Pharmacist Hypertension Management Quality Review at an Ambulatory Care Clinic

Background: A reduction of 10 mm Hg in systolic blood pressure (SBP) significantly decreases the risk of major cardiovascular disease events. Pharmacists’ management of blood pressure may assist with this reduction. Objective: Assess the impact of pharmacist management of hypertension via a collaborative practice agreement with physicians in an ambulatory care clinic. Methods: The first phase of this study was a retrospective chart review of physician/nurse hypertension visits from October 2019 to August 2020. The second prospective phase consisted of pharmacist managed hypertension visits from December 2020 to January 2021. The primary outcome was the change in SBP from the beginning to the end of the study period in the prospective group. Secondary outcomes included the proportion of patients achieving their blood pressure goal and the proportion of patients adherent to all antihypertensive medications at their follow-up visits in both groups. This study was institutional review board approved. Results: Forty-seven patients were included and analyzed (24 in the retrospective group and 23 in the prospective group). Patients in the prospective group had an average SBP lowering of 10.83 mm Hg ( P = .0035). Thirteen patients (56.5%) met their blood pressure goal of <130/80 mm Hg in the prospective group, compared to 5 patients (20.8%) in the retrospective group ( P = .012). One adverse event occurred during this study. Limitations included small sample size and short duration of study. Conclusion: Patients had an average SBP lowering of >10 mm Hg. More patients reached a goal blood pressure of <130/80 mm Hg when managed by pharmacists.

Evaluation of Cumulative Effect of Standard Triple Immunosuppression on Prevention of De Novo Donor Specific Antibodies (dnDSA) Production in Children after Kidney Transplantation—A Retrospective and Prospective Study

De novo Donor Specific Antibodies (dnDSA) are associated with inferior graft outcomes. Standard immunosuppression is expected to prevent dnDSA production in low-risk patients. We have evaluated a cumulative effect of a triple immunosuppression (CNI/MMF/Pred), as well as TAC concentration and coefficient of variation on the incidence of dnDSA production. Overall, 67 transplanted patients were evaluated in retrospective (dnDSA for-cause; n = 29) and prospective (dnDSA by protocol; n = 38) groups. In the retrospective group, the eGFR value at first dnDSA detection (median interval—4.0 years post-transplant) was 41 mL/min/1.73 m2; 55% of patients presented biopsy-proven cAMR, and 41% lost the graft within next 2.4 years. Patients from the prospective group presented 97% graft survival and eGFR of 76 mL/min/1.73 m2 at 2 years follow-up, an overall incidence of 21% of dnDSA and 18% of acute (T cell) rejection. None of the patients from the prospective group developed cAMR. Median value of Vasudev score within 2 years of follow-up was not significantly higher in dsDSA negative patients, while median value of TAC C0 > 1–24 months post-transplant was 7.9 in dnDSA negative vs. 7.1 ng/mL in dnDSA positive patients (p = 0.008). Conclusion: dnDSA-negative patients presented a higher exposure to tacrolimus, while not to the combined immunosuppression.

53. Optimizing Transitions of Care Antimicrobial Prescribing at a Community Teaching Hospital

Background Antimicrobial stewardship integral to patient care. Institutions with stewardship decrease antibiotic use, cost, and antibiotic-associated infections. However, few efforts have been formally made to address discharge antimicrobial prescribing, even though many patients started on antibiotic therapy in the hospital are prescribed oral antibiotics to complete their regimens. Methods This was an IRB approved, quasi-experimental, pre-post study. Patients were included if they were &gt;18 years and were discharged from the hospital with an oral antibiotic prescription. Patients discharged against medical advice, prescribed indefinite prophylactic antimicrobial therapy for legitimate reasons, or discharged to a skilled nursing facility were excluded. The retrospective group evaluated a random sample of patients discharged in 2/2020. The prospective group included patients discharged between 1/2021 – 6/2021. In the prospective group, a clinical pharmacist assessed the indication for antibiotics and pended discharge antibiotic prescriptions for physician review. Antibiotic choice and duration of therapy were based on local and national guidelines. Patient Screening for Inclusion and Exclusion Breakdown of patients screened, included, and excluded for study Results 86 (53.1%) of 162 retrospective patients from 2/2020 prior to implementation of the program demonstrated were discharged on inappropriate antimicrobial therapy with excessive duration being the principal driver for inappropriateness. In the prospective group of 64 patients, the rate of patients discharged on inappropriate antibiotics decreased to 28.1% (p=0.001). The duration of inappropriate therapy decreased from a mean of 4.6 days to 2.7 days (p=0.001). 45 (70.3%) of 64 prospective pharmacist’s interventions were accepted by providers. Study Outcomes Outcomes including overall appropriate prescribing, appropriate duration, spectrum, frequency, and dose, as well as days of inappropriate therapy Conclusion Literature demonstrates that prospective evaluation of discharge antibiotics by a clinical pharmacist is effective in improving appropriateness of discharge antibiotic prescriptions, optimizing duration of outpatient antibiotics as well as reducing unnecessarily broad-spectrum therapy. The prospective results from this study demonstrate that this innovative approach can improve outpatient oral antibiotic prescribing and provide a framework for other institutions to implement similar programs. Disclosures All Authors: No reported disclosures

