Rethinking the Drug Distribution and Medication Management Model: How a New York City Hospital Pharmacy Department Responded to COVID-19.

Beginning in March 2020, New York City began the fight against coronavirus disease 2019. Health care workers were faced with a disease that led to significant morbidity and mortality with no proven therapies. As hospitals became inundated with patients and underwent rapid expansion of capacity, resources such as drugs, protective and medical equipment, and hospital staff became limited. Pharmacists played a critical role in the management of clinical care and drug delivery during the pandemic. As members of the department of pharmacy within NewYork-Presbyterian Hospital, we describe our experiences and processes to overcome challenges faced during the pandemic. Strict inventory management through the use of daily usage reports, frequent communication, and minimization of waste was critical for the management of drug shortages. The creation of guidelines, protocols, and restrictions were not only used to mitigate drug shortages, but also helped educate health care providers and guided medication use. Managing technology through setting up new automatic dispensing cabinets to address hospital expansions and modifying the electronic order entry system to include new protocols and drug shortage information were also vital. Additional key pharmacist functions included provision of investigational drug service support and training of pharmacists, prescribers, nurses, and respiratory therapists to educate and standardize medication use. Through implementation of operational and clinical processes, pharmacists managed critical drug inventory and guided patient treatment. As the pandemic continues, pharmacists will remain vital members of the multidisciplinary team dedicated to the fight against the virus.

Bronchoscopic delivery of aminocaproic acid as a treatment for pulmonary bleeding: A case series.

OBJECTIVE: Bronchoscopy is an essential therapeutic modality in the treatment of pulmonary bleeding. Although numerous endoscopic treatments exist, topical ε-aminocaproic acid has not been described in the literature. This study documents the use of this novel treatment for pulmonary bleeding and compares it to available evidence for tranexamic acid, a similar anti-fibrinolytic agent. DESIGN: Case-series study. SETTING: ICU and general inpatient floors of a tertiary medical center. PATIENTS: Forty-six patients receiving endobronchial ε-aminocaproic acid for the treatment or prevention of pulmonary bleeding. MEASUREMENTS AND MAIN RESULTS: Of the 46 patients included in the study, 41.6% and 13% presented with non-massive and massive hemoptysis, respectively. In patients with active pulmonary bleeding, endobronchial application of ε-aminocaproic acid and accompanying therapies resulted in cessation of bleeding in 94.7% of cases. A total of six patients received ε-aminocaproic acid monotherapy; in three patients with active bleeding, 100% achieved hemostasis after treatment. Of the 36 patients successfully treated for active pulmonary bleeding, 27.8% had recurrent bleeding within 30 days. Thirty-day adverse events were as follows: death (10 patients), deep vein thrombosis (2 patients), renal failure (2 patients), and stroke (2 patients). CONCLUSIONS: Endobronchial administration of ε-aminocaproic acid during bronchoscopy may be a safe and efficacious option in the treatment and prevention of pulmonary bleeding. Further studies are necessary to better define ε-aminocaproic acid's safety profile, optimal routes of administration, and comparative effectiveness to tranexamic acid.

Knowledge, Attitudes, and Practices Regarding Antimicrobial Use and Stewardship Among Prescribers at Acute-Care Hospitals.

OBJECTIVE To assess antimicrobial prescriber knowledge, attitudes, and practices (KAP) regarding antimicrobial stewardship (AS) and associated barriers to optimal prescribing. DESIGN Cross-sectional survey. SETTING Online survey. PARTICIPANTS A convenience sample of 2,900 US antimicrobial prescribers at 5 acute-care hospitals within a hospital network. INTERVENTION The following characteristics were assessed with an anonymous, online survey in February 2015: attitudes and practices related to antimicrobial resistance, AS programs, and institutional AS resources; antimicrobial prescribing and AS knowledge; and practices and confidence related to antimicrobial prescribing. RESULTS In total, 402 respondents completed the survey. Knowledge gaps were identified through case-based questions. Some respondents sometimes selected overly broad therapy for the susceptibilities given (29%) and some "usually" or "always" preferred using the most broad-spectrum empiric antimicrobials possible (32%). Nearly all (99%) reported reviewing antimicrobial appropriateness at 48-72 hours, but only 55% reported "always" doing so. Furthermore, 45% of respondents felt that they had not received adequate training regarding antimicrobial prescribing. Some respondents lacked confidence selecting empiric therapy using antibiograms (30%), interpreting susceptibility results (24%), de-escalating therapy (18%), and determining duration of therapy (31%). Postprescription review and feedback (PPRF) was the most commonly cited AS intervention (79%) with potential to improve patient care. CONCLUSIONS Barriers to appropriate antimicrobial selection and de-escalation of antimicrobial therapy were identified among front-line prescribers in acute-care hospitals. Prescribers desired more AS-related education and identified PPRF as the most helpful AS intervention to improve patient care. Educational interventions should be preceded by and tailored to local assessment of educational needs. Infect Control Hosp Epidemiol 2018;39:316-322.

Drug-Induced QT Prolongation And Torsades de Pointes.

