (1) compare the canine eruption path on the cleft and noncleft side, (2) examine the number of congenially missing lateral incisors and the rate of canine impaction, and (3) examine the relationship between the eruption status of the canine and timing of alveolar bone grafting relative to age and canine root development using cone beam computed tomography (CBCT). METHODS: Cone beam computed tomography scans for 17 nonsyndromic unilateral cleft lip and palate (UCLP), and four bilateral cleft lip and palate (BCLP) consecutive cases of alveolar bone grafting surgery were obtained after orthodontic expansion and before alveolar bone grafting and at least 1 year postsurgery on the Hitachi MercuRay CBCT machine. The DICOM files were imported into Dolphin 3D Imaging 10.5 and reoriented for consistency. The X, Y, and Z coordinates were determined for the canine cusp tip and root tip on both the cleft and noncleft sides. The direction of movement of the canine in 1 year was determined. RESULTS: Most canines on both the cleft and noncleft sides moved incisally, facially, and mesially. Twelve percent of the canines on the cleft side appeared to require surgical exposure. Eighty percent of the canines had less than half root development at the time of bone grafting. The amount of root development did not affect the outcome in terms of eruption amount or direction. CONCLUSIONS: Most canines on both the cleft and noncleft side moved incisally, facially, and mesially.

Response of the maxillary dentition to a statically determinate one-couple system with tip-back mechanics: A prospective clinical trial.

OBJECTIVE: To quantify the effects of tip-back mechanics on the maxillary first molars and incisors. MATERIALS AND METHODS: Sixteen subjects with Class II end-on malocclusion were treated with an intrusion arch to achieve distalization of the maxillary molar through tip-back mechanics. Lateral cephalograms were taken prior to molar tip-back (T1), after molar tip-back (T2), and after molar root uprighting (T3). Data were analyzed using the Friedman's and Wilcoxon signed rank tests to evaluate differences in time points (P ≤ .016). RESULTS: The maxillary first molar distalized 1.53 mm (P = .001) with 6.65° (P = .001) of distal tipping and 0.86 mm (P = .001) of extrusion at T2. Minor relapse of the first molar (mesial direction) was seen at T3. The maxillary incisors flared labially 0.4 mm, and the incisor root apex moved palatally 1.19 mm (P = .005) at T2. At T3, the incisor root apex moved palatally 1.5 mm (P = .003) from T1. An angular change from T1 of 3.31° (P = .008) and 3.53° (P = .014) was seen at T2 and T3, respectively, as a result of palatal root movement of the maxillary incisors. CONCLUSIONS: A significant amount of distalization of maxillary molars was attained at the crown level with tip-back mechanics. Palatal root angulation change was significant in the incisors with minimal anteroposterior movement of the incisal edge.

Volumetric assessment of secondary alveolar bone grafting using cone beam computed tomography.

OBJECTIVE: To assess the radiographic outcome of secondary alveolar bone grafting in individuals with nonsyndromic unilateral or bilateral cleft lip and palate using cone beam computed tomography. METHODS: This prospective study was conducted at the University of California at San Francisco Center for Craniofacial Anomalies on 21 consecutive nonsyndromic complete cleft lip and palate individuals between 8 and 12 years of age who required alveolar bone grafting. Seventeen unilateral and four bilateral cleft lip and palate individuals had preoperative and postoperative cone beam computed tomography scans that were analyzed using Amira 3.1.1 software. RESULTS: The average volume of the preoperative alveolar cleft defect in unilateral cleft lip and palate was 0.61 cm(3), and the combined average volume of the right and left alveolar cleft defects in bilateral cleft lip and palate was 0.82 cm(3). The average percentage bone fill in both unilateral cleft lip and palate and bilateral cleft lip and palate was 84%. The outcome of alveolar bone grafting was assessed in relation to (1) type of cleft, (2) size of preoperative cleft defect, (3) presence or absence of lateral incisor, (4) root development stage of the maxillary canine on the cleft side, (5) timing, and (6) surgeon. None of these parameters significantly influenced the radiographic outcome of alveolar bone grafting. CONCLUSIONS: Secondary alveolar bone grafting of the cleft defect in our center was successful, based on radiographic outcome using cone beam computed tomography scans. Volume rendering using cone beam computed tomography and Amira software is a reproducible and practical method to assess the preoperative alveolar cleft volume and the adequacy of bone fill postoperatively.