Variability among Online Opioid Conversion Calculators Performing Common Palliative Care Conversions.

Introduction: Online opioid conversion calculators (OOCCs) are commonly used to aid conversion between opioids to overcome tolerance, reduce adverse effects, or challenges related to administration. The purpose of this study was to describe and characterize variability among OOCC used by health care practitioners when converting common opioids and doses encountered in the hospice and palliative care setting. Methods: We collected 58 quantitative surveys and performed sentiment analysis on 62 qualitative responses from adult learners primarily practicing in the palliative care setting and enrolled in an online palliative care Master of Science program through the University of Maryland, Baltimore, who were asked to perform opioid conversion calculations using realistic patient cases. Results: OOCC have substantial variability leading to a wide range of outputs, which may put patients at risk for opioid-related harm. Assessing participant sentiment toward OOCC showed most participants held a "Negative Sentiment" toward these calculators after the activity. Conclusion: Overall, findings reveal that given the same information, clinicians can come to widely different opioid doses and these differences can be amplified by OOCC. These differences can be particularly dangerous given the higher opioid doses commonly used in the palliative care setting. Considering the significant harm that can arise from an error when converting between opioids, clinicians should avoid the routine use of OOCC in real-world patient care settings. If an OOCC is used, organizations should endorse a specific calculator, provide training and education about the algorithm that supports the calculations, and encourage clinicians to use it only after their own manual calculation, which should be documented in the medical record.

Clinical strategies for optimizing infusion center care through a pandemic.

The national pandemic resulting from the novel coronavirus, COVID-19, has made the delivery of care for patients with cancer a challenge. There are competing risks of mortality from cancer versus serious complications and higher risk of death from COVID-19 in immunocompromised hosts. Furthermore, compounding these concerns is the inadequate supply of personal protective equipment, decreased hospital capacity, and paucity of effective treatments or vaccines to date for COVID-19. Guidance measures and recommendations have been published by national organizations aiming to facilitate the delivery of care in a safe and effective manner, many of which, are permanently adoptable interventions. Given the critical importance to continue chemotherapy, there remains additional interventions to further enhance patient safety while conserving healthcare resources such as adjustments in medication administration, reduction in laboratory or drug monitoring, and home delivery of specialty infusions. In this manuscript, we outline how to implement these actionable interventions of chemotherapy and supportive care delivery to further enhance the current precautionary measures while maintaining safe and effective patient care. Coupled with current published standards, these strategies can help alleviate the numerous challenges associated with this pandemic.

Interventions to reduce polypharmacy and optimize medication use in older adults with cancer.

The use of polypharmacy and potentially inappropriate medications (PIMs) is an increasingly common, concerning public health issue in older adults, and a concurrent cancer diagnosis only further escalates the prevalence and complexity. Polypharmacy and PIM use has been associated with negative patient outcomes, including falls, chemotherapy toxicities and other adverse events, postoperative complications, frailty, functional impairment, and shortened survival. Despite the recognition of the harms, the prevalence of polypharmacy and PIM use continues to rise due to a lack of standardized identification and intervention methods. Efforts to reduce the prevalence have included use of explicit PIM screening tools (e.g., Beers criteria), comprehensive medication reviews, and deprescribing algorithms. However, these efforts are not widespread and the research on the effectiveness of such interventions is limited. To better understand what is known, this paper summarized available studies evaluating the effect of interventions on reducing the burden of polypharmacy/PIMs and provided recommendations to guide further practice models to reduce the negative consequences associated with polypharmacy and PIM use. Furthermore, we aim to establish a framework for clinical practice and to highlight areas for future intervention-based research to improve outcomes for older adults with cancer.

Review of Emerging Pharmacotherapy for the Treatment of Coronavirus Disease 2019.

The outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has evolved into an emergent global pandemic. Coronavirus disease 2019 (COVID-19) can manifest on a spectrum of illness from mild disease to severe respiratory failure requiring intensive care unit admission. As the incidence continues to rise at a rapid pace, critical care teams are faced with challenging treatment decisions. There is currently no widely accepted standard of care in the pharmacologic management of patients with COVID-19. Urgent identification of potential treatment strategies is a priority. Therapies include novel agents available in clinical trials or through compassionate use, and other drugs, repurposed antiviral and immunomodulating therapies. Many have demonstrated in vitro or in vivo potential against other viruses that are similar to SARS-CoV-2. Critically ill patients with COVID-19 have additional considerations related to adjustments for organ impairment and renal replacement therapies, complex lists of concurrent medications, limitations with drug administration and compatibility, and unique toxicities that should be evaluated when utilizing these therapies. The purpose of this review is to summarize practical considerations for pharmacotherapy in patients with COVID-19, with the intent of serving as a resource for health care providers at the forefront of clinical care during this pandemic.

Clinical pharmacology of oncology agents in older adults: A comprehensive review of how chronologic and functional age can influence treatment-related effects.

