The impact of the implementation of computerized insulin order sets for the control of hyperglycemia in hospitalized cardiac patients.

Background: Glycemic control is crucial in managing hospitalized patients with type II diabetes (T2DM), and it presents as a clinical challenge in the cardiac population. Therefore, we aimed to evaluate the impact of computerized insulin order sets in T2DM hospitalized cardiac patients. Methods: A quasi-experimental, pre- and post-study design. We included T2DM patients who were hospitalized for at least 3 days. Patients undergoing cardiac surgery were excluded. The primary endpoint was the mean difference in random blood glucose level (BGL) before and after the implementation of insulin order sets. While the secondary endpoints were to compare the median differences in fasting BGLs and the number of hyperglycemic and hypoglycemic episodes during the first 7 days. The study consisted of three phases: pre-implementation, intervention and post-phase. In the intervention phase, insulin order sets were integrated into the electronic prescribing system, and education was provided to the cardiology department. The post-phase included the patient's post-implementations. Results: A total of 194 patients were enrolled during the study period. The mean random BGL was 11.17 mmol/L, 95% CI, 10.6-11.7 in the pre-phase and 9.5 mmol/L, 95% CI, 9-1 -9.9 mmol/L in the post-phase (P < 0.001). The median fasting BGL was 9.2 mmol/L (7.4-11.8, IQR) in the pre-phase and 8.5 mmol/L (6.6-10.3, IQR) in the post-phase (P = 0.027). The number of hypoglycemic episodes was 24 in pre-phase and 33 in post-phase (P = 0.13). Conclusion: The use of computerized insulin order sets was associated with potential improvements in random and fasting glycemic control without increasing the risk of hyperglycemia or hypoglycemia.

The Bayesian-Based Area under the Curve of Vancomycin by Using a Single Trough Level: An Evaluation of Accuracy and Discordance at Tertiary Care Hospital in KSA.

The AUC0-24 is the most accurate way to track the vancomycin level while the Cmin is not an accurate surrogate. Most hospitals in Saudi Arabia are under-practicing the AUC-guided vancomycin dosing and monitoring. No previous work has been conducted to evaluate such practice in the whole kingdom. The current study objective is to calculate the AUC0-24 using the Bayesian dosing software (PrecisePK), identify the probability of patients who receive the optimum dose of vancomycin, and evaluate the accuracy and precision of the Bayesian platform. This retrospective study was conducted at King Abdulaziz medical city, Jeddah. All adult patients treated with vancomycin were included. Pediatric patients, critically ill patients requiring ICU admission, patients with acute renal failure or undergoing dialysis, and febrile neutropenic patients were excluded. The AUC0-24 was predicted using the PrecisePK platform based on the Bayesian principle. The two-compartmental model by Rodvold et al. in this platform and patients' dose data were utilized to calculate the AUC0-24 and trough level. Among 342 patients included in the present study, the mean of the estimated vancomycin AUC0-24 by the posterior model of PrecisePK was 573 ± 199.6 mg, and the model had a bias of 16.8%, whereas the precision was 2.85 mg/L. The target AUC0-24 (400 to 600 mg·h/L) and measured trough (10 to 20 mg/L) were documented in 127 (37.1%) and 185 (54%), respectively. Furthermore, the result demonstrated an increase in odds of AUC0-24 > 600 mg·h/L among trough level 15-20 mg/L group (OR = 13.2, p < 0.05) as compared with trough level 10-14.9 mg/L group. In conclusion, the discordance in the AUC0-24 ratio and measured trough concentration may jeopardize patient safety, and implantation of the Bayesian approach as a workable alternative to the traditional trough method should be considered.

Comparing the Efficacy and Safety of Apixaban Versus Warfarin in Morbidly Obese Patients.

