A Systematic Review of Escape Room Gaming in Pharmacy Education.

OBJECTIVES: The objectives of this review were to review the current literature on escape rooms in pharmacy education, determine their impact on educational outcomes, and identify areas for future research. FINDINGS: A literature search retrieved 14 reports, of which 10 studies met all of the study criteria. The majority of the studies used the escape room to review previously taught content (90%). More than half the studies (60%) assessed a change in a student's knowledge. One study testing a broad content area found a decrease in the before and after knowledge assessment from 70% to 67%, while other studies found before and after content knowledge increase. On average, 5.8 faculty facilitators and 33 h were needed for each activity. SUMMARY: This review suggests that pharmacy students enjoy escape rooms and perceive that it helps in their clinical knowledge and teamwork skills. Additionally, there is a potential that it can demonstrate an increase in content knowledge, particularly escape rooms that had a singular content focus. Faculty planning on implementing an escape room activity should give strong consideration to the preparation, delivery/logistics, and content.

A Systematic Review of Weight-Based Metoprolol for Acute Atrial Fibrillation with Rapid Ventricular Rate.

Atrial fibrillation (AF) is the most common cardiac arrhythmia encountered in the emergency department (ED) and when patients present in acute AF with rapid ventricular rate (RVR), it can result in significant morbidity and mortality. Primary treatment modalities are aimed at rate control with the two most common agents being intravenous metoprolol and diltiazem. Some evidence suggests that diltiazem may be more effective at controlling rate in these patients; however, the dosing strategies, pharmacologic differences, and study designs may play a role in the observation of these differences. The purpose of this article is to review the evidence for using weight-based metoprolol in the treatment of AF with RVR. The vast majority of studies comparing metoprolol and diltiazem for the treatment of acute AF with RVR compare a flat dose of metoprolol to a weight-based dose of diltiazem. Following a comprehensive review, only two studies have compared a weight-based dosing strategy of intravenous (IV) metoprolol versus IV diltiazem for this disease state. Overall, the two studies only contained 94 patients and failed to meet power. Beyond differing dosing strategies, differences in pharmacokinetics between the two medications (like the onset of action and metabolism) could have played a role in the differences observed in the studies. Further studies are warranted to provide better guidance on which agent should be used in the treatment of acute AF with RVR.

Comparison of nimodipine formulations and administration techniques via enteral feeding tubes in patients with aneurysmal subarachnoid hemorrhage: A multicenter retrospective cohort study.

BACKGROUND: Nimodipine improves outcomes following aneurysmal subarachnoid hemorrhage (aSAH) and current guidelines suggest that patients with aSAH receive nimodipine for 21 days. Patients with no difficulty swallowing will swallow the whole capsules or tablets; otherwise, nimodipine liquid must be drawn from capsules, tablets need to be crushed, or the commercially available liquid product be used to facilitate administration through an enteral feeding tube (FT). It is not clear whether these techniques are equivalent. The goal of the study was to determine if different nimodipine formulations and administration techniques were associated with the safety and effectiveness of nimodipine in aSAH. METHODS: This was a retrospective multicenter observational cohort study conducted in 21 hospitals across North America. Patients admitted with aSAH and received nimodipine by FT for ≥3 days were included. Patient demographics, disease severity, nimodipine administration, and study outcomes were collected. Safety end points included the prevalence of diarrhea and nimodipine dose reduction or discontinuation secondary to blood pressure reduction. Predictors of the study outcomes were analyzed using regression modeling. RESULTS: A total of 727 patients were included. Administration of nimodipine liquid product was independently associated with higher prevalence of diarrhea compared to other administration techniques/formulations (Odds ratio [OR] 2.28, 95% confidence interval [CI] 1.41-3.67, p-value = 0.001, OR 2.76, 95% CI 1.37-5.55, p-value = 0.005, for old and new commercially available formulations, respectively). Bedside withdrawal of liquid from nimodipine capsules prior to administration was significantly associated with higher prevalence of nimodipine dose reduction or discontinuation secondary to hypotension (OR 2.82, 95% CI 1.57-5.06, p-value = 0.001). Tablet crushing and bedside withdrawal of liquid from capsules prior to administration were associated with increased odds of delayed cerebral ischemia (OR 6.66, 95% CI 3.48-12.74, p-value <0.0001 and OR 3.92, 95% CI 2.05-7.52, p-value <0.0001, respectively). CONCLUSIONS: Our findings suggest that enteral nimodipine formulations and administration techniques might not be equivalent. This could be attributed to excipient differences, inconsistency and inaccuracy in medication administration, and altered nimodipine bioavailability. Further studies are needed.