Possibilities of non-operative and minimally invasive organ-preserving spleen injuries management in blunt abdominal injuries in adults

The Objective was to assess and improve the treatment results of victims with spleen injury in blunt abdominal trauma by using high-tech minimally invasive methods of diagnosis and treatment.Methods and materials. The article analyzed the results of treatment of 86 patients with isolated and combined blunt spleen injuries who received conventional surgery, and 52 similar patients who were treated in accordance with the new algorithm. This algorithm included conventional splenectomy for unstable hemodynamics and non-operative and minimally invasive management for stable hemodynamics after MSCT. In the absence of CT signs of ongoing bleeding, non-operative management was performed, if ongoing bleeding signs were detected, angiography with selective angioembolization was performed.Results. In both groups, most of the victims with blunt spleen injury were admitted to the trauma center after traffic accidents and catatraumas. There were no statistically significant differences in the injury severity (ISS, Tsibin scales), and the condition severity (VPH-SP). The tactics of non-operative and minimally invasive management was applied in 31 patients of the prospective group with stable hemodynamics. Non-operative management was performed on 16 patients of the prospective group. Four patients of this group underwent angiography and selective embolization of the branches of the splenic artery. In the retrospective group, there was a greater number of local complications compared to the prospective group (p=0.006). The decrease in the number of visceral and generalized complications was statistically insignificant (p>0.05). In the retrospective group, 21 victims died. Of these, 12 patients died from severe combined trauma and massive blood loss during the first 24 hours. In the prospective group, the total number of deaths was 10 patients. Of these, 6 died from polytrauma with acute massive blood loss, 1 – from severe traumatic brain injury, 1 – from PE, 2 – from sepsis. In the prospective group, among the patients with stable hemodynamics who had conservative treatment of abdominal trauma, 2 deaths were observed in the long-term period due to severe traumatic brain injury and PE.Conclusion. Organ-preserving management was carried out in 26 of 52 (50 %) patients, the number of performed diagnostic laparocenteses was reduced by 50.6 %, laparoscopies – by 16.5 %, laparotomies – by 60.7 %, the duration of inpatient treatment of surviving patients was more than for 7 days, mortality – by 5.2 %.

High-resolution esophageal manometry in patients with achalasia

Introduction. At present, high-resolution esophageal manometry is the «gold standard» for the diagnosis of esophageal achalasia, based on the determination of the integrated relaxation pressure of the lower esophageal sphincter, the value of which in the case of achalasia must exceed 15 mm Hg (MMS System). However, in some patients with clinically and radiologically confirmed achalasia, this value is normal. There is no unified view of the cause of this phenomenon. We assumed that low pressure figures may be affected by incorrect installation of the manometric catheter.Methods and materials. This research included 149 patients (61 by retrospective estimating the patients data and 88 new patients) with achalasia established during the period from January 2017 to March 2020. When it was impossible to localize the lower esophageal sphincter and take correct measurements during high-resolution manometry in new patients, the X-rays or upper endoscopy was performed to control the manometric catheter placement. If its’ placement was incorrect and the integrated relaxation pressure level was lower than 15 mmHg, repeated high-resolution manometry was performed with the over-the-guidewire manometric catheter placing.Results. In 36 patients of both groups (24.2 %), the manometric data did not correspond to esophageal achalasia; in the prospective group, 12 out of the 19 patients had incorrect manometric data due to inability to visualize lower esophageal sphincter. In the prospective group, the manometric catheter was reinstalled by a guidewire, which allowed visualizing the signs of the lower esophageal sphincter in all cases, and in 15 out of 19 patients (79 %), the integrated relaxation pressure of the lower esophageal sphincter was more than 15 mm Hg.Conclusions. In some cases, the over-the-guidewire installing makes it possible to pass catheter through the lower esophageal sphincter correctly, visualize the lower esophageal sphincter during the high-resolution manometry examination and obtain true pressure values.

Long-term stability of Onyx: is there any indication for repeated angiography after dural arteriovenous fistula embolization?

