Abstract Background Infectious Diseases (ID) consult services, typically led by ID physicians, benefit significantly from the support of ID pharmacists. These pharmacists, with specialized training in ID pharmacotherapy through post-graduate residencies or fellowships, play a crucial role in advising on the selection, dosing, duration, and monitoring of antimicrobials. While the contribution of ID pharmacists to antimicrobial stewardship programs is well described, their impact in supporting ID consult services remains underdocumented. This report explores the clinical inquiries made by ID physicians and advanced practice providers (APP) to ID pharmacists on consult services, detailing how these interactions influence patient treatment and monitoring plans.Figure 1ID Pharmacist Curbside Question Categories (Categories with 2+ Submissions) Methods Ten ID residency- or fellowship-trained clinical pharmacists practicing in various practice settings documented questions they received from ID providers (attendings, fellows, and APPs) for patients on their respective ID consult service over a 6-month period. The impact of the conversations was documented if the pharmacist recommending a new drug, dose, duration, or monitoring plan which resulted in a change in care. Additional information was captured on the time spent answering questions, category of question, and pertinent microbiology or organism phenotype to describe areas of highest need for ID pharmacist support.Figure 2Questions Leading to Therapeutic Change Results Over the first three months of documentation, 782 questions were asked by ID providers to ID pharmacists. Total direct time spent answering questions was 8,937 minutes. The top three question categories were gram-negative resistance, antifungal therapy, and antimicrobial allergies. Seven hundred and three (89.8%) questions resulted in a clinical change in management as recommended by the ID pharmacist. The most common clinical change category was recommending a new dose which occurred in 57.4% of questions followed by new antimicrobial 50.4%, new monitoring plan 24.2% and new duration of therapy 8.8%. Conclusion ID pharmacists offer critical support that frequently changes management on ID consult services. Integrating their expertise into a multidisciplinary ID team is essential for achieving optimal patient safety and treatment outcomes. Disclosures Wesley D. Kufel, Pharm.D., BCPS, BCIDP, Merck & Co.: Grant/Research Support|Shionogi, Inc: Grant/Research Support Jennifer Ross, PharmD, BCIDP, Shionogi Inc.: Advisor/Consultant Frank Tverdek, PharmD, Merck: Advisor/Consultant
Smith, Ethan A., M.S., Autumn 2006 Environmental Studies An Evaluation of Interactions between the Imported Cabbage Worm (Pieris rapae), an Assemblage of Six Arthropod Predators, and Two Insecticides Within a Minimum-Till Brussels Sprouts Agroecosystem Chairperson: Neva Hassanein Agricultural systems are being re-engineered with hedgerows, living mulches, or minimum tillage activities in hopes of retaining populations of beneficial, predatory insects that may decrease the need for pesticide use. The purpose of this research was twofold. First, this on-farm research assessed the population and activity of six beneficial arthropod predators the carabid beetle (Carabidae: Coleoptera), minute pirate bug (Orius spp.: Hemiptera), nabid bug (Nabis spp.: Hemiptera), lady beetle larvae (family Coccinellidae: Coleoptera), syrphid fly larvae (Syrphidae: Diptera) and spiders (Araneae) and one crop pest the imported cabbage worm (Pieris rapae: Lepidoptera) within a no-till Brussels sprouts (Brassica oleracea, gemmifera group) and red clover (Trifolium pratense) living-mulch system. Second, using two common organic insecticides Bacillus thuringiensis var. kurstaki (Bt) and a pyrethrin/rotenone blend – this research assessed the capacity of these aforementioned predatory or parasitic arthropods to control the P. rapae population and crop damage through biological (as compared to chemical) means. Field investigations for predators/pests involved weekly sweep-net sampling, pitfall trap installation, and direct plant examination. Insecticides were applied as a bi-weekly “calendar” application (pyrethrin/rotenone) or as a pest-density “threshold” dependant application (Bt). Generally, pest control and damage prevention were more successful in Bt treatments than in pyrethrin/rotenone treatments. Bt pesticides had no significant effect on any arthropods sampled, while the pyrethrin/rotenone insecticide appeared to significantly reduce the activity or population levels of all arthropods sampled. P. rapae activity and crop damage was lowest in Bt treated plots, moderate in control plots (no pesticides were applied, yet natural levels of arthropods were present) , and highest in plots treated with pyrethrin/rotenone sprays. Preliminary results indicate that Bt treatments worked as an additive control measure, which then augmented natural predator populations. The increased pest activity and damage in pyrethrin/rotenone treated plots which coincided with reduced “beneficial” insect numbers as compared to the other treatments may indicate a disruption of the multiple-arthropod predator assemblage that kept pest impacts lower in the “control” plots.
