All posts by sikula_web@centrum.cz

Looking Good for That High School Reunion


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Finding coolsculpting in Austin Texas 78746 helped solved my conundrum quite nicely. I received the dreaded notice that my 30 year high school reunion was coming up. Now I could just skip the reunion and go on with my life, but I hadn’t gone to any of the previous ones and I was really interested in seeing how everyone turned out. I especially wanted to see a few specific people who I have been in constant contact online, but haven’t seen for some time. They’re old friends and it would be fun to meet up and rehash the old days.

My problem with going to this event is that I’ve really put on the pounds in the last five years or so. I think it has more to do with age than any problems with exercise or diet. Continue reading

Getting the Drugs You Need Without a Prescription

Apoteket online is a boon for someone like me, someone who doesn’t enjoy going to doctors when I know exactly what is wrong with me. Obviously, a serious problem, or a life threatening one, means you must go in and submit to a doctor poking and prodding you in order to find out what is wrong and fix it immediately. But when you are suffering from erectile dysfunction and you know your heart is healthy, why would you go to a doctor and pay big bucks out of pocket when you know all he will do is write a prescription for the little blue pill.

I don’t see the point in paying out of the nose for something like this. It’s ridiculous. That is why I am a big believer in doing your own research and finding a way to get around that doctor visit. The internet is a great way to self-diagnose your problems, but it is also a great place to find sites that will sell you pharmaceutical drugs without the prescription. Even better is that it is perfectly legal. Continue reading

Trying a New Medication for My Dysfunction

I’ve been having trouble in the bedroom for several years now. I’ve always just sort of dealt with it quietly, without seeking out help or medical advice. I finally decided to do something about it, so I went to my doctor. I told him about everything that’s been happening and how I’ve been having trouble with sexual dysfunction. I thought he was going to recommend an expensive solution to me, but instead he recommended Kamagra in Australia. I asked him to tell me more about that, because I hadn’t heard of it before. It turns out that this drug is just like a competing medication, but it’s much cheaper for consumers to purchase. I was definitely interested in what he had to say.

He told me more about how a person just like me who is in very good health shouldn’t have any side effects from taking this medication. He was sure that it would do me much good, and help me with my problem. Continue reading

Development of a bedside scoring system for predicting a first recurrence of Clostridium difficile-associated diarrhea [Clinical Research Reports]

Purpose

A scoring system for identifying patients at high or low risk for recurrent Clostridium difficile–associated diarrhea (CDAD) is described.

Methods

A retrospective cohort study was performed using data on adults with CDAD admitted to a 3-hospital system from 2009 to 2014. The primary endpoint was the rate of recurrent CDAD within 60 days of clinical cure of CDAD. Risk factors for CDAD recurrence were identified, and a risk prediction tool was developed using multivariate logistic regression.

Results

The CDAD cure rate in the study cohort (n = 340) was 92.3%; the 60-day recurrence rate was 16.9%. Five factors were significantly associated with high recurrence risk: presence of CDAD at admission, body temperature of >37.8 °C at admission, leukocytosis, nosocomial CDAD, and abdominal distention on CDAD presentation. From that information a risk prediction tool, the CDAD "recurrence score," was developed (1 point is assigned for each factor present, for a maximum score of 5). Validation testing of the recurrence score indicated an area under the receiver operating characteristic curve of 0.72 (95% confidence interval, 0.65–0.80). A score of ≥2 had a negative predictive value of 91%, while a score of ≥4 had a positive predictive value of 70%.

Conclusion

If externally validated in future studies, a tool for predicting the risk of recurrent CDAD using data readily available at the time of presentation could allow clinicians to identify patients at high risk for recurrence, address modifiable risk factors, and select tailored treatments to improve patient outcomes.

Analysis of variations in the display of drug names in computerized prescriber-order-entry systems [Descriptive Reports]

Purpose

The variations in how drug names are displayed in computerized prescriber-order-entry (CPOE) systems were analyzed to determine their contribution to potential medication errors.

Methods

A diverse set of 10 inpatient and outpatient CPOE system vendors and self-developed CPOE systems in 6 U.S. healthcare institutions was evaluated. A team of pharmacists, physicians, patient-safety experts, and informatics experts created a CPOE assessment tool to standardize the assessment of CPOE features across the systems studied. Hypothetical scenarios were conducted with test patients to study the medication ordering workflow and ways in which medications were displayed in each system. Brand versus generic drug name ordering was studied at 1 large outpatient system to understand why prescribers ordered both brand and generic forms of the same drug.

Results

Widespread variations in the display of drug names were observed both within and across the 6 study sites and 10 systems, including the inconsistent display of brand and generic names. Some displayed drugs differently even on the same screen. Combination products were often displayed inconsistently, and some systems required prescribers to know the first drug listed in the combination in order for the correct product to appear in a search. It also appeared that prescribers may have prescribed both brand and generic forms of the same medication, creating the potential for drug duplication errors.

Conclusion

A review of 10 CPOE systems revealed that medication names were displayed inconsistently, which can result in confusion or errors in reviewing, selecting, and ordering medications.

Automated detection of look-alike/sound-alike medication errors [Notes]

Purpose

The development and evaluation of an algorithm for detecting potential medication errors due to look-alike/sound-alike (LASA) drug names are described.

