Clam calamity: five concurrent cases of neurotoxic shellfish poisoning with varying presentations following ingestion of clams from Gulf of Mexico water contaminated with Karenia brevis confirmed by serum brevetoxin assays.

INTRODUCTION: Karinia brevis, a marine dinoflagellate, is the causative organism for "red-tide" on the east coast of Florida.This microbe produces brevetoxins, which bioaccumulate in filter feeding bivalve shellfish. In humans, inhalational exposure is common, while ingestion of contaminated shellfish is more rare. Ingested brevetoxin causes gastrointestinal and neurological symptoms collectively known as neurotoxic shellfish poisoning. CASE CLUSTER: A group of tourists collected clams from a beach during a red tide event. The clams were soaked in brine, microwaved, and consumed for lunch. The index patient experienced seizure-like activity postprandially prompting the cohort to present for medical attention. Five people presented to the emergency department with neurotoxic shellfish poisoning-related symptoms. All patients received supportive care only. Symptoms resolved within 24 hours. Serum brevetoxin concentrations were reported for four patients. DISCUSSION: Ingestion of brevetoxin is rare but may become more common as the frequency and severity of "red-tide" events increase. In our cluster, each person consumed a different number of clams and presented with classic and some "non-classic" symptoms. A trend toward more severe symptoms with a larger number of clams ingested was observed. CONCLUSIONS: This case cluster describes the clinical course of individuals after consumption of brevetoxin contaminated shellfish.

Adverse events of undiluted intravenous push levetiracetam.

BACKGROUND: In patients who experience a seizure, the seizure duration is a strong indicator of prognosis. Thus, reducing time to antiepileptic medications in patients who are actively seizing is critical. While findings from retrospective studies suggest that the rapid administration of undiluted intravenous (IV) levetiracetam may be safe, some gaps in the literature remain. OBJECTIVE: The purpose of this research study was to prospectively assess adverse events associated with the rapid administration of undiluted IV levetiracetam. METHODS: This was a prospective, observational cohort study of adult patients who received rapid administration of undiluted IV levetiracetam at doses up to 4500 mg in the emergency department (ED) of a large community, teaching hospital. The primary endpoint was the incidence of any pre-defined adverse event. Secondary endpoints included the incidence of each type of adverse event, the incidence of seizure termination, and the time to completion of drug administration in patients actively seizing at the time of study inclusion. RESULTS: A total of 321 doses of IV push levetiracetam were ordered for 318 patients and 250 patients were subsequently included. Fourteen (5.6%) patients experienced an adverse event, most commonly due to injection site reactions (9/14). Clinically relevant hypotension, tachycardia, and hypertension occurred in five patients. For actively seizing patients, 79% (15/19) achieved seizure termination and the median time from medication order to completion of therapy was 12 min. CONCLUSION: This study found that the rapid administration of undiluted IV levetiracetam in ED patients was associated with few adverse events.

Effect of a pharmacist-based toxicology consult service on appropriate use of intravenous N-acetylcysteine for acetaminophen toxicity: A retrospective cohort study.

Background: Incorporating clinical pharmacists on the medical team has been associated with fewer medication errors and increased error interception. Due to the logistical complexities of the intravenous (IV) N-acetylcysteine (NAC) regimen for acetaminophen toxicity, many opportunities for medication errors exist. A pharmacist-based toxicology consultation service was implemented at our institution, allowing pharmacists to formally aid in the management of toxicology patients throughout their hospital admission, including those with acetaminophen toxicity. The purpose of this study was to evaluate the effect of a house-wide pharmacist-based toxicology consult service on errors associated with IV NAC treatment for patients admitted with acetaminophen toxicity. Methods: A retrospective, pre-post cohort study was conducted on patients who received IV NAC for acetaminophen toxicity. The intervention evaluated was the implementation of a pharmacist-based toxicology consult service, known as the pharmacy toxicology team. The primary end point was the incidence of an error associated with IV NAC. An error was defined as the composite of inappropriate dose, administration rate, initiation, continuation, or discontinuation. Results: Eighty-four patients were included; 30 patients in the pregroup, and 54 patients in the postgroup. Fewer patients experienced an error in the postgroup compared to the pregroup (30% vs 63%, P = 0.003). Conclusion: The implementation of this unique pharmacist-based toxicology consult service was associated with fewer patients experiencing an error related to IV NAC therapy for acetaminophen toxicity. Application of this data may aid in the justification for development of clinical pharmacist-based toxicology consult services at other institutions.

Impact of Incorporating Pharmacy Residents Into a Pharmacist-Managed Culture Review Service During Weekend Staffing Commitments.

