Increasing Medication Access by Promoting Appropriate Use of Multi-dose Vials.

Medication shortage is a problem that affects patients, providers, and institutions of all sizes and scope across the United States. The objective of this quality improvement project was to promote the appropriate use of multi-dose vials (MDVs) by anesthesia providers at an independent plastic surgery office. Multi-dose vials can be used to decrease waste and potentially cost, thus increasing access to necessary medications for the patients at this practice. A focus group was used to obtain an understanding of barriers to the use of MDVs at this practice. A focused E-learning module on safe use based on established guidelines was then created, and a simplified flow sheet was implemented and placed in medication preparation areas as a cognitive aid. The education and flow sheet focused on identification and preparation of the medication area, proper identification of MDVs versus single-use vials, hand hygiene, proper beyond-use labeling, septum cleaning, use of a new sterile syringe and needle, and administration time frames. Provider feedback included high levels of satisfaction with the E-learning module. Our comparison of the use of ketamine from MDVs during the pre- and postimplementation phases showed a 14% increase in the number of doses used per vial. This finding suggests that were similar practices implemented at a larger site with MDVs of medications other than ketamine, resources could be impacted to manage shortages and increase access to medications.

Glycocalyx breakdown is increased in African children with cerebral and uncomplicated falciparum malaria.

Cerebral malaria (CM) from Plasmodium falciparum infection is associated with endothelial dysfunction and parasite sequestration. The glycocalyx (GCX), a carbohydrate-rich layer lining the endothelium, is crucial in vascular homeostasis. To evaluate the role of its loss in the pathogenesis of pediatric CM, we measured GCX degradation in Tanzanian children with World Health Organization-defined CM (n = 55), uncomplicated malaria (UM; n = 20), and healthy controls (HCs; n = 25). Urine GCX breakdown products [glycosaminoglycans (GAGs)] were quantified using dimethylmethylene blue (DMMB) and liquid chromatography-tandem mass spectrometry assays. DMMB-GAG and mass spectrometry (MS)-GAG (g/mol creatinine) were increased in CM and UM compared with HCs (P < 0.001), with no differences in DMMB-GAG and MS-GAG between CM and UM children or between those with and without a fatal outcome. In CM survivors, urinary GCX DMMB-GAG normalized by d 3. After adjusting for disease severity, DMMB-GAG was significantly associated with parasitemia [partial correlation coefficient (Pcorr) = 0.34; P = 0.01] and plasma TNF (Pcorr = 0.26; P = 0.04) and inversely with plasma and urine NO oxidation products [Pcorr = -0.31 (P = 0.01) and Pcorr = -0.26 (P = 0.03), respectively]. GCX breakdown is increased in children with falciparum malaria, with similar elevations in CM and UM. Endothelial GCX degradation may impair endothelial NO production, exacerbate adhesion-molecule expression, exposure, and parasite sequestration, and contribute to malaria pathogenesis.-Yeo, T. W., Bush, P. A., Chen, Y., Young, S. P., Zhang, H., Millington, D. S., Granger, D. L., Mwaikambo, E. D., Anstey, N. M., Weinberg, J. B. Glycocalyx breakdown is increased in African children with cerebral and uncomplicated falciparum malaria.

Glycocalyx Breakdown Is Associated With Severe Disease and Fatal Outcome in Plasmodium falciparum Malaria.

BACKGROUND: Interactions between the endothelium and infected erythrocytes play a major role in the pathogenesis of falciparum malaria, with microvascular dysfunction and parasite sequestration associated with worsening outcomes. The glycocalyx is a carbohydrate-rich layer that lines the endothelium, with multiple roles in vascular homeostasis. The role of the glycocalyx in falciparum malaria and the association with disease severity has not been investigated. METHODS: We prospectively enrolled Indonesian inpatients (aged ≥18 years) with severe (SM) or moderately severe (MSM) falciparum malaria, as defined by World Health Organization criteria, and healthy controls (HCs). On enrollment, blood and urine samples were collected concurrently with measurements of vascular nitric oxide (NO) bioavailability. Urine was assayed for glycocalyx breakdown products (glycosaminoglycans) using a dimethylmethylene blue (GAG-DMMB) and liquid chromatography-tandem mass spectrometry (GAG-MS) assay. RESULTS: A total of 129 patients (SM = 43, MSM = 57, HC=29) were recruited. GAG-DMMB and GAG-MS (g/mol creatinine) were increased in SM (mean, 95% confidence interval: 3.98, 2.44-5.53 and 6.82, 5.19-8.44) compared to MSM patients (1.78, 1.27-2.29 and 4.87, 4.27-5.46) and HCs (0.22, 0.06-0.37 and 1.24, 0.89-1.59; P < 0.001). In SM patients, GAG-DMMB and GAG-MS were increased in those with a fatal outcome (n = 3; median, interquartile range: 6.72, 3.80-27.87 and 12.15, 7.88-17.20) compared to survivors (n = 39; 3.10, 0.46-4.5 and 4.64, 2.02-15.20; P = 0.03). Glycocalyx degradation was significantly associated with parasite biomass in both MSM (r = 0.48, GAG-DMMB and r = 0.43, GAG-MS; P < 0.001) and SM patients (r = 0.47, P = 0.002 and r = 0.33, P = 0.04) and inversely associated with endothelial NO bioavailability. CONCLUSIONS: Increased endothelial glycocalyx breakdown is associated with severe disease and a fatal outcome in adults with falciparum malaria.

