Physician and nurse practitioner perspectives of a modified Routine Opioid Outcome Monitoring (ROOM) Tool.

Introduction The Routine Opioid Outcome Monitoring (ROOM) Tool was developed for use in community pharmacies in Australia. It facilitates pharmacists' screening and brief interventions regarding an individual's opioid use for chronic pain. At our academic teaching hospital, the ROOM Tool was adapted to incorporate a communication tool that includes a pharmacist's assessment and recommendations for primary care providers. This modified ROOM Tool was implemented as part of usual care in our outpatient pharmacies; however, the value to primary care providers is unknown. Aim The aim of this study was to determine primary care provider perspectives on the modified ROOM Tool. Methods Focus groups were conducted with primary care providers from an Academic Family Health Team. The focus group encompassed topics related to the positive and negative aspects of the modified ROOM Tool in supporting the care of patients using opioids for chronic pain. Qualitative content analysis of transcripts was performed to identify themes. Results Three focus groups were conducted with a total of six participants. Four themes emerged: (i) Facilitators to using the tool, (ii) Barriers to using the tool, (iii) Recommendations for improvement, (iv) Impact of the tool on patient care and safety. Discussion The ROOM Tool paired with the communication tool supports collaboration between pharmacists and primary care providers. The communication tool standardises the approach for communicating the pharmacist's assessment and recommendations. Recommendations to refine this modified ROOM Tool may increase its utility to primary care providers and enhance the impact on patient care and safety.

Anticoagulation management: an interdisciplinary curriculum for family medicine residents.

Anticoagulants are high-risk medications with the potential to cause significant patient harm if inappropriately managed. Medical trainees and practicing physicians often report inadequate education and uncertainty in decision-making related to anticoagulation therapy. To address this gap, an interdisciplinary Anticoagulation Management Training Program was developed for family medicine residents at the Toronto Western Family Health Team. Evaluation data demonstrated both improved knowledge and confidence in prescribing, monitoring, and adjusting anticoagulation therapy. This suggests that similar dedicated curricula be considered in other family medicine programs in order to optimize patient safety by enhancing the knowledge and self-efficacy of future practising physicians.

Les anticoagulants sont des médicaments à haut risque qui, mal gérés, peuvent causer des dommages importants aux patients. De nombreux étudiants en médecine et médecins en exercice déclarent que leur formation est inadéquate et qu'ils ont des doutes lorsqu'ils prescrivent un traitement anticoagulant. Pour combler cette lacune, une formation interdisciplinaire en gestion des anticoagulants a été élaborée pour les résidents en médecine familiale au sein de la Toronto Western Family Health Team. Les données d'évaluation de la formation indiquent une amélioration sur le plan des connaissances et de la confiance lors de la prescription, ainsi que sur celui du suivi et de l'ajustement de l'anticoagulothérapie. Ces résultats suggèrent qu'il serait donc pertinent d'envisager l'introduction de formations spécialisées de ce type dans les programmes de médecine familiale pour mieux assurer la sécurité des patients par le développement des connaissances et de l'auto-efficacité des futurs praticiens.

Supramolecular Ionic Liquid Gels for Enzyme Entrapment.

Reported herein is an entrapment method for enzyme immobilization that does not require the formation of new covalent bonds. Ionic liquid supramolecular gels are formed containing enzymes that can be shaped into gel beads and act as recyclable immobilized biocatalysts. The gel was formed from two components, a hydrophobic phosphonium ionic liquid and a low molecular weight gelator derived from the amino acid phenylalanine. Gel-entrapped lipase from Aneurinibacillus thermoaerophilus was recycled for 10 runs over 3 days without loss of activity and retained activity for at least 150 days. The procedure does not form covalent bonds upon gel formation, which is supramolecular, and no bonds are formed between the enzyme and the solid support.

Development and evaluation of a primary care antimicrobial stewardship program (PC-ASP) in Toronto, Ontario, Canada.

