Evaluation of Tacrolimus Concentrations and Clinical Outcomes Between Extended and Immediate Release Formulations in Kidney Transplant.

Objectives: Tacrolimus remains the mainstay of immunosuppression in kidney transplantation. Understanding the relationship between therapeutic tacrolimus levels and outcomes of acute rejection, patient/graft survival, and tolerability are important. The relationship between time to therapeutic tacrolimus levels and outcomes has not been well established, specifically with the use of extended release tacrolimus formulation (LCP-Tac). This study investigated time to therapeutic tacrolimus levels of 2 tacrolimus formulations, LCP-Tac and immediate release tacrolimus (IR-Tac), as a predictor of clinical outcomes. Methods: This was a single-center, retrospective, cohort study of kidney transplant recipients at Duke Hospital between 2013-2021. The primary objective evaluated the difference in time to therapeutic tacrolimus levels with LCP-Tac vs IR-Tac regimens. Secondary endpoints included time within therapeutic range during the first 3 months post-transplant, incidence of biopsy-proven rejection, development of de novo donor specific antibodies, and patient and allograft survival at 12 months post-transplant. Results: 128 patients were included (63 in LCP-Tac group and 65 in IR-Tac group). The time to therapeutic tacrolimus level was similar between formulations (7.2 days with LCP-Tac compared to 6.7 days with IR-Tac, P = .63). The time within therapeutic range during the first 3 months post-transplant, via modified Rosendaal, was similar with LCP-Tac and IR-Tac (56.1% vs 64.8%, respectively). Rates of biopsy-proven acute rejection at 12 months were similar (7/63 (11.1%) compared to 4/65 (6.2%)). There was no difference in patient/graft survival between groups. Conclusions: The time to therapeutic tacrolimus levels did not differ based on tacrolimus formulation and was not correlated with clinical outcomes.

Lean management for improving hospital waiting times-Case study of a Vietnamese public/general hospital emergency department.

INTRODUCTION: Emergency departments (EDs) at public hospitals in Vietnam typically face problems with overcrowding, as well as being populated by a wide variety of illnesses, resulting in increasing dissatisfaction from patients. To alleviate these problems, we used the increasingly popular value-stream mapping (VSM) and lean strategy approaches to (1) evaluate the current patient flow in EDs; (2) identify and eliminate the non-valued-added components; and (3) modify the existing process in order to improve waiting times. METHODS: Data from a total of 742 patients who presented at the ED of 108 Military Central Hospital in Hanoi, Vietnam, were collected. A VSM was developed where improvement possibilities were identified and attempts to eliminate non-value-added activities were made. A range of issues that were considered as a resource waste were highlighted, which led to a re-design process focusing on prioritizing blood tests and ultrasound procedures. On the administrative side, various measures were considered, including streamlining communication with medical departments, using QR codes for healthcare insurance payments, and efficient management of X-ray and CT scan online results. RESULTS: By implementing a lean approach, the following reductions in delay and waiting time were incurred: (1) pre-operative test results (for patients requiring medical procedures/operations) by 33.3% (from 134.4 to 89.4 min); (2) vascular interventions by 10.4% (from 54.6 to 48.9 min); and (3) admission to other hospital departments by 49.5% (from 118.3 to 59.8 min). Additionally, prior to the implementation of the lean strategy approach, only 22.9% of patients or their proxies (family members or friends), who responded to the survey, expressed satisfaction with the ED services. This percentage increased to 76.5% following the curtailment of non-value-added activities. Through statistical inferential test analyses, it can be confidently concluded that applying lean strategy and tools can improve patient flow in public/general hospital EDs and achieve better staff coordination within the various clinical and administrative hospital departments. To the authors' knowledge, such analysis in a Vietnamese hospital's ED context has not been previously undertaken.

Predicting drug-induced liver injury from anti-tuberculous medications by early monitoring of liver tests.

OBJECTIVE: Tuberculosis Drug Induced Liver Injury (TB-DILI) is a common and potentially severe complication associated with anti-tuberculous treatment (ATT). Optimal liver test monitoring for standard TB medication has not been established. We describe the predictive value of pre-treatment liver tests (LTs) and at 2-weeks after initiation of ATT for the detection of TB-DILI. METHODS: Patients initiating ATT were monitored with routine LTs pre-treatment and after 2-weeks. Logistic regression models were constructed to retrospectively identify pre-treatment variables associated with 'late' TB-DILI (>2 weeks after treatment initiation) and whether pre-treatment and 2-week alanine aminotransferase (ALT) levels could predict late TB-DILI. RESULTS: 1247 patients with active tuberculosis managed at 5 sites across north west London between January 2015 and December 2018 were monitored with routine LTs. 103 cases (8.3%) of ATT-associated DILI were diagnosed. 60 cases (58.3%) of TB-DILI occurred later than 2-weeks. The risk of late TB-DILI was 2.2-fold greater for every 30 U/L increment in ALT pre-treatment (OR 2.16, 95% CI 1.38-3.29 p<0.001) and 2.1-fold greater for every 30 U/L increment in ALT gradient at 2-weeks (OR 2.06, 95% CI 1.52-2.76 p<0.001). CONCLUSION: Routine 2-week LTs capture early TB-DILI and may be valuable in predicting late TB-DILI in patients on ATT.