The Role of a Simulation-Based Activity on Student Perceptions of Parenteral Nutrition Education.

Introduction: Parenteral nutrition (PN) education in pharmacy schools and postgraduate programs may not sufficiently prepare future pharmacists for clinical practice. Limited data exist regarding innovative teaching strategies in the area of PN. The purpose of this study was to identify students' perceptions of a simulated PN activity in a pharmacotherapeutics course. Methods: Second-year Doctor of Pharmacy (PharmD) students from two cohorts (N = 84 for both cohorts) completed a PN assignment using simulated PN materials, which resembled those seen in clinical practice. Before and after the activity, students completed identical surveys about their perceived competence and interest in PN, which were analyzed using Wilcoxon signed-rank tests. Results: Following the simulation, the percentage of students affirming their perceived competence (selecting strongly agree or agree in the survey) in their ability to describe the process of combining ingredients to make a PN admixture (45.2% vs. 83.3%, p < 0.001) and calculate PN-related problems (58.3% vs. 83.3%, p < 0.001) improved. The proportion of students expressing interest in PN increased after the simulation (78.6% vs. 86.9%, p < 0.001). Conclusion: A simulated practicum experience in PN was viewed positively by PharmD students at this university, and may be a valuable active learning experience to incorporate in a PharmD curriculum.

Comparison of the Efficacy of Posaconazole Delayed Release Tablets and Suspension in Pediatric Hematology/Oncology Patients.

OBJECTIVES: Posaconazole is effective in preventing invasive fungal infections in neutropenic pediatric patients. The oral suspension has challenges in administration and absorption that are theorized to be minimized with delayed release tablets. However, this has not been validated in the pediatric population. This study was conducted to compare the efficacy and safety of posaconazole suspension and delayed release tablets in pediatric hematology/oncology patients. METHODS: A retrospective chart review in pediatric hematology/oncology patients was conducted from February 2013 to February 2017. Data collected include patient demographic data; posaconazole formulation, dose, and serum concentrations; and adverse events. RESULTS: Sixty-five patients with 353 serum posaconazole concentrations were included; 51.6% of concentrations drawn while patients were receiving posaconazole suspension were therapeutic, whereas 62.5% of concentrations drawn while patients were receiving posaconazole delayed release tablets were therapeutic (p = 0.035). Serum concentrations drawn while taking acid suppression (histamine receptor antagonists or proton pump inhibitors) and posaconazole suspension were less likely to be therapeutic (p < 0.0001) compared with those taken while receiving delayed release tablets. Adverse event profiles were similar between both formulations. CONCLUSIONS: Delayed release tablets proved more effective in achieving therapeutic serum posaconazole concentrations than posaconazole suspension, with minimal difference in adverse events, in pediatric hematology/oncology patients.

Surface APRIL Is Elevated on Myeloid Cells and Is Associated with Disease Activity in Patients with Rheumatoid Arthritis.

OBJECTIVE: To assess surface APRIL (a proliferation-inducing ligand; CD256) expression by circulating myeloid cells in rheumatoid arthritis (RA) and to determine its relationship to disease activity. METHODS: Peripheral blood mononuclear cells (PBMC) and plasma were obtained from patients with RA and healthy donors. PBMC were stained for flow cytometry to detect surface APRIL and blood cell markers to identify circulating myeloid cell subsets. Based on CD14 and CD16 phenotypes, monocyte subsets described as classical (CD14+CD16-), intermediate (CD14+CD16+), and nonclassical (CD14loCD16+) were identified. Levels of surface APRIL expression were measured by flow cytometry and median fluorescence intensity was used for comparisons. Levels of soluble APRIL in the plasma were determined by ELISA. Disease activity was measured by the Disease Activity Score in 28 joints. RESULTS: In patients with RA, total myeloid cells showed expression of surface APRIL that correlated with disease activity and with plasma APRIL levels observed in these patients. In healthy donors, classical monocytes were composed of > 80% of circulating monocytes. However, in patients with RA, the intermediate and nonclassical subsets were elevated and made up the majority of circulating monocytes. In contrast to healthy donors, where high levels of surface APRIL were only observed in nonclassical monocytes, patients with RA showed high levels of surface APRIL expression by all circulating monocyte subsets. CONCLUSION: Surface APRIL is elevated in circulating myeloid cells in patients with RA where it is highly correlated with disease activity. Patients with RA also showed skewing of monocytes toward subsets associated with secretion of tumor necrosis factor-α and/or interleukin 1ß.

Complications associated with outpatient parenteral antibiotic therapy in children.

