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2.
Am J Health Syst Pharm ; 76(15): 1097-1103, 2019 Jul 18.
Artigo em Inglês | MEDLINE | ID: mdl-31361869

RESUMO

PURPOSE: The use of buprenorphine, methadone, and long-acting naltrexone for treatment of opioid use disorder (OUD) is discussed, including a review of current literature detailing treatment approaches and action steps to optimize treatment in acute care and office-based settings. SUMMARY: The U.S. epidemic of opioid-related deaths has been driven by misuse of prescription opioids and, increasingly, illicit drugs such as heroin, fentanyl, and fentanyl analogs, necessitating a refocusing of treatment efforts on expanding access to life-saving, evidence-based OUD pharmacotherapy. Inpatient treatment of opioid withdrawal includes acute symptom control through a combination of nonopioid medications and long-term pharmacotherapy to lessen opioid craving and facilitate stabilization and recovery. Methadone and buprenorphine reduce opioid craving, increase treatment retention, reduce illicit opioid use, and increase overall survival. Buprenorphine has logistical advantages over methadone, such as greater flexibility of treatment setting and less risk of adverse effects. Studies have shown the efficacy of long-acting injectable naltrexone to be comparable to that of buprenorphine if patients are detoxified prior to initiation of therapy; however, patients with active OUD are often not able to complete the week-long period of opioid abstinence needed prior to initiation of naltrexone injections. Although buprenorphine is preferred by many patients and can be prescribed in office-based settings, there remains a paucity of physicians certified to prescribe it. CONCLUSION: Buprenorphine has become the medication of choice for many patients with OUD, but its use is limited by the low number of physicians certified to prescribe the agent. Other agents studied for treatment of OUD include methadone and naltrexone.


Assuntos
Analgésicos Opioides/efeitos adversos , Medicina Baseada em Evidências/métodos , Antagonistas de Entorpecentes/uso terapêutico , Tratamento de Substituição de Opiáceos/métodos , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Buprenorfina/uso terapêutico , Prescrições de Medicamentos , Humanos , Metadona/uso terapêutico , Naltrexona/uso terapêutico , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Transtornos Relacionados ao Uso de Opioides/etiologia
3.
Int J Pharm Pract ; 27(3): 279-285, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30536468

RESUMO

OBJECTIVE: To compare pharmacist-led prescribing changes and associated 30-day revisit rates across different regimens for patients discharged from an emergency department (ED) with a diagnosis of community-acquired pneumonia (CAP). METHODS: An observational, retrospective cohort analysis was conducted of patients who were discharged from an ED over a 4-year period with a diagnosis of CAP. Patient demographics, clinical characteristics, antibiotic selection and comorbidity and condition severity scores were collected for two cohorts: 2012-13 (before protocol change) and 2014-15 (post-protocol change). During January 2014, a pharmacist-led protocol change with prescriber education was implemented to better align ED treatment practices with clinical practice guidelines. The primary endpoint was the change in prescribing practices across the two cohorts. KEY FINDINGS: A total of 741 patients with CAP were identified, including 411 (55.5%) patients in 2012-13 and 330 (44.5%) in 2014-15. Prescribing of macrolide monotherapy regimens decreased significantly following protocol change (70.1% versus 42.7%; difference: 27.4%, 95% CI: 23.8-31.0%) with a reciprocal increase in macrolide/ß-lactam combination prescribing (6.3-21.8%; difference: 15.5%, 95% CI: 12.9-18.1%). A total of 12.2% of patients who received macrolide/ß-lactam combination treatment revisited a network ED within 30 days due to worsening pneumonia, compared to 8.6% of patients who received macrolide monotherapy treatment (P = NS). CONCLUSIONS: The current study showed a significant increase in antibiotic prescribing compliance following a pharmacist-driven protocol change and education, but no statistical difference in rates of return for macrolide monotherapy versus other regimens.