Torsades de pointes (TdP)-an uncommon but life-threatening polymorphic ventricular tachycardia-is almost always drug induced. The authors describe the causes, risk factors, symptoms, diagnosis, and treatment of TdP.

A função do autorretrato na obra de Van Gogh / The function of the self-portrait in the work of Van Gogh

O texto busca trabalhar a função cumprida pela pintura dos autorretratos a partir de certo momento da obra de Vincent van Gogh, como exemplo da tentativa de sustentação da imagem de si, interrogando os efeitos psíquicos e corporais da precária inscrição do nome próprio, da singular inscrição do traço unário e das marcas primárias e secundárias de lutos patológicos, na genealogia e na vida do pintor. (AU)

The text seeks to work the function fulfilled by the self-portraits from a certain point in the work of de Vincent van Gogh, as an example of attempt to sustain the image of yourself, interrogating the psychic and corporal effects of the precarious inscription of the proper name, of the singular inscription of the unary trait and primary and secondary marks of pathological mourning, in the genealogy and in the life of the painter. (AU)

Management of Acute Alcohol Withdrawal Syndrome in Critically Ill Patients.

Approximately 16-31% of patients in the intensive care unit (ICU) have an alcohol use disorder and are at risk for developing alcohol withdrawal syndrome (AWS). Patients admitted to the ICU with AWS have an increased hospital and ICU length of stay, longer duration of mechanical ventilation, higher costs, and increased mortality compared with those admitted without an alcohol-related disorder. Despite the high prevalence of AWS among ICU patients, no guidelines for the recognition or management of AWS or delirium tremens in the critically ill currently exist, leading to tremendous variability in clinical practice. Goals of care should include immediate management of dehydration, nutritional deficits, and electrolyte derangements; relief of withdrawal symptoms; prevention of progression of symptoms; and treatment of comorbid illnesses. Symptom-triggered treatment of AWS with γ-aminobutyric acid receptor agonists is the cornerstone of therapy. Benzodiazepines (BZDs) are most studied and are often the preferred first-line agents due to their efficacy and safety profile. However, controversy still exists as to who should receive treatment, how to administer BZDs, and which BZD to use. Although most patients with AWS respond to usual doses of BZDs, ICU clinicians are challenged with managing BZD-resistant patients. Recent literature has shown that using an early multimodal approach to managing BZD-resistant patients appears beneficial in rapidly improving symptoms. This review highlights the results of recent promising studies published between 2011 and 2015 evaluating adjunctive therapies for BZD-resistant alcohol withdrawal such as antiepileptics, baclofen, dexmedetomidine, ethanol, ketamine, phenobarbital, propofol, and ketamine. We provide guidance on the places in therapy for select agents for management of critically ill patients in the presence of AWS.

Trauma: ficção, história, verdade / Trauma: fiction, history, truth

O presente texto trabalha o trauma, a partir das obras de Freud e Lacan, abordando os movimentos necessários para a inscrição do real, como condições de elaboração. Para relançar a interrogação sobre o lugar desde onde o analista pode operar frente ao trauma, foi utilizada uma obra de Mia Couto. (AU)

This text deals with the trauma, from the works of Freud and Lacan, adressing the movements necessary for the inscription of the real, as conditions for working through. To revive the question upon the place from where the psychoanalyst is able to deal with the trauma, a work of Mia Couto was used. (AU)

“Secretários do alienado”? A psicose e a instituição psicanalítica / “Secretary of the insane”? Psychosis and the psychoanalytic institution

O texto resgata o conceito freudiano de descrença (unglaben) para problematizar a questão do tratamento da psicose na instituição psicanalítica. Busca articular a contribuição da instituição na direção do tratamento do paciente, levando em consideração o fenômeno do unglaben, mobilizado pela psicose. (AU)

This text recovers the Freudian concept of unbelief (Unglaben) to problematize the treatment of psychosis in the psychoanalytic institution. It seeks to articulate the contribution of the institution on patient’s treatment direction, considering the phenomenon of the Unglaben, mobilized by psychosis. (AU)

Non-oral treatment with ivermectin for disseminated strongyloidiasis.

Critically ill patients with disseminated strongyloidiasis may not be candidates for oral treatment. We report four patients with disseminated strongyloidiasis, believed to be unable to absorb oral therapy, who were treated with ivermectin by rectal and/or subcutaneous administration. Obtaining subcutaneous ivermectin and dosing it appropriately is a challenge. These cases underscore the need for improved access to subcutaneous ivermectin and more pharmacological data to guide use of this treatment approach.

O ato de Lacan / The act of Lacan

O presente texto aborda a ruptura de Jacques Lacan

com a Sociedade Francesa de Psicanálise e com a Associação

Psicanalítica Internacional, em 1963, como um ato de Lacan

no interior do movimento psicanalítico

Intercâmbio estudantil: uma nova tentatica de interdição / Student excharge: a new form of interdiction?

Através da análise de uma jovem de 16 anos, o texto aborda a angústia na adolescência, momento em que se altera a posição psíquica quanto ao desejo e se específica a identidade sexual(AU)

The text approaches anguish in adolescence throught the analysis of a 16 years old girl. In this moment the psiquic position as lo desire is modified an sexual identity is specific(AU)