BACKGROUND: The authors sought to determine the prevalence, risk factors, and clinical impact of complications associated with outpatient parenteral antimicrobial therapy (OPAT) in children. METHODS: A cohort of patients ≤18 years old with infections, who received OPAT were evaluated retrospectively. Antibiotic-associated complications (AACs), catheter-associated complications (CACs), and unplanned medical care visits were the main outcome measures. RESULTS: Overall, 36 complications (25 CACs and 11 AACs) occurred in 32 of 98 patients. Mean age of patients, race, gender, and infecting organism did not differ between study groups. The use of OPAT for osteomyelitis was associated with complications (odds ratio = 2.69; 95% confidence interval = 0.99-7.35; P = .05). All patients, except for 4 who had complications, clinically improved by the end of OPAT. Unplanned medical visits occurred in 17 patients, 15 of which were because of CACs. CONCLUSION: Complications occurred commonly in children receiving OPAT and resulted in unplanned medical visits.

Detection and characterization of focal liver lesions with contrast-enhanced ultrasonography in patients with hepatitis C-induced liver cirrhosis.

BACKGROUND: Hepatitis C virus (HCV)-associated liver cirrhosis provides a major preneoplastic condition for hepatocellular carcinoma (HCC). Ultrasonography (US) is usually used for screening of HCC, but needs improvement. PURPOSE: To assess whether use of a second-generation ultrasound contrast agent can improve characterization of focal liver lesions and detection of HCC in HCV-infected patients with liver cirrhosis. MATERIAL AND METHODS: In total, 96 US studies in 49 HCV-infected patients with liver cirrhosis were performed. The patients were first examined with a baseline US. After this, a diagnostic decision was made and recorded. The patients were then re-examined with contrast-enhanced ultrasound (CEUS), and the diagnostic triage was repeated. The patients were followed up for at least 1 year. RESULTS: On baseline US, indeterminate focal lesions were found in 27 examinations. After CEUS, a confident diagnosis of HCC was made in eight of these examinations. In an additional eight US examinations, diagnosis of regenerative/dysplastic noduli was established. In one patient with no detectable focal lesion at baseline examination, an indeterminate malignant lesion was detected with CEUS. This lesion was further investigated with computed tomography and diagnosed as HCC. CONCLUSION: Our study indicates that the use of CEUS significantly improves diagnostic confidence. CEUS improves the detection of HCC in patients with HCV-induced liver cirrhosis. Also, CEUS makes it possible to rule out malignancy in many cases where baseline US shows indeterminate focal lesions. In low-endemic countries, the use of CEUS in screening for HCC may be considered.

High sensitivity with color duplex sonography in thrombosis screening after ankle fracture surgery.

BACKGROUND: Phlebography is regarded as the reference standard for diagnosing asymptomatic deep vein thrombosis (DVT) in studies of thromboprophylaxis. However, technical advances with noninvasive color duplex sonography (CDS) have made this procedure an interesting alternative. OBJECTIVES: The objective of the present prospective study was to compare the sensitivity and specificity of CDS with those of phlebography. PATIENTS: The first 180 consecutive patients included in a larger randomized trial for prolonged thromboprophylaxis were subject to unilateral CDS and to phlebography after ankle fracture surgery. The patients were examined 6 weeks after surgery, all examinations being evaluated blindly. After patient drop outs and exclusions, 144 patients were left for analysis. RESULTS: Phlebography and CDS examinations were inconclusive or were not completed for 19% of these patients (28/144). DVT was diagnosed by phlebography in 21% (24/116) of the remaining patients. Most of the thrombi were isolated calf DVTs (18/24). In contrast, DVT was diagnosed by CDS in 31% of these patients (36/116): only one case diagnosed by phlebography was missed by CDS. The specificity of CDS is thus 86% and its sensitivity is 96%. The positive predictive value is 64%, and the negative predictive value is 99%. CONCLUSIONS: CDS is a safe method for detecting asymptomatic distal DVT. It has a high sensitivity and high negative predictive value, which means that the method is highly reliable to rule out DVT. Our results indicate that CDS could be considered as an alternative method for DVT screening.

Ultrasound and power Doppler evaluation of the hand and wrist in patients with psoriatic arthritis.