This study was conducted to evaluate the efficacy and safety of apixaban versus warfarin in morbidly obese patients. A total of 250 morbidly obese patients with a body mass index (BMI) higher than 40 kg/m2 or a body weight higher than 120 kg who were on anticoagulation therapy with either apixaban or warfarin for over one month were included in the study. This retrospective cohort, multicenter study was executed using the medical records of 125 morbidly obese patients treated with apixaban, while patients on warfarin were selected using a systemic random sampling to match the sample size of the apixaban group. There was no significant difference between apixaban and warfarin in the development of thromboembolic events and major bleeding. However, incidences of minor bleeding significantly decreased in the apixaban group compared to patients treated with warfarin. This difference was overcome by controlling serum creatinine and nonsteroidal anti-inflammatory drugs (NSAIDs). In conclusion, apixaban efficacy and safety are nearly the same as that of warfarin in morbidly obese patients with a lower incidence of minor bleeding with apixaban. Controlling serum creatinine and NSAIDs use may improve warfarin safety and decrease its complications.

Visual loss and optic neuropathy in a patient with Klinefelter's syndrome, open-angle glaucoma, vitamin B12 (cobalamin) and folate deficiency.

A 54-year-old man with Klinefelter's syndrome presented to the neuro-ophthalmology clinic with progressive painless visual blurring in the right eye over 2 years. He was receiving intramuscular testosterone therapy for hypogonadism and hypromellose for dry eye. Acuity was reduced bilaterally, and the right optic nerve head appeared pale and asymmetrically cupped. Optical coherence tomography revealed loss of retinal nerve fibre layer thickness in the right eye and visual field testing showed a developing right-ring scotoma. Blood tests showed vitamin B12 and folate deficiencies and polycythaemia. The patient was managed with intramuscular hydroxocobalamin, oral folate administration and re-initiation of his glaucoma medication. In Klinefelter's syndrome, signs of comorbid deficiency can be masked by the polycythaemic effect of testosterone therapy. For patients on long-term testosterone therapy, such as those with Klinefelter's syndrome, we recommend baseline ophthalmic examination and assessment, including intraocular pressure measurement, pachymetry, gonioscopy and screening 24-2 visual field testing.

Safety and efficacy of nurse led intravitreal injection service with Precivia® injection assist device.

INTRODUCTION: Intravitreal anti-VEGF injections are the most frequently performed outpatient procedure in the UK. Ophthalmic allied healthcare professionals are replacing medical professionals in delivering injections nationwide. The use of injection assist devices such as Precivia® has been well established and increasingly adopted to aid in their safe delivery. We present outcomes of nurse-led intravitreal injections using the Precivia® injection assist device over a five-year period in the UK. METHODS: A retrospective review was completed of all anti-VEGF intravitreal injections delivered at the Great Western Hospital between May 2015 and May 2020. RESULTS: Over the five-year study period, 2318 patients underwent a total of 26,923 intravitreal injections; 20,421 (75.8%) of which were delivered by appropriately trained ophthalmic nurses. The annual number of injections increased year-on-year from 2112 injections in 2015-2016 to 5410 injections in 2019-2020. The mean age of patients was 75.7±12.2 years with a female-to-male ratio was 1.17:1. Wet age-related macular degeneration represented the major indication for injections followed by retinal vein occlusion and diabetic maculopathy respectively. Three cases of post-injection endophthalmitis out of 20,421 (0.015%) injections in nurse injection group were identified during the study period. There were no cases of lens touch, retinal detachment or systemic thromboembolic events. CONCLUSION: Use of the Precivia® intravitreal injection assist device by trained ophthalmic allied health professionals is a safe and cost-effective way to deliver intravitreal injections service.

Assessing the Clinical Utility of Point of Care HbA1c in the Ophthalmology Outpatient Setting.

