Lithium-related medication problems on nonpsychiatric inpatient medical units.

PURPOSE: Results of a study of medication-related problems (MRPs) associated with lithium use on nonpsychiatric inpatient medical units are reported. METHODS: In a single-center, retrospective study, the records of all patients hospitalized over a 21-month period who received lithium or had a documented serum lithium concentration during hospitalization were evaluated. The primary objective was to identify patient-specific factors associated with lithium MRPs on nonpsychiatric inpatient medical units. Secondary objectives included characterization of lithium MRPs. Identified MRP occurrences were further evaluated to determine if an intervention was necessary to resolve the MRP and whether or not an intervention was made. RESULTS: A total of 150 patients were included in the study sample. One or more lithium MRPs were identified in 85% of the patients, with a total of 255 lithium MRPs identified. None of the patient-specific factors analyzed were significantly associated with MRP occurrence. Of the 128 patients in whom a lithium MRP occurred, 92.2% (n = 118) were judged to be appropriate candidates for interventions as defined per the study definitions; among those 118 patients, such interventions were documented for only 40.7% (n = 48). CONCLUSION: Lithium MRPs were found to have occurred frequently on nonpsychiatric inpatient medical units at 1 hospital. Laboratory test- related MRPs and drug-drug interactions were the most commonly identified types of MRPs. Interventions to address MRPs were not made in the majority of patients; however, interventions were more frequently made when psychiatry consultation was involved.

Caffeine Sodium Benzoate for Electroconvulsive Therapy Augmentation.

OBJECTIVES: Because of an ongoing manufacturer shortage of injectable caffeine sodium benzoate (CSB), patients at our health system were given CSB compounded in-house to increase seizure response during electroconvulsive therapy (ECT). Therefore, we aimed to evaluate its effectiveness and safety as an ECT augmentation agent. METHODS: Medical records of patients who received compounded CSB at Virginia Commonwealth University Health System were reviewed to identify adults receiving it as part of an index ECT treatment course between June 2012 and December 2016. The primary outcome was change in electroencephalogram seizure duration from pre-caffeine session to initial caffeine session. Data were also collected on demographics, motor seizure duration, maximum heart rate, mean arterial pressure, and concurrent medication use for these sessions and the last caffeine session. RESULTS: Seven-one patients were included in the study, predominantly white females with a mean age of 58.6 years. The most common indication for ECT was major depressive disorder resistant to pharmacotherapy (71.8%), followed by catatonia associated with another mental disorder (19.7%). Electroencephalogram seizure duration increased by 24.1 seconds on average with first CSB use (P < 0.0001), allowing 24 more patients overall to achieve goal of at least 30 seconds (P < 0.0001). No clinically significant changes in maximum heart rate or mean arterial pressure were observed, nor did any patients require an abortive agent for prolonged seizure. Five patients (7%) discontinued CSB prematurely: 4 related to adverse effects and 1 secondary to ineffectiveness. CONCLUSIONS: We confirm results of prior studies of the utility of CSB and add that compounded CSB is effective for ECT augmentation, maintaining effectiveness throughout the index course with minimal safety concerns.

Correlation of venous thromboembolism prophylaxis and electronic medical record alerts with incidence among surgical patients.

BACKGROUND: Venous thromboembolism events are potentially preventable adverse events. We investigated the effect of interruptions and delays in pharmacologic prophylaxis on venous thromboembolism incidence. Additionally, we evaluated the utility of electronic medical record alerts for venous thromboembolism prophylaxis. METHODS: Venous thromboembolisms were identified in surgical patients retrospectively through Core Measure Venous ThromboEmbolism-6-6 and Patient Safety Indicator 12 between November 2013 and March 2015. Venous thromboembolism pharmacologic prophylaxis and prescriber response to electronic medical record alerts were recorded prospectively. Prophylaxis was categorized as continuous, delayed, interrupted, other, and none. RESULTS: Among 10,318 surgical admissions, there were 131 venous thromboembolisms; 23.7% of the venous thromboembolisms occurred with optimal continuous prophylaxis. Prophylaxis, length of stay, age, and transfer from another hospital were associated with increased venous thromboembolism incidence. Compared with continuous prophylaxis, interruptions were associated with 3 times greater odds of venous thromboembolism. Delays were associated with 2 times greater odds of venous thromboembolism. Electronic medical record alerts occurred in 45.7% of the encounters and were associated with a 2-fold increased venous thromboembolism incidence. Focus groups revealed procedures as the main contributor to interruptions, and workflow disruption as the main limitation of the electronic medical record alerts. CONCLUSION: Multidisciplinary strategies to decrease delays and interruptions in venous thromboembolism prophylaxis and optimization of electronic medical record tools for prophylaxis may help decrease rates of preventable venous thromboembolism.