PURPOSE: To evaluate the ability of high-resolution and power Doppler sonography in detecting joint and tendon abnormalities in patients with psoriatic arthritis (PsA) of the hands and wrists compared with clinical and radiological findings. MATERIAL AND METHODS: Thirty-six patients with psoriatic arthritis of the hands and wrists and 10 healthy controls were examined with ultrasound (US). The degree of synovial proliferation, tenosynovitis, presence of joint effusion as well as the vascularity of synovial tissue was estimated. US findings were scored using a newly devised scoring system. RESULTS: Thirty-two patients had articular synovial proliferation and/or tenosynovitis/ tendinitis or joint effusion in one or more joints according to US. Twenty-two patients had tendon changes; only five had joint effusion. The synovial, Doppler, and total articular-teno scores were all significantly correlated to the number of swollen joints. The scores, however, did not correlate to other clinical or laboratory measurements of disease activity. CONCLUSION: US proved effective in demonstrating PsA involvement of the hands and wrists and was more sensitive than clinical examination in detecting pathology. Long-term follow-up studies are needed to evaluate whether this can change the traditional approach for assessing involvement of joints and tendons in PsA.

Ultrasonography of the rotator cuff: a comparison with arthroscopy in one-hundred-and-ninety consecutive cases.

PURPOSE: To evaluate the accuracy of high-resolution ultrasonography compared to arthroscopy in the detection of rotator cuff tears. MATERIAL AND METHODS: Preoperative ultrasonography (US) with a 10-MHz commercially available linear-array transducer and a standardized study protocol was performed in 190 consecutive shoulders in 185 patients with a history of shoulder pain for more than 3 months. The findings at US were classified into intact cuff, partial-thickness, and full-thickness rotator cuff tears, and correlated with findings at shoulder arthroscopy. RESULTS: US correctly depicted 118 of 124 rotator cuff tears with sensitivity 95%, specificity 94%, PPV 97%, NPV 91% and accuracy 95%, all 94 full-thickness tears (sensitivity 100%, specificity 91%, PPV 91%, NPV 100%, and accuracy 95%), 24 of 30 partial-thickness tears (sensitivity 80%, specificity 98%, PPV 86%, NPV 96%, and accuracy 95%). CONCLUSION: US is a highly accurate diagnostic method for detecting full-thickness rotator cuff tears, but is less sensitive in detecting partial-thickness rotator cuff tears.

A comparative clarithromycin bioavailability study: determination of clarithromycin and 14-(R)-hydroxyclarithromycin under fasting and fed conditions.

OBJECTIVE: To report the first comprehensive analysis of clarithromycin (CLA) and 14-(R)-hydroxyclarithromcin (14R) bioequivalence metrics under both fasting and fed conditions when using a validated analytical method. METHODS AND MATERIALS: In separate, single dose bioequivalence studies, fasting (n = 40) and fed (n = 18) non-smoking subjects entered a 2-treatment, 2-period, 2-sequence, crossover trial to assess the comparative bioavailability of a 500 mg generic clarithromycin tablet (IVAX Pharmaceuticals, NJ, USA) relative to the reference product (Biaxin Filmtab, Abbott Laboratories, IL, USA). The validated assay employed an HPLC coupled to a triple stage quadrupole mass spectrometer. RESULTS: The analytics permitted plasma samples to be measured for both analytes with high precision and a lower limit ofquantitation (LLOQ) of 11 ng/ml. In both fasting and fed studies, and for both analytes, the IVAX product met the common mean geometric ratio and 90% confidence limits in order to be declared bioequivalent with Biaxin Filmtab. Furthermore, the intra-subject variabilities for the comparative AUC metrics in both studies and for both analytes were < or = 21% and < or = 26% for Cmax. CONCLUSIONS: The fasting and fed results present definitive evidence that 500 mg IVAX clarithromycin and Biaxin Filmtab are bioequivalent under both fasting and fed conditions, whether based on CLA or 14R. Furthermore, at a 500 mg dose, clarithromycin is not a highly variable drug.

Intra-operative uses of contrast-enhanced ultrasound.

Intra-operative ultrasound (IOUS) is considered to be the most sensitive imaging modality for detection of focal liver lesions. It has been shown to affect the clinical management of patients with hepatic colorectal metastases and primary liver tumours undergoing exploratory laparotomy and segmental resection. However, small, and especially iso-echoic lesions are still missed and characterization of subcentimetre lesions is difficult. The improvement of detection and characterization of focal liver lesions using second-generation gas-containing contrast agents with specific non-linear detection modes in transabdominal scanning can be expected to apply to IOUS. Initial experience of contrast-enhanced IOUS based on use of conventional abdominal probes provided impressive results. The recent development of high-frequency linear array probes for small parts use with contrast-specific software enables the detection of lesions as small as 2-3 mm and allows characterization of small lesions. Though only preliminary experience is available, this appears to be an exciting and promising new application.

Ultrasound-guided percutaneous cholecystostomy in high-risk surgical patients.