BACKGROUND/AIMS: Effective management of diabetic retinopathy requires multidisciplinary input. We aimed to evaluate the impact of point of care (POC) HbA1c testing as a tool to identify patients most in need of specialist diabetologist input and assess the accuracy and determinants of patients' insight into their glycaemic and blood pressure control. METHODS: Forty-nine patients with diabetic retinopathy were recruited from the eye clinic at Great Western Hospital. Patients completed a questionnaire and POC HbA1c and blood pressure values were measured. Statistical analysis was completed with SPSS v23. RESULTS: Mean age was 64.4 years, median interval since the last formal HbA1c reading was 10.2 months and the mean POC HbA1c was 64.1 mmol/mol. HbA1c significantly correlated with the degree of retinopathy. Of the patients, 81.6% had POC readings above the levels recommended by the National Institute for Health and Care Excellence, with only 16.3% having insight into this. Insight to HbA1c levels was predicted by age but not by duration of disease. Fourteen patients (33.3%) identified with high HbA1c readings were referred to secondary diabetic services and 88.8% of patients felt that the test was useful and likely to improve their diabetic control. CONCLUSION: The majority of patients had poor insight into their diabetes control, with sub-optimal treatment and follow-up. Poor insight is high in younger patients, suggesting that POC HbA1c testing is particularly important in educating younger patients who may be Type 1 diabetics with more severe disease. POC HbA1c represents a cost-effective, reproducible and clinically significant tool for the management of diabetes in an outpatient ophthalmology setting, allowing the rapid recognition of high-risk patients and appropriate referral to secondary diabetic services.

An objective method of diagnosing hydroxychloroquine maculopathy.

BACKGROUND: Hydroxychloroquine (HCQ) maculopathy is irreversible; primary prevention is done by regular monitoring. Guidelines of the Royal College of Ophthalmologists identify definite toxicity as having abnormal results of two screening tests, we present a quantitative method for interpreting these guidelines. METHODS: We obtained ocular coherence tomography (OCT) scans of 100 patients who have been on HCQ for 5 years or more (patients) and 70 age-matched controls. Both groups had 10'2 visual field (VF) test. We used linear regression to determine the cut-off points for each of the eight Early Treatment of Diabetic Retinopathy Study (ETDRS) macular sectors for the VF and OCT. We calculated the probability of developing maculopathy using logistic regression. RESULTS: Mean patient age: 59.9 years, 85% females, no statistically significant age difference between the patients and the control groups. DIAGNOSIS: 64% rheumatoid arthritis, 14% Sjogren's syndrome, 16% systemic lupus and 6% various other rheumatology conditions. Mean duration of use was 6.3 years. Logistic regression results show strong negative correlation between the outer nuclear layer (ONL) volume and probability of toxicity. Goodness of fit was tested using Hosmer and Lemeshow test that indicates a high significance with a high P-value of 1. CONCLUSIONS: Combining the ONL volume reduction and VF retinal sensitivity reduction per each of the eight ETDRS macular sectors provides an accurate and objective way of diagnosing HCQ maculopathy, this helps busy eye units establishing an optometrist-led or virtual service because it is independent of the assessor's level of experience.

Setting up a successful nurse-led intravitreal injections service: pearls from Swindon.

The demand for performing intravitreal injections has increased in recent years, prompting the need for more nurse training in their administration. The Great Western Hospitals NHS Trust in Swindon has developed a structured nurse training programme and now has 8 independent nurse injectors trained to undertake injections independently; nurse practitioners now contribute upwards of 85% of the total number of injections. The authors have also demonstrated the financial benefits of using injection assistant devices and shown the positive impact such devices have on training. In September 2019, the authors organised the first course to offer nurses and doctors hands-on experience in administering injections, using the Swindon training model to provide participants with a structured approach to learn how to perform intravitreal injections safely. Nurses made up 96% of participants; the remainder were doctors and managers; 6% had never performed an intravitreal injection; of units where they had, disposable drapes and a speculum were used in 71% of these. The number of injections performed per session at participants' units at the time they attended the course was: 17 or more injections=46%, 13-14=39%, and 11-12=15%. The course was rated 8.9/10 overall for content, with 85% very likely to recommend it to colleagues. All participants indicated that using the Swindon model made them feel confident to deliver injections safely. The authors demonstrated that using a structured training protocol and intravitreal assistant device improves the quality of nurse training and increases confidence in administering intravitreal injections.

Bridging the Gap between Theory and Practice; the Active Role of Inpatient Pharmacists in Therapeutic Drug Monitoring.

