Pharmacist-led transitions-of-care program reduces 30-day readmission rates for Medicare patients in a large health system.

PURPOSE: This report describes the growth and development of the Pharmacy Transitions of Care (PTOC) program at a Florida health system and examines its impact on 30-day readmission rates for Medicare core-measure patients. SUMMARY: BayCare Health System is a large not-for-profit community health system with 15 hospitals in central Florida. In 2015, the PTOC program was developed to integrate 2 pharmacists into the transitions-of-care space to reduce readmissions, enhance patient care, and improve medication safety. The PTOC program focuses on traditional Medicare beneficiaries 65 years of age or older with the goal of preventing 30-day readmissions. The service model includes integration of a pharmacist into the discharge medication reconciliation process, as well as postacute care telephonic follow-up. Data and outcomes have been carefully tracked since program inception and consistently demonstrate a reduction in 30-day readmissions, with a 63% relative risk reduction during the beginning phases of the program and a ratio of observed to expected readmissions of 0.77. As a result, in less than 3 years the PTOC program has grown from 2 to 23 pharmacists and is a key component of BayCare Health System's patient care strategy. CONCLUSION: Medication reconciliation, clinical interventions, and patient education by pharmacists after hospital discharge reduced 30-day readmission rates for Medicare core-measure patients across a large health system. The adaptability of this program to other health systems and hospitals of varying size to achieve similar outcomes is valuable to share with the profession.

An update on newer pediatric supraglottic airways with recommendations for clinical use.

Supraglottic airways are an established part of routine and emergency pediatric airway management, including use in difficult airways and neonatal resuscitation. With the introduction of newer supraglottic airways in children, efficacy can only be determined by comparing these devices with those that are already well established (laryngeal mask airway Classic and laryngeal mask airway ProSeal). This narrative review aims to present the current literature on these newer supraglottic airways and give recommendations for their use in various clinical scenarios based on the existing evidence.

A randomized comparison between the i-gel™ and the air-Q™ supraglottic airways when used by anesthesiology trainees as conduits for tracheal intubation in children.

PURPOSE: Supraglottic airways are commonly used as conduits for fibreoptic bronchoscopy (FOB)-guided intubation in pediatric patients. We hypothesized that anesthesiology trainees with limited prior experience with FOB-guided intubation through a supraglottic airway in children would intubate the trachea faster through the air-Q™ supraglottic airway than through the i-gel™. METHODS: Ninety-six children aged one month to six years were randomized to receive either the i-gel or air-Q for FOB-guided tracheal intubation by anesthesiology trainees. Time for successful tracheal intubation was the primary endpoint. Secondary endpoints included: time for device insertion, number of attempts for successful device insertion, airway leak pressures, FOB grade of laryngeal view, total number of attempts for tracheal intubation, time for removal of the device after tracheal intubation, and associated complications. RESULTS: The median (interquartile range [IQR]) times to successful tracheal intubation for the air-Q (62.5 [47.9-77] sec) and the i-gel (55.9 [48.5-81.8] sec) were not significantly different (median difference 6.6 sec; 95% confidence interval [CI] -13.3 to 8.7; P = 0.53). The median (IQR) time to insertion for the air-Q (16.7 [14.4-20.0] sec) was shorter than for the i-gel (19.6 [16.7-23.0] sec) (median difference 2.9 sec; 95% CI 0.8 to 4.7; P = 0.005). There were no differences between devices with respect to airway leak pressures, success rates, and time to removal. Compared with the air-Q, the i-gel was associated with more problems during device removal after tracheal intubation, including breakage of the tracheal tube pilot balloon (n = 0 vs n = 13, respectively; P < 0.001), inadvertent extubation (n = 1 vs n = 5, respectively; P < 0.001), and difficulty controlling the tracheal tube (n = 0 vs n = 21, respectively; P < 0.001). CONCLUSIONS: Contrary to our hypothesis, both the air-Q and i-gel supraglottic airways served as effective conduits for FOB-guided tracheal intubation in children when performed by trainees with limited prior experience. The i-gel, however, was associated with more problems during device removal following tracheal intubation. This study was registered at http://clinicaltrials.gov/show/NCT02189590 .