Assuntos
Antibacterianos/uso terapêutico , Infecções Comunitárias Adquiridas/tratamento farmacológico , Serviço Hospitalar de Emergência/estatística & dados numéricos , Farmacêuticos/estatística & dados numéricos , Pneumonia/tratamento farmacológico , Adulto , Idoso , Prescrições de Medicamentos/estatística & dados numéricos , Quimioterapia Combinada/estatística & dados numéricos , Quimioterapia Combinada/tendências , Feminino , Humanos , Macrolídeos/uso terapêutico , Masculino , Pessoa de Meia-Idade , Readmissão do Paciente/estatística & dados numéricos , Padrões de Prática Médica/estatística & dados numéricos , Estudos Retrospectivos , beta-Lactamas/uso terapêutico
4.
Ann Pharmacother ; : 1060028019897100, 2019 Dec 30.
Artigo em Inglês | MEDLINE | ID: mdl-31888350

RESUMO

Background: A vancomycin target of area under the curve to minimum inhibitory concentration (AUC:MIC) ratio ≥400 is recommended for treatment of methicillin-resistant Staphylococcus aureus (MRSA) bacteremia. Objective: To evaluate vancomycin total daily dose (TDD) achieving trough targets versus a calculated strategy achieving AUC targets based on body mass index (BMI). Methods: A retrospective cohort study was performed within a large hospital network. Patients with MRSA bacteremia were eligible if they received vancomycin with a steady-state trough (15-20 mg/L). Cockcroft-Gault was used to estimate creatinine clearance, calculating vancomycin clearance and AUC. Patients were stratified by BMI (less than/greater than 30 kg/m2). The primary outcome was vancomycin TDD for the trough-based strategy compared with an AUC-dosing strategy. Results: A total of 119 patients were included, including 51 (42.9%) and 68 (57.1%) patients with high- and low-BMI, respectively. The TDD for trough-based dosing (2390.76 ± 1224.59 mg) differed significantly from AUC-based dosing (1985.07 ± 616.18 mg) across the cohort (P = 0.0014). For patients with high BMI, there was a significant difference (P < 0.0001) in TDD between trough (2637.25 ± 1327.89 mg) versus AUC (1918.71 ± 625.89 mg) strategies. No difference in TDD between dosing strategies was observed among low-BMI patients. Across all patients, 46 (38.7%) experienced acute kidney injury (AKI); high-BMI patients experienced higher rates of AKI compared with low-BMI patients (54.9 vs 26.5%; P = 0.002). Conclusions and Relevance: An AUC-based dosing strategy may reduce vancomycin TDD required for MRSA bacteremia compared with trough-based dosing, particularly for patients with higher BMI.

5.
Curr Pharm Teach Learn ; 9(5): 808-812, 2017 09.
Artigo em Inglês | MEDLINE | ID: mdl-29233308

RESUMO

BACKGROUND AND PURPOSE: Student response systems (SRSs) or "clickers" are common tools that lecturers can implement into didactic lectures. Socrative is a convenient and free SRS application that can be downloaded on personal handheld devices and used by faculty and students. It is unknown if students prefer using this application and what advantages or disadvantages can be seen with Socrative's use. PURPOSE: To measure student preference of standard SRS methods compared to Socrative as well as the impact of Socrative use on student engagement during delivery of clinical pharmacy instruction EDUCATIONAL ACTIVITY AND SETTING: Standard SRS and Socrative incorporated lectures were presented to students during an infectious disease module. Students were given a survey at the end of the semester to determine the primary endpoint of preference for each application. The survey used a Likert scale of 1-5, with 1 = strongly disagree and 5= strongly agree. Secondary endpoints included assessing the number of questions asked, participation, and classroom time utilized. FINDINGS: A total of 114 surveys were completed and six were excluded due to discrepancies or reporting bias. A higher mean scoring for classroom facilitation of active learning (4.48 vs. 3.99, p < 0.0001) and student-reported active participation in class (4.45 vs. 3.60, p < 0.0001) was found for Socrative compared to SRSs, respectively. SUMMARY: In comparison with traditional SRS methods, students felt Socrative helped them to more actively participate in class and facilitated a better environment for asking and receiving answers to classroom questions.