Many hospitals face barriers in the implementation of TDM services, this study aimed to evaluate a pharmacist-led TDM service to optimize patients' outcomes. Adult patients who were administered vancomycin, gentamicin, or amikacin were included. The pre-phase included a retrospective assessment of patients and the intervention phase consisted of an educational program. The post-phase assessed patients based on TDM services provided by inpatient pharmacists on a 24-h, 7-day basis for 3 months. The primary outcome was to assess the mean difference in proportion of correct initial doses of prescribing orders. Secondary outcomes included assessing the mean differences in proportions of correct dose adjustments and correct drug sampling time. Seventy-five patients in each phase were eligible. Patients who received optimal initial dosing in the post-phase showed a higher statistical significance, mean difference of 0.31, [95% CI (0.181⁻0.4438), p < 0.0001]. Patients in the post-phase received more optimal dose adjustments, mean difference of 0.1, [95% CI (-0.560⁻0.260), p = 0.2113]. Drug levels were ordered more correctly in the post-phase, mean difference of 0.03, [95% CI (-0.129⁻0.189), p = 0.7110]. This study demonstrated the important role of TDM services led by pharmacists in optimizing the initial dosing for these antibiotics.

Intravitreal injections service: a patient experience evaluation.

INTRODUCTION: This survey has been conducted following the introduction of nurse-led intravitreal injections clinics at the Great Western Hospital. A team of 5 nurses regularly carry out an average of 90 injections per week. METHODS: A series of 169 consecutive injection patients have been offered the study questionnaire between 28 January 2016 and 28 February 2016; patients with no previous experience with a nurse injector were excluded. RESULTS: 76.9% strongly agree that the nurse is more friendly and sensitive to their needs. Only 12.4% strongly agree that a doctor will be more suitable to deliver the injections. Seventy-five percent stated that they were very happy with the care, while 0.4% thought a nurse would be unsafe; 69.2% feel more comfortable asking questions when with a nurse injector. Anxiety and nervousness were found to be the main two symptoms experienced by patients around the time of injections (27.8% and 34.9%, respectively). DISCUSSION: The questionnaire was designed based on the feedback from the local friends and family test. A clear majority of patients gave highly positive feedback about nurse injectors. Considering patients' individual needs at the time of injections, such as allergies or points that needs clarification, helps in overcoming some of the psychological complications of treatment.

Evaluating handoffs in the context of a communication framework.

BACKGROUND: The implementation of mandated restrictions in resident duty hours has led to increased handoffs for patient care and thus more opportunities for errors during transitions of care. Much of the current handoff literature is empiric, with experts recommending the study of handoffs within an established framework. METHODS: A prospective, single-institution study was conducted evaluating the process of handoffs for the care of surgical patients in the context of a published communication framework. Evaluation tools for the source, receiver, and observer were developed to identify factors impacting the handoff process, and inter-rater correlations were assessed. Data analysis was generated with Pearson/Spearman correlations and multivariate linear regressions. Rater consistency was assessed with intraclass correlations. RESULTS: A total of 126 handoffs were observed. Evaluations were completed by 1 observer (N = 126), 2 observers (N = 23), 2 receivers (N = 39), 1 receiver (N = 82), and 1 source (N = 78). An average (±standard deviation) service handoff included 9.2 (±4.6) patients, lasted 9.1 (±5.4) minutes, and had 4.7 (±3.4) distractions recorded by the observer. The source and receiver(s) recognized distractions in >67% of handoffs, with the most common internal and external distractions being fatigue (60% of handoffs) and extraneous staff entering/exiting the room (31%), respectively. Teams with more patients spent less time per individual patient handoff (r = -0.298; P = .001). Statistically significant intraclass correlations (P ≤ .05) were moderate between observers (r ≥ 0.4) but not receivers (r < 0.4). Intraclass correlation values between different types of raters were inconsistent (P > .05). The quality of the handoff process was affected negatively by presence of active electronic devices (ß = -0.565; P = .005), number of teaching discussions (ß = -0.417; P = .048), and a sense of hierarchy between source and receiver (ß = -0.309; P = .002). CONCLUSION: Studying the handoff process within an established framework highlights factors that impair communication. Internal and external distractions are common during handoffs and along with the working relationship between the source and receiver impact the quality of the handoff process. This information allows further study and targeted interventions of the handoff process to improve overall effectiveness and patient safety of the handoff.