Background: Effective community-based antimicrobial stewardship programs (ASPs) are needed because 90% of antimicrobials are prescribed in the community. A primary care ASP (PC-ASP) was evaluated for its effectiveness in lowering antibiotic prescriptions for six common infections. Methods: A multi-faceted educational program was assessed using a before-and-after design in four primary care clinics from 2015 through 2017. The primary outcome was the difference between control and intervention clinics in total antibiotic prescriptions for six common infections before and after the intervention. Secondary outcomes included changes in condition-specific antibiotic use, delayed antibiotic prescriptions, prescriptions exceeding 7 days duration, use of recommended antibiotics, and emergency department visits or hospitalizations within 30 days. Multi-method models adjusting for demographics, case mix, and clustering by physician were used to estimate treatment effects. Results: Total antibiotic prescriptions in control and intervention clinics did not differ (difference in differences = 1.7%; 95% CI -12.5% to 15.9%), nor did use of delayed prescriptions (-5.2%; 95% CI -24.2% to 13.8%). Prescriptions for longer than 7 days were significantly reduced (-21.3%; 95% CI -42.5% to -0.1%). However, only 781 of 1,777 encounters (44.0%) involved providers who completed the ASP education. Where providers completed the education, delayed prescriptions increased 17.7% (p = 0.06), and prescriptions exceeding 7 days duration declined (-27%; 95% CI -48.3% to -5.6%). Subsequent emergency department visits and hospitalizations did not increase. Conclusions: PC-ASP effectiveness on antibiotic use was variable. Shorter prescription durations and increased use of delayed prescriptions were adopted by engaged primary care providers.

Historique: Des programmes de gestion antimicrobienne (PGA) communautaires efficaces doivent exister, parce que 90 % des antimicrobiens sont prescrits dans la communauté. Des chercheurs ont évalué un PGA en première ligne (PGA-PL) afin d'en déterminer l'efficacité à réduire les prescriptions d'antibiotiques pour six infections courantes. Méthodologie: Les chercheurs ont évalué un programme de formation polyvalent au moyen d'une méthodologie avant-après dans quatre cliniques de soins de première ligne entre 2015 et 2017. Le résultat clinique primaire était la différence entre les cliniques de contrôle et d'intervention pour ce qui est du total de prescriptions antibiotiques contre six infections courantes avant et après l'intervention. Les résultats cliniques secondaires incluaient des modifications à l'utilisation des antibiotiques propres au trouble de santé, le report des prescriptions d'antibiotiques, des prescriptions de plus de sept jours, l'utilisation des antibiotiques recommandés et les visites à l'urgence ou les hospitalisations dans les 30 jours. Les chercheurs ont utilisé des méthodes multimodèles tenant compte de la démographie, du mélange de cas et du regroupement par médecin pour évaluer l'effet des traitements. Résultats: Les prescriptions totales d'antibiotiques dans les cliniques de contrôle et d'intervention ne différaient pas (différences des différences = 1,7 %; IC à 95 %, ­12,5 % à 15,9 %), ni l'utilisation de prescriptions reportées (­5,2 %; IC à 95 %, ­24,2 % à 13,8 %). Les prescriptions de plus de sept jours étaient très peu courantes (­21,3 %; IC à 95 %, ­42,5 % à ­0,1 %). Cependant, seulement 781 des 1 777 rencontres (44,0 %) avaient eu lieu avec des dispensateurs qui avaient suivi la formation sur le PGA. Lorsque les dispensateurs avaient suivi la formation, les reports de prescriptions augmentaient de 17,7 % (p = 0,06) et les prescriptions de plus de sept jours diminuaient (­27 %; IC à 95 %, ­48,3 % à ­5,6 %). Les visites subséquentes à l'urgence et les hospitalisations n'ont pas augmenté. Conclusions: L'efficacité du PGA-PL pour l'utilisation d'antibiotiques était variable. Les dispensateurs de soins de première ligne qui y avaient participé préparaient des prescriptions de moins longue durée et reportaient davantage leurs prescriptions.