Assuntos
Educação em Farmácia/métodos , Percepção , Estudantes de Farmácia/psicologia , Ensino/normas , Doenças Transmissíveis/tratamento farmacológico , Avaliação Educacional/métodos , Humanos , Filosofia , Inquéritos e Questionários
6.
Am J Health Syst Pharm ; 72(2): 121-6, 2015 Jan 15.
Artigo em Inglês | MEDLINE | ID: mdl-25550135

RESUMO

PURPOSE: The differences in free fraction serum valproic acid concentrations between inpatients and outpatients were compared, and factors associated with therapeutic discordance were evaluated. METHODS: This retrospective, single-center, cross-sectional study included patients with both a free and a total valproic acid concentration drawn within 30 minutes of each other between January 7, 2003, and June 1, 2011. Serum valproic acid concentrations were stratified by admission status (inpatient versus outpatient). In the primary analysis, for patients who had multiple paired concentrations drawn, one free valproic acid level and one total valproic acid level (i.e., one pair) were chosen at random for each inpatient. Information regarding patient demographics, laboratory data, and concomitant medication therapy was collected. Single and multivariable logistic regressions were performed to determine the odds of therapeutic discordance. RESULTS: During the study period, inpatient concentrations were measured in 220 patients, and outpatient concentrations were measured in 41 patients. The median total valproic acid concentration in the inpatient group was significantly lower than that in the outpatient group (54 µg/mL versus 83 µg/mL, p < 0.001). The median free fraction of inpatient levels was nearly twice as high as that of outpatient levels (28.8% versus 15.5%, p < 0.001). Levels drawn in inpatients were therapeutically discordant 63% of the time compared to only 19% in outpatients (p < 0.001). Multivariable logistic regression identified low albumin as an independent risk factor for therapeutic discordance. CONCLUSION: The median free fraction of valproic acid was significantly higher in inpatients than in outpatients. Low albumin concentration was a predictor of discordance between free and total valproic acid concentrations.


Assuntos
Pacientes Internados , Pacientes Ambulatoriais , Ácido Valproico/sangue , Adolescente , Adulto , Idoso , Estudos Transversais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Adulto Jovem
7.
Ann Pharmacother ; 47(11): 1440-7, 2013 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-24285761

RESUMO

BACKGROUND: From September 2002 to August 2010, 13 patients who were discharged from the emergency department (ED) were immunized against influenza. This correlates with a time when pharmacists were not permitted to vaccinate patients in New York. OBJECTIVE: The objectives of this study were to determine the feasibility of a pharmacist-based influenza vaccination program in the ED, assess patients' willingness to be vaccinated by a pharmacist, and identify reasons for declination. METHODS: This was a cross-sectional study involving English-speaking patients older than 18 years. The pharmacist vaccinated patients, if they consented. Patients who refused to be vaccinated were asked why they did not want to receive the vaccine and their perception of pharmacists vaccinating patients in the ED. The percentage of patients vaccinated; time elements associated with the process of screening, counseling, and vaccinating; and the type and frequency of adverse events were recorded. RESULTS: Of 149 patients, 62 patients (41%) agreed to receive the vaccine, a 4-fold increase from the previous 8 years. The median screening and vaccination time was 8 minutes. Of those not receiving a vaccine in the ED, 74% were willing to receive the influenza vaccine from a pharmacist, and 78% were willing to receive the vaccine in the ED. The most common reason for refusal was perception of low self-risk (43.9%). No adverse events were reported. CONCLUSIONS: A pharmacist-based influenza immunization program is feasible in the ED and has the potential to successfully and safely increase the percentage of adult patients receiving the vaccine.


Assuntos
Centros Médicos Acadêmicos/organização & administração , Serviço Hospitalar de Emergência/organização & administração , Programas de Imunização/organização & administração , Influenza Humana/prevenção & controle , Serviço de Farmácia Hospitalar/organização & administração , Vacinação , Centros Médicos Acadêmicos/estatística & dados numéricos , Adolescente , Adulto , Estudos Transversais , Serviço Hospitalar de Emergência/estatística & dados numéricos , Estudos de Viabilidade , Humanos , Programas de Imunização/estatística & dados numéricos , Pessoa de Meia-Idade , New York , Serviço de Farmácia Hospitalar/estatística & dados numéricos , Vacinação/estatística & dados numéricos , Adulto Jovem
9.
Rev. psiquiatr. Rio Gd. Sul ; 18(supl): 79-82, ago. 1996.
Artigo em Português | LILACS | ID: lil-181814

RESUMO

O presente trabalho descreve um panorama geral das correntes psicanalíticas da atualidade, particularmente do movimento psicanalítico na França. Após mencionar brevemente as diversas instituiçöes psicanalíticas francesas e seus principais autores, o artigo detem-se mais demoradamente em Lacan e sua Escola Estruturalista


Assuntos
Psicanálise/história , Teoria Psicanalítica
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