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Winchester, VA, United States

Jannuzzi R.G.,Winchester Medical Center
Clinical Journal of Pain

Objectives: Opioid-induced pruritus is a common side effect of opioid treatment in patients with acute pain associated with surgery or childbirth. There are several options available to treat opioid-induced pruritus, including nalbuphine. However, it is not known whether nalbuphine offers greater efficacy in treating pruritus without attenuation of analgesia and an increase in the incidence of adverse outcomes. Methods: A systematic search of studies assessing treatment efficacy of nalbuphine was conducted through Medline, PubMed, Cochrane Library, CINAHL, and ProQuest databases. The primary outcome was reduction of pruritus, whereas the secondary outcomes included analgesia and adverse outcomes. Results: Ten studies that met all inclusion criteria were identified, 9 of which were randomized controlled trials and 1 case report. The incidence of pruritus was higher among patients receiving neuraxial opioids than those with the intravenous route. Nalbuphine provided greater efficacy in treating opioid-induced pruritus when compared with placebo, control, or other pharmacologic agents such as diphenhydramine, naloxone, and propofol. There was no attenuation of analgesia or increase in sedation with low-dose nalbuphine treatment - 25% to 50% of the dose to treat pain, that is, 2.5 to 5 mg versus 10 mg intravenously. Further, nalbuphine was associated with reduction of nausea or vomiting, and reversal of respiratory depression. Conclusions: Nalbuphine is superior in treating opioid-induced pruritus when compared with placebo, control, diphenhydramine, naloxone, or propofol in patients receiving neuraxial opioids for acute pain related to surgery or childbirth. Therefore, it is recommended that nalbuphine should be used as a first-line treatment of opioid-induced pruritus. © 2015 Wolters Kluwer Health, Inc. All rights reserved. Source

Brackbill M.L.,Shenandoah University | Kline V.T.,Winchester Medical Center | Sytsma C.S.,Heart and Vascular Center | Call J.T.,Winchester Cardiology and Vascular Medicine
Journal of Managed Care Pharmacy

BACKGROUND: Chronic aspirin therapy is recommended by the American College of Cardiology/American Heart Association (ACC/AHA) following acute myocardial infarction (AMI) and by the Society of Thoracic Surgeons (STS) following coronary artery bypass graft (CABG). Aspirin therapy at discharge following a hospitalization for AMI or CABG is a common pay-for-performance indicator used by third-party payers and was included as a quality measure in the Centers for Medicare & Medicaid Services (CMS)/Premier Hospital Quality Incentive Demonstration initiated in 2003. A formal prescription for aspirin, such as required for other cardiovascular drugs, could serve as a reminder to all health care providers (doctors, nurses, and pharmacists) to include aspirin on a discharge medication list. OBJECTIVE: To evaluate if an aspirin prescription placed in the patient chart shortly after hospital admission would increase compliance with guidelines for aspirin use at discharge in patients with AMI or CABG. METHODS: This was a single-center prospective pre-intervention to post-intervention comparison study in a 411-bed hospital. Patients admitted during the 3-month period from July through September 2008 with an AMI or undergoing CABG surgery served as the pre-intervention group, and patients admitted during the 3-month period from January through March 2009 were in the post-intervention group. The intervention included multiple educational sessions with clinical staff, conducted both prior to and during the pilot, and blank pre-printed aspirin prescriptions placed in the charts of patients for whom no contraindication to aspirin was present. The blank prescriptions were then completed by the attending physician (or physician extender), and the discharge nurse used the completed aspirin prescription, with other prescriptions and written orders, as a reference when creating the discharge medication list. The primary outcome measure was the percentage of patients who had aspirin documented on the discharge medication list. Differences in compliance rates in the comparison and pilot periods were assessed using the Pearson chi-square test. RESULTS: A total of 458 patients were identified with a CABG procedure and/or an admitting diagnosis of AMI; 447 met inclusion criteria, and 11 were excluded (1 patient in each of the groups had a contraindication to aspirin due to bleeding, and 9 died during hospitalization). The intervention was associated with an increase in the proportion of patients with aspirin documented on the discharge medication list, 266 of 269 patients (98.9%) compared with 169 of 178 patients (94.9%, P = 0.012) in the pre-intervention group. In the subsample of patients with CABG, 54 of 59 (91.5%) patients in the pre-intervention group had aspirin documented on the discharge medication list compared with 100% of 66 patients in the post-intervention group (P = 0.016). In the subsample of patients with AMI, aspirin was documented in 115 of 119 (96.6%) patients in the pre-intervention group versus 200 of 203 (98.5%) in the post-intervention group (P = 0.263). CONCLUSION: A quality improvement initiative that included clinical staff education and placement of aspirin prescriptions in patient charts during the hospital stay was associated with an increase in the proportion of patients who had aspirin documented on the discharge medication list for the overall sample of patients with AMI or CABG and for patients with CABG alone but not for the quality measure for AMI patients. Copyright © 2010, Academy of Managed Care Pharmacy. All rights reserved. Source