Histological findings correlated with clinical outcomes in telangiectasia treated with ohmic thermolysis and 940 nm laser.

BACKGROUND: Heat modalities are commonly used as either primary or adjunctive treatment for telangiectasia. Minimal information is available as to the nature of injury to the vessel and surrounding tissue. METHOD: A total of 135 patients were treated over a 2-year period using ohmic thermolysis (45), 940 nm laser (50), and 940 nm laser with sclerotherapy (40). After treatment, 1 mm biopsies were done in selected patients in each group. Clinical correlation was studied in each group by observing vessel response at 4-6 weeks postprocedure. RESULTS: Ohmic thermolysis produces electrodessication of the squamous epithelium, reticular dermis, and fusion of the target vessel. 940 nm laser results include squamous epithelial damage, subcutaneous water blister, collagen denaturation, and vessel endothelial cell loss with thrombus at point of maximal impact. The addition of sclerotherapy at time of laser potentiates vessel damage. There was no long-term skin sequelae after treatment when each device is used at recommended settings and on appropriate vessel size. CONCLUSION: Each device causes damage to the squamous epithelium and papillary reticular dermis that is transient. Ohmic thermolysis provides vessel clearance of >90% in telangiectasias <0.5 mm. 940 nm laser effectiveness is <70% for vessel clearance, but improves to >90% when sclerotherapy is performed at time of treatment.

Evaluation of sodium tetradecyl sulfate and polidocanol as sclerosants for leg telangiectasia based on histological evaluation with clinical correlation.

Introduction This study was designed to determine by histological evaluation and clinical correlation the most effective sclerosant concentration of Sotradecol® (sodium tetradecyl sulfate) and Asclera® (polidocanol) for the treatment of leg telangiectasia. Methods Histological studies were completed on 40 patients, all of whom were female with a mean age of 53. After sclerotherapy with varying concentrations of sclerosant solutions for the treatment of 0.8 mm and 1 mm leg telangiectasia, histological specimens were examined for the following criteria: luminal changes, subintimal changes, smooth muscle wall alterations, and vessel wall integrity. Six patients from this group were also treated with sodium tetradecyl sulfate foam 0.1%-0.2% or polidocanol foam 0.31% for the treatment of 2 mm reticular veins. In a second group of 20 patients, clinical results after treatment with sodium tetradecyl sulfate 0.15% and polidocanol 0.31% were evaluated. Results Histological findings in patients treated with sodium tetradecyl sulfate 0.05% and polidocanol 0.25% were minimal. Sclerosant concentrations of sodium tetradecyl sulfate ≥0.2% revealed intraluminal debris and greater smooth wall damage. Polidocanol 0.5% was equivalent in strength to sodium tetradecyl sulfate 0.2% on histological evaluation. Sodium tetradecyl sulfate 0.15% and polidocanol 0.31% had similar findings on histological examination with mild smooth muscle wall changes, endothelial cell lysis, and subintimal layer damage. Reticular veins treated with 0.1%, 0.15%, and 0.2% sodium tetradecyl sulfate foam and 0.31% polidocanol foam produced identical histological findings. Conclusion Sodium tetradecyl sulfate 0.15% and polidocanol 0.31% based on histological evaluations and clinical correlation are the best sclerosant concentrations for 0.8 mm to 1 mm leg telangiectasia. Sodium tetradecyl sulfate foam is comparable to polidocanol foam at these concentrations as well.

Cultivating a Culture of Medication Safety in Prelicensure Nursing Students.

Safety education in nursing has traditionally focused at the level of individual nurse-patient interactions. Students and novice clinicians lack clinical experience to create context and understand the complexity of the health care system and safety science. Using the Quality and Safety Education for Nurses quality and safety competency as a framework, the objective of this education project was to design comprehensive, engaging, learner-centered, online modules that increase knowledge, skills, and attitudes about medication safety.