Novel target for Spinal Cord Injury Neuropathic Pain.

In the world today, millions of people suffer from spinal cord injury (SCI) with little known effective clinical therapy. Neuropathic pain (NP) is often the result of SCI, making clinical treatment difficult. Even though key mediators in the development of NP have been discovered, the pathogenesis is still unclear. Some of the key mediators in the formation of NP include the inflammatory process, cannabinoid receptors, matrix metalloproteases, and their tissue inhibitors. Animal models have shown promising results with these mediators, yet the clinical models are still unsuccessful. One such study focusing on matrix metalloproteases (MMPs) has produced encouraging results. The relationship between MMPs and their tissue inhibitors (TIMPs) plays a significant role in the pathogenesis and recovery of SCI and the CNS. Key factors that lead to the functional consequences of MMP activity are cellular localization, tissue distribution, and temporal pattern of MMP expression. Controlling the MMP activity and expression are transcription factors, signaling molecules, and inhibition by TIMPs. Studies saying that MMPs can be seen as contributors of tissue damage and as contributors in the repair mechanisms have provided a need to reexamine their roles after acute and chronic process like traumatic SCI and NP, respectively. In this review, we focus on novel findings related to NP mediators like cannabinoid receptors, MMPs, and TIMPs. We will also review current clinical findings; stressing areas that show great therapeutic potential.

Novel targets for Spinal Cord Injury related neuropathic pain.

Millions of people suffer from spinal cord injury (SCI) with little known effective clinical therapy. Neuropathic pain (NP) is often accompanied with SCI, making clinical treatment challenging. Even though the key mediators in the development of NP have been discovered, the pathogenesis is still unclear. Some of the key mediators in the sustenance of NP include the inflammatory processes, cannabinoid receptors, matrix metalloproteases, and their tissue inhibitors. Animal models have shown promising results with modulation of these mediators, yet the clinical models have been unsuccessful. One such study with matrix metalloproteases (MMPs) has yielded encouraging results. The relationship between MMPs and their tissue inhibitors (TIMPs) plays a significant role in the pathogenesis and recovery of SCI and the CNS. Key factors that lead to the functional consequences of MMP activity are cellular localization, tissue distribution, and temporal pattern of MMP expression. Studies concluding that MMPs can be seen as contributors of tissue damage and as contributors in the repair mechanisms have provided a need to reexamine their roles after acute and chronic neuropathic pain.

A Case Study Examining the Effectiveness of Mechanical Diagnosis and Therapy in a Patient who Met the Clinical Prediction Rule for Spinal Manipulation.

This single-subject case study was conducted as a part of a randomized trial investigating the efficacy of mechanical diagnosis and therapy (MDT) and spinal thrust manipulation (STM) in patients who meet a clinical prediction rule (CPR) for spinal manipulation. Following initial examination, a patient who met the CPR was treated initially with STM and then eventually with MDT. The Oswestry Disability Questionnaire (ODI), Fear-Avoidance Beliefs Questionnaire, and the Numerical Pain Rating Scale (NPRS) were administered at the initial examination and at a two-week follow-up. Data were analyzed based on changes in the pain rating scale, ODI, and straight leg raise scores from initial examination to discharge. In accordance with a study protocol in which the patient was part of, this patient was changed from STM to MDT after the second physical therapy visit due to failure of overall improvement. The patient received MDT during the third session and continued with this approach until discharge. This patient responded favorably to MDT presenting with a 20 degrees improvement in SLR on the left and 10 degrees on the right, 6 points lower on the NPRS, and a 4% decrease on the OSW after a total of 6 visits.