Effects of health literacy and polypharmacy on medication adherence.

OBJECTIVE: To determine if health literacy has an effect on medication adherence in patients taking fewer than five prescriptions (no polypharmacy), and those taking five or more prescriptions (polypharmacy). DESIGN: Retrospective cohort. SETTING: The Primary Care Residents' Clinic at Virginia Commonwealth University Health System (VCUHS). PATIENTS: Those who received a Rapid Estimate of Adult Literacy in Medicine-Revised (REALM-R) assessment at the clinic between June 1, 2009, and June 30, 2010, and utilized the VCUHS outpatient pharmacies to fill their prescriptions. A total of 648 individuals were identified. INTERVENTIONS: The degree of health literacy and level of medication adherence were analyzed per patient by accessing the clinic's electronic health records. The number of medications each patient filled was determined using VCUHS outpatient pharmacy databases. MAIN OUTCOME MEASURE: To determine if there are any associations among the degree of health literacy, the level of medication adherence, and the amount of medications a patient is taking. RESULTS: There was a significant association found between the level of medication adherence and the degree of polypharmacy. We found no association between the degree of health literacy and the level of adherence to a prescribed medication regimen. Additionally, there was no relationship between the degree of polypharmacy and health literacy. Those patients with more medications were also found to have lower levels of medication adherence and vice versa. CONCLUSION: Our study does not show an association between health literacy and medication adherence nor between health literacy and polypharmacy. Thus, potential changes to improving health literacy may not have a significant effect on adherence.

Azithromycin for the treatment of gastroparesis.

OBJECTIVE: To evaluate the use of azithromycin for the treatment of gastroparesis. DATA SOURCES: Literature was accessed through PubMed/MEDLINE and Web of Science (both 1966-October 2012) using the terms gastroparesis, diabetic gastroparesis, and azithromycin. Literature was limited to English-language publications. In addition, references from publications identified were reviewed. STUDY SELECTION AND DATA EXTRACTION: All articles published in English identified from the data sources were evaluated. DATA SYNTHESIS: The treatment of gastroparesis depends on the severity of the symptoms, but generally includes dietary modifications, prokinetic medications, and antiemetics. The initial treatment for gastroparesis is a prokinetic agent, and because erythromycin has the greatest effect on gastric emptying, it is often used. Limitations to erythromycin include adverse reactions (nausea, vomiting, and abdominal pain), QTc interval prolongation, CYP3A-associated drug interactions, and tachyphylaxis. Azithromycin, another macrolide, has been shown to increase gastrointestinal motility and may have fewer limitations to its use. Azithromycin has fewer drug interactions, less incidence of QTc interval prolongation, a longer half-life, and fewer gastrointestinal adverse effects. Use of azithromycin may be beneficial in patients with gastric and small bowel dysmotility. Two observational studies have supported its use in gastroparesis, but there have been no controlled studies. All studies published have been performed during testing procedures for gastroparesis; thus, longer-term treatment effects and symptom control need to be studied. There is one ongoing prospective controlled trial with preliminary data available only in abstract form. CONCLUSIONS: Azithromycin may prove to be an alternative prokinetic agent in gastroparesis, but further study is needed before it can be recommended.

Budesonide for the treatment of autoimmune hepatitis.