OBJECTIVE The natural course of dural arteriovenous fistulas (DAVFs) is unfavorable. Transarterial embolization with Onyx is currently the therapeutic method of choice, although the long-term stability of Onyx has been questioned. The literature reports a significant difference in the recurrence rate after complete DAVF occlusion and lacks larger series with long-term follow-up. The authors present the largest series to date with a long-term follow-up to determine the stability of Onyx, prospectively comparing magnetic resonance angiography (MRA) and digital subtraction angiography (DSA) as follow-up diagnostic methods. METHODS Demographics, clinical symptomatology, length of follow-up, diagnostic methods, and angiographic findings of DAVFs were recorded and retrospectively evaluated in 112 patients. A prospective group of 15 patients with more than 5 years of follow-up after complete DAVF occlusion was established. All 15 patients in the prospective group underwent a clinical examination and MRA; 10 of these patients also underwent DSA. The recurrences and the correlation between the two diagnostic methods were evaluated. RESULTS Among the 112 patients, 71 were men and 41 were women, with an average age of 60 years. Intracranial hemorrhage (40%) was the most common clinical presentation of DAVF. At the last follow-up, 73% of the patients experienced clinical improvement, 21% remained unchanged, and 6% worsened. Overall, 87.5% of the DAVFs were occluded entirely with endovascular treatment, and 93% of the DAVFs were classified as cured at the last follow-up (i.e., completely embolized DAVFs and DAVFs that thrombosed spontaneously or after Gamma Knife surgery). Two recurrences of DAVFs were recorded in the entire series. Both were first diagnosed by MRA and confirmed with DSA. The mean follow-up was 27.7 months. In the prospective group, a small asymptomatic recurrence was diagnosed. The mean follow-up of the prospective group was 96 months. CONCLUSIONS Onyx is a stable embolic material, although recurrence of seemingly completely occluded DAVFs may develop because of postembolization hemodynamic changes that accentuate primarily graphically absent residual fistula. These residuals can be diagnosed with MRA at follow-up. The authors’ data suggest that MRA could be sufficient as the follow-up diagnostic method after complete DAVF occlusion with Onyx. However, larger prospective studies on this topic are needed.

POS0868 THE FORMULA TO PREDICT TACROLIMUS CONCENTRATION ACCORDING TO GENOTYPING OF CYP3A5 IS USEFUL FOR EFFECTIVE TREATMENT IN INTERSTITIAL LUNG DISEASE WITH DERMATOMYOSITIS

Background:Tacrolimus (TAC), an immunosuppressant, can be used in second-line maintenance therapy for interstitial lung disease (ILD) in patients with dermatomyositis (DM) [1]. Although some studies reported the clinical efficacy of initial high-trough levels of TAC in combination with GC and IVCY in induction therapy for severe DM-ILD [2], there have been no useful clinical tools for deciding suitable initial dose of TAC. Genotype of polymorphisms in cytochrome P450 (CYP) 3A5 enzyme was reported to play an important role in pharmacokinetics of TAC [3], and we made a formula for deciding initial dose of TAC according to CYP3A5 genotypes in our previous study.Objectives:In our previous study (retrospective study), we set the target trough according to the severity for nine DM-ILD patients, six of whom were CYP3A5 *3/*3 and investigated the dose of TAC that could attain the trough using their CYP3A5 genootyping. Using these results, we developed a formula for deciding initial daily dose of TAC (target trough*weight / [(151.1, if CYP3A5 *3/*3) or (86.5, if CYP3A5 *1 allele)]). In this study, we prospectively examined the usefulness and accuracy of this formula.Methods:We introduced TAC for new six DM-ILD patients who visited our hospital between November 2019 and May 2020 (prospective study). The starting dose of TAC was decided by using the formula. We assessed the association between predicted and observed trough concentration of TAC at first measurement date (from day 2 to day4), using linear regression analysis. We also assessed the days for attaining the target trough concentration between the patients using the formula (prospective group) and six patients with CYP3A5 *3/*3 (retrospective group).Results:CYP3A5 genotype of all six DM-ILD patients were *3/*3 and underwent the TAC treatment by using the formula. The predicted and observed trough concentration of first measurement date were significantly correlated in the patients (r 2= 0.897, p=0.0041) (Fig.1). Compared with our retrospective study, target trough was more quickly attained in patients of the prospective study (Fig.2).Conclusion:The formula which we made for attainment target trough concentration based on CYP3A5 genotype was useful for deciding the starting dose of TAC. We also showed that we could attain the target trough concentration at early stage of initial treatment by using the formula.References:[1]Oddis CV and Aggarwal R. Nat Rev Rheumatol 2018;14(5):279-89.[2]Suzuka T et al. Int J Rheum dis 2019;22: 303-13.[3]Y. Muraki et al. Exp Ther Med 2018;15:532-38.Figure 1.Correlation of predicted and observed tacrolimus trough concentration at first measurement in the prospective studyFigure 2.Days to attain the target trough concentration of tacrolimus in the prospective group and the retrospective groupDisclosure of Interests:None declared