Summary

A computer algorithm that detects potential LASA errors by analyzing medication orders and diagnostic claims data was developed. The algorithm flags a potential error when (1) a medication order is not justified by a diagnosis documented in the patient’s record, (2) another medication whose orthographic similarity to the index drug exceeds a specified threshold exists, and (3) the latter drug has an indication that matches an active documented diagnosis. A review of medication orders and diagnostic claims at a large health system identified cases in which cycloserine was ordered but cyclosporine was the intended treatment. Subsequent review of all cycloserine orders over a 7-year period indicated that 11 of 16 orders were erroneous, prompting placement of an alert regarding the potential for LASA errors involving cycloserine and cyclosporine in the electronic order-entry system. Automated detection and confirmation of LASA errors via chart review can be used retrospectively to identify problematic pairs of drug names and to assess associated error rates within a healthcare system. The same techniques can be used to prevent errors in real time through indication alerts if accurate diagnostic information is available at the time of order entry.

Conclusion

Automated methods involving the use of medication orders, diagnostic claims, and indications can be used to detect and prevent LASA errors.

Standardizing concentrations of adult drug infusions in Indiana [Descriptive Reports]

Purpose

A multidisciplinary, consensus-driven initiative to promote the use of standardized medication concentrations for adult drug infusions across the state of Indiana is described.

Methods

To accomplish development of the Indiana Standard Concentrations of Adult Drug Infusions List ("the Indiana List"), several available lists of i.v. concentrations were compiled, consolidated, and compared. Lists of adult standardized i.v. concentrations were primarily drawn from Indiana regional patient safety coalitions, published literature, and publicly available lists of recommended i.v. concentrations. The standardization project, which expanded initial work completed by the Indianapolis Coalition for Patient Safety, was conducted in conjunction with Purdue University’s Center for Medication Safety Advancement, the Indiana Hospital Association, and the 11 regional patient safety coalitions across the state.

Results

After a review of 9 existing lists of standard i.v. concentrations, an initial list of 69 concentrations representing a total of 37 medications was derived; 34 of those concentrations were represented on at least 1 of the 3 evaluated Indiana regional patient safety coalition lists. A statewide interdisciplinary work group of representatives of regional patient safety coalitions and 9 health systems representing a total of 81 hospitals ranging from academic medical centers to critical access hospitals assembled to develop consensus on a final list of standard medication concentrations for adult i.v. infusions.

Conclusion

A final list of 28 concentrations of 26 medications was identified for the recommended Indiana List by an interdisciplinary work group. A checklist of considerations for implementation was also developed.

Successful use of laboratory monitoring to facilitate an invasive procedure for a patient treated with dabigatran [Case Report]

Purpose

A case in which novel and traditional laboratory markers were successfully used to determine surgical intervention timing in an elderly patient receiving dabigatran for atrial fibrillation is reported.

Summary

An 86-year-old woman who was taking dabigatran for atrial fibrillation suffered a right femoral neck fracture requiring surgical intervention. Dabigatran was withheld once the patient was admitted to the hospital, and the pharmacy inpatient anticoagulation management team was consulted for guidance on determining appropriate scheduling of surgical intervention with regard to the time since her most recent dabigatran dose to minimize bleeding complications. The team recommended delaying surgery, as dabigatran clearance would likely take 3–5 days and an ecarin chromogenic assay (ECA) dabigatran value of <50 ng/mL would be desirable before surgical intervention. During her hospitalization, novel and traditional laboratory markers for dabigatran, such as ECA value, activated partial thromboplastin time, thrombin time, and prothrombin time, were measured and followed closely to determine the best time to perform surgical intervention to minimize bleeding risk. Renal dysfunction likely delayed dabigatran elimination in the patient and may have led to potential accumulation of dabigatran. The patient ultimately had to wait 5 days after the last dabigatran dose for surgical intervention.

Conclusion

Coagulation assay monitoring for dabigatran, with emphasis on an ECA dabigatran concentration of <50 ng/mL, was used to assess safety regarding bleeding risk before a nonemergent surgical procedure in an 86-year-old woman with a right femoral neck fracture.

Impact of an antimicrobial stewardship initiative on time to administration of empirical antibiotic therapy in hospitalized patients with bacteremia [Notes]

Purpose

The impact of an antimicrobial stewardship initiative on time to first antibiotic dose and clinical outcomes in bacteremic patients was evaluated.

Methods

A single-center, retrospective study was conducted for adult inpatients who received antibiotics before and after implementation of a rapid administration of antimicrobials by an infectious diseases specialist (RAIDS) protocol. Patients admitted to an inpatient service from June to October 2011 (pre-RAIDS protocol) and from December 2011 to February 2012 (post-RAIDS protocol) were eligible for inclusion if (1) they were age 18 years or older, (2) their infection occurred two or more days after hospital admission, and (3) they had a blood culture growing an organism other than common skin contaminants (i.e., coagulase-negative staphylococci, Bacillus species). The primary outcome was the time to the first antibiotic dose (TFAD), defined as the time that elapsed from a positive blood culture result to administration of the first empirical antimicrobial dose.

Results

A total of 111 bacteremic patients were included in the analysis. Implementation of the RAIDS protocol led to significantly faster antibiotic order entry, verification, and administration of empirical antibiotics in patients with bacteremia. The median TFAD was approximately 8 hours faster in the post-RAIDS group than in the pre-RAIDS group (9:09 hr:min versus 1:23 hr:min, p < 0.001). Patients in the post-RAIDS group had a significant reduction in infection-related mortality (p = 0.047), though all-cause 30-day mortality was similar.

Conclusion

Early notification of an infectious diseases pharmacist about positive blood cultures using the RAIDS protocol led to increased appropriateness of empirical drug selection and a dramatic reduction in the administration of antibiotics and was associated with decreased infection-related mortality.