Characterization of early versus late opioid iatrogenic withdrawal syndrome in critically ill children transitioning from fentanyl -infusions to methadone.

OBJECTIVE: Methadone is used to prevent opioid iatrogenic withdrawal syndrome (IWS) in children, but the optimal dose and overlap time with an opioid infusion have not been elucidated. The purpose was to compare clinical manifestations among patients who developed opioid IWS within 24 hours (early) versus ≥24 hours (late) of fentanyl discontinuation when enteral methadone was initiated. DESIGN: A retrospective, descriptive study. SETTING: Pediatric and cardiovascular intensive care units at a tertiary care health system. PARTICIPANTS: Sixty-seven children received fentanyl infusions for ≥3 days and initiated on methadone prior to fentanyl discontinuation. MAIN OUTCOME MEASURES: The primary objective was to compare clinical characteristics between those with early versus late opioid IWS. Opioid IWS was defined as a Withdrawal Assessment Tool-1 score ≥3 within 5 days of fentanyl discontinuation. Secondary objectives included a comparison of time to IWS, clinical characteristics, and risk factors among patients with and without IWS. RESULTS: Fifty children (74.6 percent) developed opioid IWS within a median time of 3.5 hours. No differences were noted for those with and without IWS. Thirty-seven patients (74.0 percent) with IWS developed early IWS. A higher percentage of males in the late versus early group developed IWS, 100 percent versus 51.4 percent, p = 0.002. The median overlap time with methadone and fentanyl was shorter in the early versus late IWS group without reaching statistical significance, 27.5 versus 64.0 hours, p = 0.127. CONCLUSIONS: The majority developed opioid IWS, with most developing early IWS, despite methadone initiation. Future studies should evaluate the optimal methadone dosing and overlap time to prevent opioid IWS.

Patients with moderate to severe COVID-19 outcomes on remdesivir according to baseline 4C mortality score.

BACKGROUND: Remdesivir was the first antiviral to show clinical benefit in patients with moderate-to-severe COVID-19. Previous trials demonstrated a faster time to recovery in hospitalized patients treated with remdesivir vs placebo. Current guidelines recommend treatment with remdesivir based on hospitalization status, oxygen requirements, and time from symptom onset. However, other factors may be evaluated to determine disease severity and risk for progression. The 4C mortality score is a validated, eight variable score that may be used to categorize patients by mortality risk at the time of hospital admission for COVID pneumonia. The objective of this study was to determine if the 4C mortality score may be used to predict which patients with moderate to severe COVID-19 would benefit the most from remdesivir at the time of hospital admission. METHODS: This was a single-center retrospective cohort study comparing time to recovery among hospitalized patients with moderate-to-severe COVID-19 who were treated with remdesivir compared to those who were treated with standard of care (SOC). The primary outcome was time to recovery, defined as discharge from the hospital or no longer requiring supplemental oxygen, stratified by the 4C mortality score risk group. Secondary outcomes included in-hospital mortality, hospital length of stay, and time to recovery in patients who were started on remdesivir within 7 days from symptom onset vs after 7 days from symptom onset. A survival analysis was used to analyze time to recovery outcomes. RESULTS: Data was collected and analyzed for a total of 300 patients, of which 200 received remdesivir and 100 received SOC. Patients in the remdesivir group had a longer time to recovery compared to patients in the SOC group (6 days vs 4 days). This finding was driven by patients who were categorized to the intermediate risk and high risk mortality groups. Additionally, patients who received remdesivir had a longer length of hospital stay compared to those who received SOC (12 days vs 9 days). Remdesivir was not associated with an increased rate of adverse events. CONCLUSIONS: This study of patients admitted with moderate-to-severe COVID-19 found that patients who were treated with remdesivir had a longer time to recovery and a longer length of stay compared to those who received SOC. These findings add to the body of evidence questioning the benefit of remdesivir therapy among patients hospitalized with COVID-19.