Prolonged intravenous infusion therapy of lidocaine in treatment of chronic venous insufficiency in C6 and C6R stage

Chronic venous disease (CEAP stage C2 - C3) is found in approximately 25% of the population, and trophic skin changes, including leg ulcers (C4 - C6), up to 5%.The aim of the work was to develop an effective dose and concentration of lidocaine and the optimal method of its administration for the treatment of chronic venous disease in the stage of active trophic wounds and accelerate the healing process.Materials and methods. The results of treatment of 97 patients with chronic venous insufficiency in stage C6 and C6r were evaluated, which were divided into two clinical groups: retrospective (n= 50) in which classical surgical treatment was performed (Coquette veins ligation, Narat phlebectomy) and prospective (n=47) in which classical surgical intervention (crossectomy + Bebcock and / or Narat phlebectomy) was used in combination with the prolonged intravenous infusion therapy of lidocaine.Research results and their discussion. In the period of 3-6 months, complete healing of trophic wounds was observed in the prospective group. At the same time, in 25.53% of patients in this group complete healing was observed up to 7 days. Whereas, in patients of the retrospective group, this was observed between 6-9 months. In addition, the rate of decrease in the area of trophic wound for the first month in the prospective group was 23.72% higher than in the retrospective group (р˂0.05). We did not observe a recurrence of a trophic wound in the follow-up period up to 1 year in the prospective group.

Safety and medical cost effectiveness of preventive treatment of children with latent tuberculosis infection

The objective: to assess the safety and medical cost effectiveness of different LTBI treatment regimens in children and adolescents.Subjects and methods. 205 children in the age from 6 to 17 years old with latent tuberculosis infection were included in the study: The main (prospective) group included 31 children who were treated with isoniazid and rifapentine (HRpt). The comparison (retrospective) group included 174 pediatric patients: 128 patients received the regimen consisting of isoniazid and pyrazinamide (HZ), 14 patients received isoniazid and rifampicin (HR), and 32 patients received isoniazid and ethambutol (HE).Results. When using the HRpt regimen, the treatment was well tolerated; adverse events (eosinophilia) were documented in 6.5% of children. The medications were taken once a week and it allowed reducing the frequency of treatment interruptions for non-medical reasons. The overall cost per patient was lower with the HRpt regimen than with the other three LTBI treatment regimens.

Massive obstetric bleeding: optimization of total hysterectomy surgery technique and conservative treatment

Objective. Reducing maternal mortality during massive obstetric bleeding (MOB) through optimizing total hysterectomy technique and improving the quality of infusion therapy. Materials and methods. The analysis and evaluation of the results of MOB treatment in a comparative aspect were carried out in retrospective and prospective groups from 2014 to 2019 in Urgench perinatal center and three maternity complexes of Khorezm region, Uzbekistan. The retrospective group included 72 pregnant women with an average blood loss of 2450.0±80.0 ml, while the prospective group included 78 pregnant women with an average blood loss of 2530.0±70.0 ml. Results and discussion. 1,419 (6.2 %) cases out of 22,896 deliveries in the retrospective group were accompanied by abnormal blood loss, and the MOB frequency of more than 1500.0 ml was determined in 0.3 % of all deliveries. 5 (62.5 %) of 8 cases of maternal mortality were directly related to MOB. In the retrospective group, a total hysterectomy was performed using traditional method for MOB, with an interoperable blood loss of 860.0±110.0 (p<0.05). Qualitative and quantitative composition of infusion therapy in this group averaged: saline sodium chloride solution 4350,0±350.0; Heloplasm (INN) -500,0±100,0; hydroxyethylated starch 1800.0±150.0; Rheosorbilact 400.0±50.0 and fresh frozen plasma (FFP) 1650.0±110.0. Optimized version of total hysterectomy in a prospective group differs from the traditional with one “hemostatic suture” imposed on all three formations (fallopian tube, own and round ligament). Imposed first in the distal, then proximal, and on descending and ascending departments a. uterinae during the operation. The optimized version of total hysterectomy resulted in reduction of interoperative blood loss by an average of 340.0±60.0 ml in MOB and reduction of operation time by 22.0±4.0 min, thereby improving the outcome of the operation. Amount of saline sodium chloride solution was injected in average by 1900.0; Refortan by 600.0; FFP by 230.0 less, and INN, Gelofuzin by 500.0 and Rheosorbilact by 400.0 more in the prospective group than in the retrospective group. Conclusions. Optimized version of total hysterectomy with improved qualitative and quantitative composition of infusion therapy for MOB contributed to reduction of maternal mortality by 19.7 % in the prospective group compared to the retrospective group.