BACKGROUND AND AIMS: In critically ill patients, cholecystectomy is associated with a high mortality rate. The aim of this study was to evaluate the safety, efficacy and long-term outcome of ultrasound-guided percutaneous cholecystostomy (USGPC) in critically ill patients with acute cholecystitis. MATERIALS AND METHODS: Clinical records of 51 patients, all considered high-risk surgical patients, with acute cholecystitis treated with USGPC between 1987 and 1999, were retrospectively reviewed. Response was defined as improvement in clinical symptoms and signs, and/or reduction in c-reactive protein and white blood count levels within 72 h. Long-term results were evaluated by means of clinical records and written correspondence. RESULTS: Gallbladder stones were seen in 28 patients whereas 23 had acalculous cholecystitis. Ninety percent showed clinical improvement after USGPC. Cholecystectomy was performed in 16%, of which 6% after recurrent cholecystitis. Recurrence of cholecystitis occurred in 22%. Hospital mortality was 16%. None of the deaths was procedure related or related to acute cholecystitis alone. Major complications relating to the USGPC were rare (4%), while minor catheter-related complications were quite common. CONCLUSIONS: USGPC is a procedure with few complications and a high success rate. In patients with acalculous cholecystitis as well as in many patients with calculous cholecystitis, no further treatment was needed.

[At the threshold of functional ultrasound]. / På tröskeln till funktionellt ultraljud.

Ultrasound diagnosis is the globally predominant single radiological modality in terms of its utilisation rate. Its relative simplicity in use, and its speed, reliability, low cost, and lack of risk, are all factors associated with its increasingly widespread use. The possibility of monitoring processes in real time opens up new approaches to ultrasound-assisted tumour treatment, biopsy, and blood flow and perfusion studies. The development of an ultrasound-specific contrast medium removed the last obstacle to functional ultrasonography and its use in the evaluation of tumour treatment.

Pretreatment, ultrasound-guided cutting needle biopsies in childhood renal tumors.

BACKGROUND: The current International Society of Paediatric Oncology (SIOP)-10 protocol does not allow pretreatment histological classification of low-stage renal tumors in children for fear of needle tract recurrences. The aims of this retrospective study were to evaluate the safety, sensitivity, and specificity of ultrasound-guided cutting needle biopsies (UCNB) performed at our institution in pediatric patients with renal tumors. PROCEDURE: Of 28 pediatric patients presenting with a renal tumor between 1988 and 1996, 25 underwent biopsy with the Biopty biopsy instrument (needle diameter 1.2 mm). The preoperative biopsy and nephrectomy slides were reviewed by a SIOP reference pathologist. The patients' hospital records were reviewed and biopsy complications were noted. RESULTS: At review of the nephrectomy slides, the diagnoses were: Wilms tumor (16 patients), with anaplasia in one case, rhabdoid tumor (2 patients), neuroblastoma (2 patients), mesoblastic nephroma (2 patients), clear cell sarcoma (1 patient), malignant teratoma (1 patient), and renal cell carcinoma (1 patient). No needle tract recurrence or other major complication was observed. The only complication was local pain at the biopsy site, which occurred in 24% (6/25) of the cases. The sensitivity of UCNB was 76% (19/25); five biopsies did not yield diagnostic material and one was not concordant. All cases of Wilms tumor were correctly diagnosed by UCNB, but only 33% (3/9) of the other tumors. CONCLUSIONS: In all cases of Wilms tumor a correct diagnosis was made. The overall sensitivity was 76%. UCNB proved to be a safe procedure that was not associated with needle tract recurrence or other serious complications.

Limited tumor involvement found at multiple endocrine neoplasia type I pancreatic exploration: can it be predicted by preoperative tumor localization?

Radiologically demonstrable pancreatic endocrine tumors are a frequent requirement for exploration in patients with multiple endocrine neoplasia type I (MEN-I). Such delayed intervention is accompanied by a 30% to 50% incidence of pancreatic endocrine metastases. This study explores biochemical tumor markers and operative findings in relation to preoperative pancreatic radiology in 25 MEN-I patients. They underwent pancreatic surgery with (n = 19) or without (n = 6) radiologic signs of primary tumor and absence of metastases upon conventional examination, including OctreoScan testing (n = 10). Biochemical diagnosis required an increasing elevation of at least two independent pancreatic tumor markers. Tumor diameters averaged 1.1 cm (0-5 cm) and 0.9 cm (0.2-1.5 cm) in the patients with and without positive preoperative radiology, respectively. These investigations never displayed more than one of the consistently multiple tumors, and the results were falsely positive in 26%. Preoperatively unidentified regional or hepatic metastases were found at surgical exploration in 26% of patients with radiologic localization and in none of the others. Limited pancreatic tumor involvement necessitated intraoperative absence of metastases and pancreatic lesions /= 7 mm in diameter. Conventional pancreatic imaging is insensitive and nonspecific for recognizing even substantial pancreatic tumors associated with MEN-I.