Comparison of Amantadine, Modafinil, and Standard of Care in the Acute Treatment of Disorders of Consciousness After Severe Traumatic Brain Injury.

OBJECTIVE: Traumatic brain injury (TBI) is a major cause of death and disability worldwide. Many patients who experience severe TBI have persistent disorders of consciousness. Amantadine and modafinil are used for some neurological disorders; however, a comparison of the 2 medications in TBI has not been reported. This study compared the effectiveness of amantadine, modafinil, and standard of care (SOC) on disorders of consciousness after TBI. METHODS: All adult TBI patients admitted between January 1, 2017, and September 31, 2020 who received amantadine, modafinil, or SOC treatments were screened. Data collection included: demographics, change in Glasgow Coma Scale (GCS), location of hemorrhage, medication duration, intensive care unit and hospital length of stay, adverse drug reactions, and concomitant sedative medications. Patients in the amantadine and modafinil groups were matched 1:2 with patients who received SOC therapies. The primary outcome was change in GCS ≥ 3 from baseline to discharge. RESULTS: A total of 142 patients met inclusion criteria. Medications were initiated a median of 8 days from admission. Patients in the SOC group experienced a greater improvement in GCS and shorter hospital length of stay compared with amantadine. A change in GCS ≥ 3 from medication initiation to hospital discharge occurred in 46.5% of amantadine patients and 53.8% of modafinil patients. CONCLUSIONS: In this study, TBI patients did not benefit from amantadine or modafinil compared with SOC therapies, and no differences were found between medication groups. Further studies are warranted to determine whether the addition of amantadine or modafinil in the weeks after TBI provides benefit.

Role of Clinical Pharmacists in Intensive Care Units.

The cost of health care has been rising in the United States and globally and will continue to increase. Intensive care unit (ICU) care carries a significant portion of the cost for the hospitals. The Institute of Medicine and subsequent studies have suggested that medication errors account for significant morbidity, mortality, and cost, frequently encountered in the ICU. Over the past three decades, clinical pharmacists have emerged from dispensing medication to getting involved in direct patient care and have become an integral part of the multidisciplinary critical care team. Clinical pharmacists play a significant role in reducing medication errors and costs, medication reconciliation, antibiotic stewardship, and patient and health care provider education. This review will discuss the health care and ICU cost, the evolving role of clinical pharmacists in managing critically ill patients, and their contributions in the ICU to mitigate the risks, improve patient outcomes, and decrease health care costs.

Treatment of Toxic Epidermal Necrolysis with Etanercept in a Pediatric Patient.

Toxic epidermal necrolysis is a rare, life-threatening skin disease with no consensus on adjunctive treatment, particularly in pediatric patients. We present the case of a 13-year-old previously healthy patient with drug-associated toxic epidermal necrolysis who experienced significantly shortened length of hospital stay and duration of symptoms compared with published literature when treated with 2 doses of etanercept 50 mg during 5 days.

Solitonic lattices in photorefractive crystals.

Two-dimensional spatial solitonic lattices are generated and investigated experimentally and numerically in a Sr(x)Ba(1-x)Nb(2)O(6):Ce crystal. An enhanced stability of these lattices is achieved by exploiting the anisotropy of coherent soliton interaction, in particular the relative phase between soliton rows. The manipulation of individual soliton channels is achieved by the use of supplementary control beams.

[Autologous transfusion in total hip endoprosthesis--a clinical concept]. / Autologe Transfusion bei der totalen Hüftendoprothese--ein klinisches Konzept.

The risks associated with blood transfusion can be minimized using autologous blood. The efficiency of preoperative blood deposit, preoperative acute-hemodilution spinal anesthesia, controlled hypotension and intra and postoperative autotransfusion in reducing homologous transfusion has been demonstrated. In a prospective study the effectivity of this concept is demonstrated. 141 patients scheduled for total hip arthroplasty were divided in three groups: group I--total hip arthroplasty without cement (n = 55); group II--total hip arthroplasty with cement (n = 52); and group III total hip revision arthroplasty (n = 34). The mean quantity of the donated blood was 900 mL. The donation was not associated with serious complications. In group I 52 patients (94.5%), in group II 40 patients (77%) and in group III 14 patients (41.2%) did not require homologous transfusion. The difference between group I and II was significant (p < 0.05). Under the conditions studied, preoperative autologous blood deposit, acute hemodilution, spinal anesthesia and controlled hypotension are effective for decreasing the application of homologous transfusions in hip arthroplasty. The efficiency of preoperative hemodilution alone is limited. Preoperative deposit of autologous blood is a simple, effective, economical, and low-risk method of reducing homologous transfusion. Autotransfusion with a cell separator can save approximately 50% of the erythrocytes lost during revision total hip arthroplasty.