Unique challenges exist when managing older adults with cancer. Associations between cancer and age-related physiologic changes have a direct impact on pharmacokinetics and pharmacodynamics of cancer therapies and can affect drug dosing, dose intensity, efficacy, safety and quality of life. The breadth and depth of these issues, however, have not been fully evaluated because the majority of clinical trials have focused on a younger and healthier population. As a consequence, little information is available to support clinicians in making evidence-based decisions regarding treatment with cancer therapies in older adults, especially those over age 75. Prior clinical pharmacology reviews summarized the literature on how age-related physiologic changes can influence and affect conventional and targeted anti-cancer treatments. Our article provides an updated review with expanded information that includes small molecule kinase inhibitors, monoclonal antibodies, immunotherapies, hormonal, conventional, and miscellaneous agents. Additionally, our article integrates how functional age, determined by the geriatric assessment (GA), can also influence treatment-related effects and health outcomes. Broadening cancer therapy trials to capture not only chronologic age but also functional age would allow clinicians to better identify subsets of older adults who benefit from treatment versus those most vulnerable to morbidity and/or mortality.

The prevalence of major drug-drug interactions in older adults with cancer and the role of clinical decision support software.

OBJECTIVES: Drug-drug interactions (DDIs) represent an escalating concern for older adults attributed to polypharmacy, multi-morbidity and organ dysfunction. Few studies have evaluated the prevalence of major DDIs and the variability between DDI detection software which confuses management. MATERIALS AND METHODS: Prevalence of major DDIs was examined as a secondary analysis of outpatients aged ≥65 years. Demographic and clinical information was collected from electronic health records including age, sex, race, cancer type, comorbidities, and medications. All DDIs were screened by a clinical pharmacist using Lexi-Interact® and Micromedex®. Major DDIs were defined as Lexi-Interact® category D or X and/or Micromedex® category major or contraindication. Summary statistics of patient characteristics and DDIs were computed. RESULTS: Our cohort included 142 patients (mean age, 77.7 years; 56% women, 73% Caucasian). The mean medications was 9.8 including 6.7 prescriptions, 2.6 non-prescriptions, and 0.5 herbals. Lexi-Interact® identified 310 major DDIs in 69% of patients (n = 98) with an average of 2.2 DDIs per patient. Micromedex® identified 315 major DDIs in 61% of patients (n = 87) with an average of 2.2 DDIs per patient. DDIs mostly involved opioids, antiplatelets, electrolyte supplements, antiemetics, and antidepressants. Variability existed with the severity rating reporting of the clinical decision support software. CONCLUSIONS: There was a high prevalence of major DDIs in older adults with cancer. Utilizing clinical decision support software was beneficial for detecting DDIs however, variability existed with severity reporting. Future studies need to identify the relevant DDIs with clinical implications in order to optimize medication safety in this population.

Exploratory Randomized Clinical Trial of an Experimental Gel-to-Foam Fluoride Dentifrice Formulation Using an In Situ Caries Model.

OBJECTIVE: To evaluate the in situ caries performance and safety of two experimental fluoride dentifrice formulations (1450 ppm fluoride) with and without 2% isopentane as an excipient, in comparison to a positive control, currently marketed dentifrice (1450 ppm fluoride) and a negative control dentifrice (0 ppm fluoride). METHODS: This was a single-center, examiner-blind, randomized, controlled, four-treatment cross-over study. During each treatment period, the subject wore a modified mandibular partial denture fitted with two gauze-covered, partially demineralized human enamel specimens, and brushed at home for one timed minute, twice daily, for two weeks. At the end of each treatment period, the enamel specimens were removed from the dentures for analysis. During the week between treatment periods, subjects returned to their usual dental hygiene practices for four to five days, received a dental prophylaxis, and used a study-designated non-fluoride dentifrice for two to three days before starting the next treatment. Treatment effect on enamel specimen remineralization was assessed by surface microhardness (SMH). Enamel fluoride uptake was assessed using microdrill enamel biopsy. RESULTS: All fluoride-containing dentifrices demonstrated significant, superior SMH recovery and levels of fluoride uptake compared to the negative control dentifrice. No significant differences were observed for either efficacy variable between the experimental dentifrice formulations and the positive control dentifrice. No significant difference was observed between the 2% isopentane dentifrice and the 0% isopentane dentifrice for SMH recovery. CONCLUSION: The addition of 2% isopentane did not positively or negatively affect fluoride efficacy in this model.

Design and construction of a magnetic resonance compatible multi-injector gas jet delivery system.

We present the design, construction, and performance of a novel multi-injector gas jet delivery capable of operating in a magnetic resonance imaging environment. This apparatus is computer controlled and built with two separate pneumatic circuits enabling gas jet applications at variable sites through four independently activated injectors. Gas jet delivery is fully controllable in terms of pressure, flow rate, gas temperature, application time, and duration of interstimulus interval. We characterized these parameters, considering effects such as pressure drop by flow transport, transient effects, and delays in activation. The system offers new possibilities for use in various biomedical contexts such as, e.g., quantitative sensory testing or dental hypersensitivity assessment.