Designing Materials for Aqueous Catalysis: Ionic Liquid Gel and Silica Sphere Entrapped Iron-TAML Catalysts for Oxidative Degradation of Dyes.

Materials have been developed that encapsulate a homogeneous catalyst and enable it to operate as a heterogeneous catalyst in water. A hydrophobic ionic liquid within the material was used to dissolve Fe-TAML and keep it from leaching into the aqueous phase. One-pot processes were used to entrap Fe-TAML in basic ionic liquid gels, and ionic liquid gel spheres structured via a modified Stöber synthesis forming SiO2 particles of uniform size. Catalytic activity was demonstrated via the oxidative degradation of dyes. Fe-TAML entrapped in a basic ionic liquid gel exhibited consistent activity in five recycles. This discovery of heterogenized H2O2 activators prepared by sol-gel and Stöber processes opens new possibilities for the creation of engineered catalytic materials for water purification.

Deprescribing in a family health team: a study of chronic proton pump inhibitor use.

BACKGROUND Proton pump inhibitors (PPIs) are often used inappropriately, without an indication, or for longer durations than recommended. Few tools exist to guide reassessment of their continued use and deprescribing if required. We aimed to reduce inappropriate drug use by developing and implementing a PPI deprescribing tool and process in a family medicine unit. ASSESSMENT OF PROBLEM Primary care providers of adults taking a PPI for 8 weeks with an upcoming periodic health examination were reminded to reassess therapy via electronic medical record (EMR) messaging. A PPI Deprescribing Tool was uploaded into the EMR as a second reminder and to guide reassessment and deprescribing where indicated. Ten weeks after the examination a chart review assessed changes to PPI use. A follow up survey of providers assessed the utility and barriers to implementing the Deprescribing Tool. RESULTS Forty-three of 46 patients on PPIs (93%) had their PPI reassessed, resulting in 11 patients (26%) having their PPI deprescribed. Strategies for Improvement Routine reassessment of long-term medications is often overlooked because of extensive demands on primary care providers' time. Deprescribing likely improved because potentially eligible patients were identified to the provider and a tool was provided at the time of the encounter to guide the deprescribing process. LESSONS Reassessment and deprescribing of PPIs can be supported by implementing a standardised process and use of guidance tools for clinicians. Providers found the timely and selective reminder message to deprescribe the most useful component of the intervention. KEYWORDS proton pump inhibitor; deprescribing; reassessment; primary care; medication therapy management; gastroesophageal reflux disease.

Identification of inappropriate medication use in elderly patients with frequent emergency department visits.

OBJECTIVE: To determine the demographic and health care characteristics of elderly family health team patients who are frequent emergency department (ED) users, focusing on potentially inappropriate medications (PIMs) and access to primary care services. DESIGN: Cross-sectional retrospective chart review. SETTING: Academic family medicine clinic in Toronto, Ontario. PARTICIPANTS: A total of 46 elderly patients (age >65 years) with 4 or more visits to a University Health Network-affiliated ED between April 1, 2010, and March 31, 2011. MAIN OUTCOME MEASURES: Using the validated STOPP (Screening Tool of Older Persons' potentially inappropriate Prescriptions) criteria, PIMs were identified. The primary objective was to determine whether PIMs were associated with more frequent ED use. The secondary objective was to determine whether patients who had previously undergone a clinic pharmacist-led medication review had fewer PIMs. We also determined the health characteristics of these patients at the time of their last ED visit of the study period. Utilization of primary care resources, both prior to and after ED visits, was determined. RESULTS: Sixty-five percent of patients were taking at least 1 PIM. The total number of PIMs in the study population was 71. Having more PIMs was significantly correlated with a higher number of ED visits (r = 0.32, p < 0.05). Patients with a previous medication review had a similar number of PIMs compared with those without a review. The mean number of concurrent medications was 12.1 and the mean Charlson Comorbidity Index score was 3.7. Significant delay between hospital discharge and primary care follow-up (median 13 days) was observed. CONCLUSION: Elderly patients who are more frequent ED users have a greater number of PIMs. Primary care resources appear to be underused in this population.