Assessing normal growth of hepatic hemangiomas during long-term follow-up.

IMPORTANCE: Few long-term data describe the natural history of hepatic hemangiomas. Because these lesions are frequently imaged repetitively on studies performed for other indications, health care professionals are commonly confronted with the problem of a growing hemangioma. Because the rate and magnitude of normal growth is not well characterized, it is difficult to recognize lesions growing at an abnormal rate, which may require further evaluation or intervention. OBJECTIVES: To establish quantitatively the expected growth rate of hepatic hemangiomas and to define a measure of hemangioma growth that could be used clinically to help identify hemangiomas for which growth is more than expected. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study at an academic hospital tertiary referral center evaluating the growth rate of hepatic hemangiomas on cross-sectional imaging studies during a 10-year period (1997-2007). The mean (SD) follow-up time was 3.7 (1.9) years. The radiology information system was searched in a 10-year period for hemangioma. Patients with hepatic hemangiomas that were 1 cm or larger as seen on cross-sectional imaging (computed tomography or magnetic resonance imaging), and 1 year or more apart were selected. Images with the longest interval between studies were selected for further review. Each study was rereviewed for diagnostic confirmation and to ensure consistency in measurement technique. Lesions were remeasured in 3 dimensions, and volumes were calculated using 3-dimensional software. MAIN OUTCOMES AND MEASURES: Primary outcomes include the fraction of hepatic hemangiomas that demonstrated growth during long-term follow-up and the annual growth rate of those lesions. RESULTS: A total of 163 hemangiomas were identified in 123 patients. The mean (SD) initial size was 3.2 (3.1) cm. During follow-up, 39.3% of hemangiomas grew 5% or more in mean linear dimension. The mean (SD) annual linear growth rate was 0.03 (0.21) cm for all lesions and 0.19 (0.23) cm for those that grew 5% or more. By volume, 44.7% of lesions grew 5% or more. The mean (SD) annual volumetric growth rate was 2.8% (21.0%) for all lesions and 17.7% (22.8%) in those that grew 5% or more. The initial size predicted the growth in linear dimension and volume (P < .001). There was no significant change in growth rate over time, indicating uniform growth (R = 0.00843; P = .92). CONCLUSIONS AND RELEVANCE: Nearly 40% of hepatic hemangiomas grow over time. Although the overall rate of growth is slow, hemangiomas that exhibit growth do so at a modest rate (2 mm/y in linear dimension and 17.4% per year in volume). Further research is needed to determine how patients with more rapidly growing hemangiomas should be treated.

Stapled transanal rectal resection for the surgical treatment of obstructed defecation syndrome associated with rectocele and rectal intussusception.

Obstructed defecation syndrome (ODS) is one of the most widespread clinical problems which frequently affects middle-aged females. There is a new surgical technique called stapled transanal rectal resection (STARR) that makes it possible to remove the anorectal mucosa circumferential and reinforce the anterior anorectal junction wall with the use of a circular stapler. This surgical technique developed by Antonio Longo was proposed as an effective alternative for the treatment of ODS. In this study we present our preliminary results with the STARR operation for the treatment of ODS. For this purpose, 40 consecutive female patients with ODS due to rectal intussusception (RI) and/or rectocele (RE) were recruited in this prospective clinical study, from May 2008 to October 2010. No major operative or postoperative complications were recorded, and after 12-month follow-up, significant improvement in the ODS score system was observed, and the symptoms of constipation improved in 90% of patients; 20% of patients judged their final clinical outcome as excellent, 55% as good, and 15% as moderate, with only 10% having poor results. After analyzing our results we can conclude that STARR is an effective and safe procedure for the treatment of obstructed defecation syndrome due to rectal intussusception and/or rectocele and can be performed safely without major morbidity.