BACKGROUND: Clinical pharmacy continues to rapidly evolve as does the need to incorporate unique learning opportunities in pharmacy residency training (eg, transitions of care). OBJECTIVE: To describe the impact of incorporating pharmacy residents into a pharmacist-managed emergency department culture review service (CRS). METHODS: This retrospective study included 500 cultures with positive results evaluated by a pharmacy resident during weekend staffing shifts for patients discharged from the emergency department or urgent care center (UCC). The primary outcome of this study was the number of interventions performed by pharmacy residents. RESULTS: Of the 500 cultures evaluated, 275 (55%) required action by the pharmacy residents, resulting in 233 interventions. Modification of antimicrobial therapy occurred 70 times. When surveyed, a majority of residents strongly agreed that the CRS had a positive impact. Based on evaluations, residents achieved mastery of pertinent residency performance objectives. CONCLUSION: Incorporation of pharmacy residents into a pharmacist-managed emergency department CRS promotes safe and effective medication use to patients discharged from an emergency department or UCC while providing residents additional experience in designing a therapeutic regimen, providing education to patients, and communicating with health-care teams to manage medication therapy.

Assessing Hyperbaric Oxygen for Carbon Monoxide Poisoning in Trauma Patients: A Call for Representation in Future Studies.

Although carbon monoxide (CO) poisoning presents infrequently, it is a consequential and serious component of burn-related injuries, especially those injured via structure fire. A multitude of retrospective reviews and prospective trials have attempted to establish evidence demonstrating the ideal modality for oxygen administration in CO-poisoned patients; however, a consensus recommendation has not been reached. Given that half of fire-related patients succumb to CO poisoning, this is an imperative area of research.

Impact of a Pharmacy-Led Medication Reconciliation Program.

OBJECTIVE: To determine the impact of a pharmacy-led medication reconciliation program at a large community hospital. The magnitude of the benefit of pharmacy-led medication reconciliation was evaluated based on the number of medication-related discrepancies between nursing triage notes and medication histories performed by pharmacy technicians or students. Discrepancies identified by pharmacy personnel medication histories that required pharmacist intervention on physician admission orders were further classified based on expected clinical impact if the error were to be propagated throughout hospitalization. METHODS: A retrospective chart review was performed on 200 patients who met the following inclusion criteria: adults admitted from the emergency department from October 1, 2015, to November 17, 2015, with a medication history collected by medication reconciliation personnel (MRP) containing at least three home medications or one high-risk home medication that was reviewed and reconciled by one of the investigators. The primary endpoint was the number of discrepancies between nursing triage notes and pharmacy personnel medication histories. The secondary endpoint was the percentage of pharmacy interventions categorized as "significant," "serious," or "life threatening" on a medication error severity scale. Additional data points included: number and type of clinical interventions; percent of interventions involving high-risk medications; amount of time spent obtaining medication histories and comparing them to admission orders; number and type of sources used; number of home medications; and percent of admitted patients interviewed by the MRP within 24 hours of admission. RESULTS: In a population of 200 patients, 1,762 medication history discrepancies were identified. MRP-collected histories identified issues involving 46 patients that required pharmacist intervention for a total of 235 interventions, of which 68% were related to errors categorized as significant, serious, or life threatening. CONCLUSION: Utilization of a pharmacy-led medication reconciliation program decreased the number of significant, serious, and life-threatening medication reconciliation errors upon hospital admission.

Identification of Risk Factors for Chemotherapy-Related 30-Day Readmissions.

PURPOSE: The goal of this study was to develop a method for practitioners to evaluate both quality of care delivered to patients receiving chemotherapy and illicit risk factors for 30-day chemotherapy-related readmissions (CRR). METHODS: Midas+ DataVision Readmission Tool Pack (Version 2.x) was used to retrospectively identify patients who received inpatient chemotherapy from April 2010 through May 2013. The population was screened for unscheduled admissions within 30 days after discharge. A multidisciplinary team was used to attribute readmissions to chemotherapy administration. Demographic information and oncology-specific characteristics were collected. The CRR rate and relative risk for readmission were calculated for each characteristic. RESULTS: A baseline CRR rate of 11.1% was established. Risk factors associated with an increased risk for experiencing a CRR included age of 65 years or older, hematologic cancer diagnosis, first cycle chemotherapy, Medicare coverage, discharge to a skilled nursing facility, and anthracycline administration. CONCLUSIONS: A baseline CRR rate was established. Institution-specific 30-day CRR risk factors were elucidated. Modifiable risk factors included discharge to a skilled nursing facility and administration of an anthracycline. Further investigation for opportunities for quality improvement in these 2 risk factors is a topic for future research. Expanded research into chemotherapy-related toxicities requiring inpatient admission/readmission outside of clinical trials is warranted.