Dosing Cefazolin for Surgical Site Infection Prophylaxis in Adolescent Idiopathic Scoliosis Surgery: Intermittent Bolus or Continuous Infusion?-A Pilot Study.

Background: Cefazolin may minimize the risk of surgical site infection (SSI) following posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS). Cefazolin dosing recommendations vary and there is limited evidence for achieved tissue concentrations. Methods: We performed a randomized, controlled, prospective pharmacokinetic pilot study of 12 patients given cefazolin by either intermittent bolus (30 mg/kg every 3 h) or continuous infusion (30 mg/kg bolus followed by 10/mg/kg per hour) during PSF for AIS. Results: Patients were well matched for demographic and perioperative variables. While total drug exposure, measured as area-under-the-curve (AUC), was similar in plasma for bolus and infusion dosing, infusion dosing achieved greater cefazolin exposure in subcutaneous and muscle tissue. Using the pharmacodynamic metric of time spent above minimal inhibitory concentration (MIC), both bolus and infusion dosing performed well. However, when targeting a bactericidal concentration of 32 µg/mL, patients in the bolus group spent a median of 1/5 and 1/3 of the typical 6 h operative time below target in subcutaneous and muscle tissue, respectively. Conclusions: We conclude that intraoperative determination of cefazolin tissue concentrations is feasible and both bolus and infusion dosing of cefazolin achieve concentrations in excess of typical MICs. Infusion dosing appears to more consistently achieve bactericidal concentrations in subcutaneous and muscle tissues.

Real-World Experience on Why Research Flatlines: A Review of Trials From the Coordinator's Perspective.

INTRODUCTION: Investigator-initiated research trial failure is a national concern that hinders the dissemination of information while wasting resources, time, and funding. The goal of this analysis was to provide an objective review of points to consider increasing an investigator's chances of success. METHODS: The included trials were divided into two groups based on whether they were successful or unsuccessful in meeting enrollment goals. Common issues were noted for each trial to identify prevalent issues and compare their quantity within each group. RESULTS: Unsuccessful trials averaged twice as many issues as trials in the successful group. The most common problems identified in unsuccessful studies involved study planning, whereas the most common problems identified in successful studies revolved around study staff. CONCLUSIONS: There is no single definitive indicator for trial failure; however, awareness of these issues in a trial's planning phase can help prevent their occurrence and aid in overall completion and publication.

Clinical pharmacists' interventions and therapeutic drug monitoring in patients with mycobacterial infections.

Purpose: Infections caused by non-tuberculous mycobacterium (NTM) are increasing, less well-known by health care clinicians, and usually require long term treatment with multiple antimicrobials. There is no existing evidence on clinical pharmacists' involvement in the care of patients with NTM infections. We sought to characterize pharmacists' interventions in providing medication management for patients with NTM infections. Methods: A retrospective review of patients aged 18 years or older seen by a pharmacist specializing in NTM from January 1, 2018 through June 1, 2020 was performed. Charts were reviewed for drug therapy problems identified by a pharmacist. Details regarding therapeutic drug monitoring (TDM) and subsequent dose adjustments were obtained. Results: Seventy-seven patients were included. Median age was 68.5 years, and most patients were female. The most common mycobacterium species treated was Mycobacterium avium/intracellulare complex. Majority of pharmacist consults (63.6%) were referred by Pulmonology physicians, with remainder by Infectious Diseases clinicians. Identified drug therapy problems included: needs additional therapy (23%), unnecessary therapy (24.3%), different drug needed (6.8%), dose too low (75.7%), dose too high (20.3%), adverse drug reaction (31.1%), and adherence (8.1%). Fifteen patients had TDM performed during treatment. A clinical pharmacist was involved in evaluation of all TDM results. Over half of patients with TDM levels had at least 1 dose change made. A minority of patients (16.9%) experienced clinical failure. Conclusion: Clinical pharmacists should be involved in this complex care to optimize medication management through identification of drug interactions, tailoring antimicrobial dosing, managing TDM results, and providing adherence counseling.

Alpha-1 Antitrypsin Replacement in Patients With COPD.

Chronic obstructive pulmonary disease can be attributed to genetic conditions and predispositions, among other factors. Alpha-1 antitrypsin deficiency (AATD) is a significant risk factor for COPD development and progression, and aggressive screening for all patients with COPD or adult-onset asthma is encouraged.

Dual-isotope subtraction SPECT-CT in parathyroid localization.

OBJECTIVE: The aim of this study was to investigate the accuracy of locating parathyroid adenomas using dual-Isotope subtraction single-photon emission computed tomography-computed tomography (SPECT-CT) in comparison with clinical follow-up and pathology findings from surgery. PATIENTS AND METHODS: A retrospective cohort study of dual-isotope subtraction SPECT-CT was carried out on 224 consecutive patients who were diagnosed with primary hyperparathyroidism. All the patients were injected with 20 MBq of iodine-123-iodide, followed 20 min later by 900 MBq of technetium-99m-sestamibi. Planar neck and chest views and SPECT-CT images were acquired 15 min after administration, followed by an additional planar image set at 2 h to view washout; all images were dual energy. In all, 115 out of 224 of the patients imaged underwent parathyroid surgery. The imaging results were compared with pathology findings when available and, in those who did not undergo surgery, and in some complex cases, with clinical measures after a 2-year clinical follow-up period. FINDINGS: Out of the 224 patients, 135 patients had complete pathology and/or clinical follow-up data and were included in the analysis. The sensitivity of the subtraction SPECT-CT findings was measured to be 95%, with a specificity of 89% for the detection and localization of parathyroid adenomas. The positive predictive value was found to be 97% and the negative predictive value was found to be 83%. The accuracy of the technique was 94% in detecting parathyroid adenoma and 92% in accurate localization. CONCLUSION: Dual-isotope subtraction SPECT-CT imaging has a very high sensitivity and specificity in detecting and locating a parathyroid adenoma, showing that it is a very reliable preoperative imaging technique in primary hyperparathyroidism.

Patterns of symptom reporting during pregnancy comparing opioid maintained and control women.

OBJECTIVE: To characterize the range of symptoms experienced by pregnant methadone-maintained (MM) and buprenorphine-maintained (BM) women to determine whether these differ from those experienced by a control group of nonopioid exposed pregnant women. Opioid-maintained (OM) patients report high rates of symptoms related to direct opioid effects and withdrawal. Pregnancy is associated with a range of symptoms, some overlapping with opioid effects and withdrawal. METHODS: Prospective, nonrandomized, open-label comparison study undertaken in a large teaching maternity hospital in South Australia. Pregnant BM (n = 25), MM (n = 25) and nonopioid exposed controls (n = 25) were recruited and matched for age, parity, gravidity, alcohol consumption, and smoking status. Symptom report patterns, maternal withdrawal, and additional substance use were assessed. RESULTS: MM women reported 10 and BM women reported 2 symptoms throughout pregnancy at rates greater than controls. Methadone-maintained women reported significantly (P < 0.05) more symptoms than BM women compared to controls throughout pregnancy. Methadone-maintained women reported 8 and BM women reported 3 symptoms in the third trimester at rates greater than controls. Methadone-maintained women reported greater opioid withdrawal than controls; this did not occur in BM women. Additional substance use was comparable between BM and MM women but greater than controls. CONCLUSIONS: Patterns of symptom reports may have clinical implications for maternal and fetal health during pregnancy for OM women including optimization of opioid dosing regimens, education regarding maternal nutritional intake and preventing postnatal depression, thereby ensuring maternal health and fetal development during pregnancy and enhancing mother-infant bonding and healthy child development postnatally.