Preliminary data from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pneumonia patients indicate that a cytokine storm may increase morbidity and mortality. Tocilizumab (anti-IL-6R) is approved by the Food and Drug Administration for treatment of cytokine storm associated with chimeric antigen receptor T-cell therapy. Here we examined compassionate use of tocilizumab in patients with SARS-CoV-2 pneumonia.
The purpose of this article is to provide a comprehensive review of the clinical and cross-sectional imaging features of a variety of acute and chronic gallbladder inflammatory diseases.Inflammatory gallbladder diseases are a common source of abdominal pain and cause considerable morbidity and mortality. Although acute uncomplicated cholecystitis and chronic cholecystitis are frequently encountered, numerous other gallbladder inflammatory conditions may also occur that can be readily diagnosed by cross-sectional imaging.
As an 886-bed tertiary care hospital with both teaching and private physician groups, Cedars-Sinai Medical Center has a unique opportunity to incorporate antimicrobial stewardship pharmacist (ASP) rounds with both a general medicine teaching service (TS) as well as a non-teaching hospitalist group (NTH). The impact of ASP rounds on antimicrobial (ABX) utilization and notable differences in clinical outcomes associated with both rounding models were evaluated. An ASP was incorporated into existing teaching rounds for TS and disposition planning rounds for NTH. ASP-TS and ASP-NTH rounds both occurred once daily on weekdays with facetime of 3-4 hours per day for TS and 0.5-1 hour per day for NTH. Metrics included ASP recommendations and acceptance rates, total ASP time, ABX utilization, and clinical outcomes. Chi-squared and the Student’s t-test were used as appropriate. Between November 2016 to April 2017, ASPs reviewed 3184 NTH patients and 1322 TS patients. More opportunities for ASP intervention were identified with TS (40% vs. 26%, P < 0.001). Overall recommendation acceptance rates were higher for TS compared with NTH (95% vs. 79%, P < 0.001). Total recommendations identified per ASP-hour were higher for NTH vs. TS (1.76 vs. 0.93). ASP recommendations targeting ABX de-escalation, unnecessary use of fluoroquinolones, and treatment of asymptomatic bacteriuria were similar for both groups. Compared with baseline rates, ASP rounds were associated with a significant reduction (-6%, P = 0.01) in ABX days-of-therapy (DOT) for NTH but not for TS (-1%, P = 0.6). Anti-Pseudomonal (PSA) DOT significantly declined in both NTH (-11%, P = 0.04) and TS (-22%, P = 0.02). No significant changes in mortality, length of stay, and 30-day readmission rates were observed for either group. ASP rounds identified ample opportunities for improvement in ABX utilization in both NTH and TS models. Rounds were associated with a significant reduction in anti-PSA DOT for both models and a significant reduction in overall ABX DOT for NTH group. Although NTH provided a higher patient volume and allowed for more interventions per ASP-hour compared with the TS model, acceptance rates were lower, which may reflect a shorter amount of time spent on patient discussions. All authors: No reported disclosures.
Background Optimal cancer care requires a multidisciplinary approach. The purpose of the current study was to evaluate the impact of a multidisciplinary tumor board on the treatment plans of children with solid tumors. Procedures The records of 158 consecutive patients discussed at a formal multidisciplinary pediatric tumor board between July 2012 and April 2014 were reviewed. Treatment plans were based on clinical practice guidelines and on current Children's Oncology Group protocols. Alterations in radiologic, pathologic, surgical, and medical interpretations were analyzed to determine the impact on changes in recommendations for clinical management. Results Overall, 55 of 158 children (35%) had alterations in radiologic, pathologic, medical, or surgical interpretation of clinical data following multidisciplinary discussion. Of these, 64% had changes to the initial recommendation for clinical management. Review of imaging studies resulted in interpretation changes in 30 of 158 patients studied (19%), with 12 clinical management changes. Six of 158 patients (3.9%) had changes in pathologic interpretation, with four patients (2.5%) requiring treatment changes. In eight patients (5%), a change in medical management was recommended, while in 11 patients (7%) there were changes in surgical management that were based solely on discussion and not on interpretation of imaging or pathology. Conclusions Formal multidisciplinary review led to alterations in interpretation of clinical data in 35% of patients, and the majority led to changes in recommendations for treatment. Comprehensive multidisciplinary tumor board incorporated into the care of children with cancer provides additional perspectives for families and care providers when delineating optimal treatment plans.
In patients with β-lactam allergies, administration of non-β-lactam surgical prophylaxis is associated with increased risk of infection. Although many patients self-report β-lactam allergies, most are unconfirmed or mislabeled. A quality improvement process, utilizing a structured β-lactam allergy tool, was implemented to improve the utilization of preferred β-lactam surgical prophylaxis.
