Simulating the impact of varying vegetation on West African monsoon surface fluxes using a regional convection-permitting model.

This study assessed the sensitivity of the West African climate to varying vegetation fractions. The assessment of a such relationship is critical in understanding the interactions between land surface and atmosphere. Two sets of convection-permitting simulations from the UK Met Office Unified Model at 12 km horizontal resolution covering the monsoon period May-September (MJJAS) were used, one with fixed vegetation fraction (MF-V) and the other with time-varying vegetation fraction (MV-V). Vegetation fractions are based on MODIS retrievals between May and September. We focused on three climatic zones over West Africa: Guinea Coast, Sudanian Sahel, and the Sahel while investigating heat fluxes, temperature, and evapotranspiration. Results reveal that latent heat fluxes are the most strongly affected by vegetation fraction over the Sahelian and Sudanian regions while sensible heat fluxes are more impacted over the Guinea Coast and Sudanian Sahel. Also, in MV-V simulation there is an increase in evapotranspiration mainly over the Sahel and some specific areas in Guinea Coast from June to September. Moreover, it is noticed that high near-surface temperature is associated with a weak vegetation fraction, especially during May and June. Finally, varying vegetation seems to improve the simulation of surface energy fluxes and in turn impact on climate parameters. This suggests that climate modelers should prioritize the use of varying vegetation options to improve the representation of the West African climate system.

Pharmaceutical care- urgency: Proposing a practical clinical framework for pharmacy students.

BACKGROUND AND PURPOSE: Prioritizing a drug therapy problem (DTP) during an experiential placement is challenging for some pharmacy students, suggesting a gap in pre-placement preparedness and the need to modify existing resources. A modified DTP prioritizing framework is proposed to enhance clinical reasoning and increase students' confidence in performing this important step in the pharmaceutical care process. EDUCATIONAL ACTIVITY AND SETTING: Students' baseline DTP prioritizing capability was assessed in an informal focus group consisting of pharmacy students and experienced hospital pharmacy preceptors. Participants ranked the urgency for addressing 47 common medical conditions and selected a time frame to resolve the DTP. Participants also provided feedback on a proposed DTP prioritizing framework. A modified, student-focused DTP prioritizing framework, incorporating elements of curricular knowledge, principal elements of urgency, and time frame for taking action to resolve the identified DTP is described. FINDINGS: Students' DTP urgency rankings were heterogeneous and showed greater deviation from the anticipated ranking (R = 0.61) compared to the pharmacist cohort (R = 0.807), reinforcing our view of the need for a modified DTP prioritizing framework for students. In qualitative terms, students felt the framework's focus on curricular knowledge would contribute to the development of expertise. Preceptors felt the framework reflected their usual practice and would help guide discussions with students. SUMMARY: The modified DTP prioritizing framework, described in this article, may be utilized both to enhance student success and preceptor development in the experiential setting.

Opioid rotation from transdermal fentanyl to continuous subcutaneous hydromorphone in a cachectic patient: A case report and review of the literature.

Opioid rotation from transdermal fentanyl to an alternate opioid is often necessitated in advanced disease, but is fraught with uncertainty due to variable absorption from the patch in end-stage illness and the lack of a clearly established opioid rotation ratio. The manufacturer of transdermal fentanyl provides opioid rotation recommendations only for rotation from the oral morphine equivalent daily dose (MEDD) of opioid to the patch, not in the opposite direction. This is a case report of a single patient with cancer and cachexia admitted to the palliative care unit of a large academic medical centre in Canada. The patient is a 50-year-old female with widely metastatic breast cancer who developed opioid toxicity when maintenance transdermal fentanyl patch therapy (100 µg patch applied every 72 h) was rotated to subcutaneous hydromorphone infusion to improve pain control. Hydromorphone was initiated at a rate of 1 mg/h by continuous infusion based on an opioid rotation ratio for transdermal fentanyl (µg/h):MEDD (mg/day) of 1:2.4. Opioid toxicity eventually resolved with downward titration of hydromorphone to only 30% of the initially estimated equianalgesic dose. This case highlights the need for close follow-up of all patients undergoing opioid rotation from transdermal fentanyl and reinforces the need to reduce the initial dose of the new opioid by 30%-50% of the calculated MEDD, especially when rotating from a high dose of transdermal fentanyl, or if there are factors potentially impairing absorption from the patch such as age, cachexia and weight loss, or if rotation is performed for reasons other than uncontrolled pain.

Safe medication swallowing in Dysphagia: a collaborative improvement project.

Episodes of choking during medication administration to patients with dysphagia prompted a chart audit and caregiver interview to identify system problems that allowed inappropriate drug administration to occur. Sixty elderly patients residing on two patient care areas in a 500-bed complex continuing care facility were studied. The audit explored the actual nursing medication administration methods and compared this to the information obtained from various communication tools including instructions that appeared on the medication administration record (MAR), the current diet order, the recommendations of the speech-language pathologist (SLP) and comments on the nursing care plan. The audit yielded a number of discrepancies between nursing actions and the instructions obtain from these sources. We proposed that changes to the process of communicating medication swallowing recommendations among team members would lead to greater patient safety. Major practice changes included the use of standardized language by the SLP when making recommendations, the writing of SLP recommendations in the doctor's orders, the inclusion of SLP recommendations on the MAR and the creation of a "dysphagia alert" on the pharmacy computer system. An educational intervention was conducted to implement process changes. Its effectiveness was evaluated using a pre- and post-test and a participant satisfaction survey. A post-implementation audit showed compliance with the practice change. In summary, process changes were implemented to improve compliance with SLP medication-related swallowing recommendations and to prevent the inadvertent prescribing, dispensing or crushing of sustained-release medications in patients with dysphagia.