Khan E.M.,Winchester Medical Center | Frumkin W.,New Hill | Ng G.A.,Glenfield Hospital | Neelagaru S.,Heart Hospital at Northwest Texas Hospital | And 9 more authors.
Journal of Interventional Cardiac Electrophysiology

Introduction: Amigo™ (Catheter Robotics, Inc., Mount Olive, NJ) remote catheter system (RCS) was designed to provide a simple and relatively inexpensive system for remote catheter manipulation. The purpose of this study was to evaluate the performance and safety of Amigo in mapping the right side of the heart. Methods and results: This non-randomized, prospective clinical trial was conducted at 13 sites (NCT: #01139814). Using the controller, a mapping catheter was moved to eight pre-specified locations in a specific sequence: right ventricular apex, mid-right ventricular septum, right ventricular outflow tract, His-bundle position, coronary sinus ostium, high right atrium, lateral tricuspid annulus, and low lateral right atrium. The pre-specified efficacy endpoint was to achieve 80 % successful navigation to all locations. Time to each location, location accuracy, and quality of contact were confirmed by imaging and specific criteria for electrograms and pacing thresholds. In 181 patients, a total of 1,396 of 1,448 (96 %) locations were successfully mapped with all protocol criteria met (one-sided p value < 0.0001). The median time to move the catheter to a new location was 24 s. The Amigo-related major complication rate was 0 % which was significantly less than the predefined endpoint of 4 % (one-sided p = 0.003). Conclusion: We found the Amigo RCS to be safe and effective for positioning a mapping catheter at sites within the right atrium and ventricle. © 2013 Springer Science+Business Media New York. Source

Wesner A.R.,Shenandoah University | Brackbill M.L.,Shenandoah University | Coyle L.L.,Winchester Medical Center | Kidd R.S.,Shenandoah University
Interdisciplinary Perspectives on Infectious Diseases

Purpose. To determine if the use of a novel vancomycin nomogram predicts dosing regimens that achieve target trough concentrations equal to or more accurate than dosing regimens calculated using traditional pharmacokinetic calculations, evaluate the incidence of subtherapeutic and supratherapeutic troughs, and assess pharmacist's impressions of the nomogram. Methods. Prospective, open-label study in 473 patients who had a new order for vancomycin and were >18 years of age and ≤120 kg. Patients were randomized to the active group, dosed using the nomogram, or to the control group, dosed using traditional pharmacokinetic calculations already in place at our institution. Results. Patients dosed via nomogram were within the appropriate trough range in 44% of cases compared to 33% in the control group (P = 0.014). Vancomycin troughs less than 10 mcg/mL were significantly decreased with the use of nomogram (P = 0.032). Incidence of supratherapeutic troughs, greater than 20 mcg/mL, was not significantly different between groups (P = 0.706), and pharmacists agreed that the nomogram was easy to use and saved their time. Conclusions. A novel vancomycin nomogram was prospectively validated and found to be more effective than traditional pharmacokinetic dosing. The nomogram is being implemented as the standard dosing protocol at our institution. © 2013 Amber R. Wesner et al. Source

Shurrab M.,University of Toronto | Schilling R.,Queen Mary, University of London | Gang E.,Cedars Sinai Medical Center | Khan E.M.,Winchester Medical Center | Crystal E.,University of Toronto
Expert Review of Medical Devices

Robotic systems allow for mapping and ablation of different arrhythmia substrates replacing hand maneuvering of intracardiac catheters with machine steering. Currently there are four commercially available robotic systems. Niobe magnetic navigation system (Stereotaxis Inc., St Louis, MO) and Sensei robotic navigation system (Hansen Medical Inc., Mountain View, CA) have an established platform with at least 10 years of clinical studies looking at their efficacy and safety. AMIGO Remote Catheter System (Catheter Robotics, Inc., Mount Olive, NJ) and Catheter Guidance Control and Imaging (Magnetecs, Inglewood, CA) are in the earlier phases of implementations with ongoing feasibility and some limited clinical studies. This review discusses the advantages and limitations related to each existing system and highlights the ideal futuristic robotic system that may include the most promising features of the current ones. © 2014 Informa UK, Ltd. Source

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