Sugar-derived organogels as templates for structured, photoluminescent conjugated polymer-inorganic hybrid materials.

Co-assembly of an inorganic-organic hybrid material through the combination of supramolecular organogel self-assembly, phase partitioning of a conjugated polymer (CP) and transcription of an inorganic oxide leads to a hybrid material with structured domains of organogel, CP and silica within tube and rod microstructures.

Minimizing side reactions in chemoenzymatic dynamic kinetic resolution: organometallic and material strategies.

Chemoenzymatic dynamic kinetic resolution (DKR) of rac-1-phenyl ethanol into R-1-phenylethanol acetate was investigated with emphasis on the minimization of side reactions. The organometallic hydrogen transfer (racemization) catalyst was varied, and this was observed to alter the rate and extent of oxidation of the alcohol to form ketone side products. The performance of highly active catalyst [(pentamethylcyclopentadienyl)IrCl(2)(1-benzyl,3-methyl-imidazol-2-ylidene)] was found to depend on the batch of lipase B used. The interaction between the bio- and chemo-catalysts was reduced by employing physical entrapment of the enzyme in silica using a sol-gel process. The nature of the gelation method was found to be important, with an alkaline method preferred, as an acidic method was found to initiate a further side reaction, the acid catalyzed dehydration of the secondary alcohol. The acidic gel was found to be a heterogeneous solid acid.

Chain confinement promotes ß-phase formation in polyfluorene-based photoluminescent ionogels.

The synthesis of photoluminescent conjugated polymer silica ionogels using sol-gel chemistry is described. Cooperative self-assembly of an ionic liquid, the silica precursor and poly(9,9-dioctylfluorene) (PFO) via hydrogen bonding and π-stacking interactions drives formation of the PFO ß-phase.

The co-entrapment of a homogeneous catalyst and an ionic liquid by a sol-gel method: recyclable ionogel hydrogenation catalysts.

Molecular hydrogenation catalysts have been co-entrapped with the ionic liquid [Bmim]NTf(2) inside a silica matrix by a sol-gel method. These catalytic ionogels have been compared to simple catalyst-doped glasses, the parent homogeneous catalysts, commercial heterogeneous catalysts, and Rh-doped mesoporous silica. The most active ionogel has been characterised by transmission electron microscopy, X-ray photoelectron spectroscopy, and solid state NMR before and after catalysis. The ionogel catalysts were found to be remarkably active, recyclable and resistant to chemical change.

Reassessment of enfuvirtide's role in the management of HIV-1 infection.

BACKGROUND: The development of new protease inhibitors, new non-nucleoside reverse transcriptase inhibitors and novel therapeutic drug classes has dramatically changed the approach to managing HIV-1 patients with multidrug resistant virus. This has led many clinicians to reevaluate the clinical utility of enfuvirtide. OBJECTIVES: To summarize recent literature on enfuvirtide and to reassess enfuvirtide's role in the management of HIV-1 infection. METHODS: MEDLINE (1990 to February Week 2 2008) and EMBASE (1990 to 2008 week 8) databases were searched using the following terms: 'enfuvirtide', 'Fuzeon', 'T20', 'HIV fusion inhibitors', and 'HIV entry inhibitor'; limits: English language. Reference lists of articles deemed relevant were hand searched for additional publications. Significant abstracts from recent international HIV conferences were also identified. CONCLUSION: Enfuvirtide can optimize the response to new combinations of HIV-1 drug regimens in multiresistant patients. Its inclusion as an active agent is effective but use is impacted by its high cost, inconvenient route of administration and cosmetic side-effect profile.