Ultrasound-guided 1.2-mm cutting-needle biopsies of head and neck tumours.

PURPOSE: To establish the role of ultrasound-guided cutting-needle biopsy in the diagnostic-work-up of tumours in the head and neck region. MATERIAL AND METHODS: Seventy-two patients (74 biopsies) with tumours in the head and neck were biopsied by means of a biopsy gun fitted with a 1.2-mm biopsy needle (midsized-needle biopsy, MNB). Twenty-four biopsies were taken from salivary glands, 29 from lymph nodes, and 21 from miscellaneous locations. Thirty-three of the patients were biopsied by MNB under ultrasound guidance after a blinded fine-needle aspiration biopsy (FNAB) was considered non-diagnostic or non-representative. RESULTS: In 91% of the cases, the MNB diagnosis was identical to the final diagnosis (surgical or radiological/clinical follow-up: at least 6 months), 9% were false-negative/ non-representative. In 17/33 patients MNB was considered to provide more diagnostic information than FNAB, the methods had equal accuracy in 12 patients, and in 4 patients the information already gained with FNAB was superior to that provided by MNB. The non-diagnostic sampling rate for FNAB was 25% versus 3% for MNB. In 26 patients with malignant lymphoma, MNB results were diagnostically correct in all but 2 cases. FNAB was correct in 2 of 9 cases. There were no biopsy-related complications. CONCLUSION: MNB was found to be safe and to possess a high degree of diagnostic accuracy, and could therefore, particularly in patients with lymphoma, be considered a diagnostic alternative to FNAB.

Interferon treatment of neuroendocrine tumour xenografts as monitored by MRI.

The neuroendocrine-differentiated colonic carcinoma cell line (LCC-18) was transplanted to 29 nude mice (Balb/c). The purpose of the present study was to establish an animal model that would allow monitoring with magnetic resonance imaging (MRI) of changes induced by interferon (IFN) therapy and to evaluate whether the therapeutic response, as expressed by changes in MR signal characteristics and tumour proliferation activity, could be modulated by different IFN dosages. IFN did not seem to have any obvious antiproliferative effect on the LCC-18 tumour cell line transplanted to nude mice and no convincing treatment-related changes in rho values or T1 and T2 relaxation values were observed. The animal model was probably unsuitable for demonstration of IFN effects.

Diagnostics of malignant lymphomas with ultrasound guided 1.2 mm biopsy-gun.

In a retrospective analysis of 129 ultrasound-guided biopsy-gun biopsies (USGB) from patients with known or suspected malignant lymphoma, a histopathological diagnosis was obtained in 101 (78%) instances and no further procedures for histological verification were required. In the 28 cases with initially non-diagnostic results, 14 new USGBs were performed and a diagnosis was obtained in 11. Thus, a total success rate of 87% was achieved. The correct diagnosis was confirmed with either surgery, autopsy, or radiological or clinical follow-up (median 40 months). The diagnoses were categorised as Hodgkin's disease and high-grade or low-grade non-Hodgkin's lymphoma. Further subtyping of the lymphoma was possible in a few cases only. Immunohistochemistry was utilised only in a minor proportion of the cases (25/129), but refined the diagnosis in several instances. The biopsy-gun method was safe and minor adverse effects were seen in two patients only.

Ultrasound-guided biopsies of neuroendocrine metastases. Comparison of 0.9 and 1.2 mm biopsy-gun needle biopsies.

Twenty-five patients with known neuroendocrine tumour disease were biopsied with 1.2 mm and 0.9 mm biopsy-gun needles to evaluate the respective diagnostic accuracy of the 2 needle sizes. The influence of treatment-related fibrosis on the histopathological diagnosis was also evaluated. The overall diagnostic accuracy with the 0.9 mm needle was 69% as compared to 92% with the 1.2 mm needle. This difference, however, seems more related to needle guiding difficulties with the 0.9 mm needle than to insufficient tissue yield. When the tumour was hit with both the 0.9 and the 1.2 mm needle the tissue yield was inferior with the 0.9 mm needle in only one of 16 cases. The increased amount of fibrous tissue due to interferon treatment did not seem to negatively influence the diagnostic accuracy.