OBJECTIVE: To evaluate the use of budesonide for the treatment of autoimmune hepatitis (AIH). DATA SOURCES: Literature was accessed through PubMed/MEDLINE (1966-June 2011) and Web of Science (1965-June 2011) using the terms autoimmune hepatitis and budesonide. Literature was limited to English-language publications. In addition, references from publications identified were reviewed. STUDY SELECTION AND DATA EXTRACTION: All articles in English identified from the data sources were evaluated. DATA SYNTHESIS: The initial treatment of choice for AIH is prednisone alone or with azathioprine. However, a significant number of patients do not respond adequately or have adverse reactions to this regimen; therefore, alternative treatments are required. Budesonide is an orally administered synthetic corticosteroid with high affinity for the glucocorticoid receptor that undergoes extensive first-pass metabolism. It has Food and Drug Administration-approved labeling for the treatment and maintenance of remission of mild-to-moderate Crohn disease involving the ileum and/or ascending colon. One prospective, active-controlled study of budesonide in the treatment of AIH was identified, as well as 5 small open-label studies and 1 retrospective chart review. Budesonide appears to have efficacy in the treatment of AIH, including in patients intolerant to standard therapy with prednisone alone or with azathioprine, with a reduced incidence of corticosteroid-related adverse reactions. However, in patients with AIH and cirrhosis, the efficacy of budesonide may be reduced and the incidence of corticosteroid-related adverse reactions may be increased. CONCLUSIONS: Budesonide may be an additional treatment option for patients with AIH but without cirrhosis who are intolerant to standard therapy with prednisone or prednisone with azathioprine.

Implementation and evaluation of vancomycin nomogram guidelines in a computerized prescriber-order-entry system.

PURPOSE: The implementation and evaluation of vancomycin nomogram guidelines in a computerized prescriber-order-entry (CPOE) system are described. METHODS: Initial vancomycin orders for patients over age 18 years who received vancomycin between August 1 and September 30, 2006 (preimplementation), and between March 1 and April 30, 2007 (postimplementation), were compared with vancomycin nomogram recommendations to determine if the vancomycin regimen ordered coincided with the nomogram recommendation. The numbers of regimen changes and vancomycin serum concentrations measured during the first five days of therapy were also assessed. A multivariate logistic regression model assessed independent predictors of an initial vancomycin order that met the nomogram recommendation RESULTS: A total of 522 vancomycin orders were included in the analysis (279 in the preimplementation group and 243 in the postimplementation group). A significant difference was observed in the percentage of initial vancomycin orders that met nomogram recommendations in the postimplementation group compared with the preimplementation group (36% versus 24%, p = 0.0028). No difference was noted between the two groups in the number of regimen changes or serum vancomycin concentrations measured during the first five days of therapy. In a multivariate analysis, age (p = 0.02) and weight (p < 0.0001) were negatively associated with a vancomycin order that met nomogram recommendations, while the postimplementation group was positively associated with an order that met nomogram recommendations (p = 0.001). CONCLUSION: A vancomycin nomogram implemented into a CPOE system increased the likelihood of patients receiving an initial vancomycin regimen that coincided with the nomogram's recommendations.

Outcome of liver transplantation in a Hispanic population: 100 liver transplants in Puerto Ricans.

BACKGROUND: The residents of Puerto Rico (PR) had limited access to liver transplantation (LTx) prior to 1996. LTx remains locally unavailable and success rates for LTx for patients from PR have never been published. The outcome of the first 100 LTx recipients from PR transplanted at our center is analyzed. METHODS: 100 consecutive patients transplanted between 3/1997 and 1/2005 were evaluated. RESULTS: Hepatitis C was the indication for LTx in 44%. Overall patient survival at 1, 3 and 5 yrs was: 94.0%, 81.4% and 75.7%, respectively, while for hepatitis C, it was 90%, 73% and 73%, respectively. At mean follow up of 44 mo., 80% of patients were alive (66% HCV were alive vs 91% non HCV, p < 0.01). CONCLUSIONS: Access to LTx in Puerto Rico has dramatically improved since 1996. The government-sponsored fund has provided access to indigent patients. Decreased survival in this minority population was not observed at 1, 3 and 5 years. Long-term survival was most affected by recurrence of HCV.