Anterior cruciate ligament suture in comparison with plasty. A 5-year follow-up study.

In this retrospective study we analyse the results of primary anterior cruciate ligament (ACL) sutures, primary ACL plasties and secondary ACL plasties 5 years after operation. All operations were performed with an additional PDS augmentation. Follow-ups of 100 of 130 patients could be done (80 male and 20 female). The average age at time of operation was 29.2 years. ACL rupture in 81 patients occurred due to a sport accident. In 26 patients a primary ACL suture was performed, in 59 patients a primary ACL plasty and in 15 patients an ACL plasty due to instability. There was no difference between the primary and secondary plasty groups, but there was between the suture and the plasty groups. In all, 92% of the suture group and 69% of the plasty group were satisfied with the surgical results. The pivot shift, Lachman and anterior drawer sign were less frequent in the ACL suture group, and the Lysholm score was higher. Primary suture combined with a PDS augmentation seems to represent an adequate treatment of acute proximal ACL ruptures.

[Capsular ligament lesions of the knee joint. 5-9 year results of surgical management]. / Kapselbandläsionen am Kniegelenk. 5-9-Jahres-Ergebnisse nach operativer Versorgung.

5-9 years follow-up results following 26 out of 37 operated injuries of the ligaments of the knee are reported. While 18 patients described the result of the operation as very good and good, the objective findings presented only 5 stable knees.

[Is arthroscopy always justified in traumatic hemarthrosis of the knee joint?]. / Hat die Arthroskopie beim traumatischen Hämarthros des Kniegelenkes immer ihre Berechtigung?

Analysis of 100 consecutive arthroscopies in patients with traumatic hemarthrosis of the knee joint demonstrates the importance of arthroscopy in diagnosis and therapy. In 48 cases injuries of the anterior cruciate ligament, isolated and in combination with lesions of other structures, were found. In 47 cases an operation was necessary. In 21 cases the reason for the hemarthrosis was luxation of the patella, in 6 cases with a flake fracture. Isolated lesions of one of the menisci were found in 11 cases and treated arthroscopically in all cases (2 meniscopexies, 1 total meniscectomy , 8 partial meniscectomies). Only in 8 cases unimportant injuries or lesions were found to have caused the hemarthrosis.

[Caudal regression syndrome]. / Beitrag zum caudalen Regressionssyndrom.

It is reported about a young girl with congenital agenesis of the os sacrum, a congenital platfoot and a luxation of the left hip. These congenital malformations can be found in children born to diabetic mothers.

[Malignant hemangiopericytoma--a soft tissue and bone tumor]. / Malignes Hämangioperizytom--ein Weichteil- und Knochentumor.

Hemangiopericytomas are very rare tumors that mostly develop in the soft tissues. In rare cases, however, they may occur as primary bone tumors which are extremely rare. In case of such an intraosseous tumor, a bone metastasis of such a soft tissue sarcoma must be considered first and has to be excluded. In a 62 year old female, a hemangiopericytoma of the left femoral neck was diagnosed that had induced a pathological bone fracture. A resection of the femoral head and neck was performed. Anamnestical investigations, however, have shown that 4 years before, such a tumor of the pelvic soft tissues was removed. Thus, the lesion of the femoral neck had to be classified as bone metastasis of a malignant hemangiopericytoma. It has to be emphasized that this special tumor always shows a questionable prognosis and, by histological investigations, it cannot be decided if we are dealing with a benign or malignant tumor growth. Diagnostic managements and clinical problems with hemangiopericytomas are discussed in detail.

[Results of 5-7 year follow-up of implantation of RM isoelastic hip endoprosthesis]. / 5-7-Jahres-Nachuntersuchungsergebnisse nach Implantation der RM-isoelastischen Hüft-Endoprothese.

From June 1976 to June 1981, 71 isoelastic total hip endoprostheses were implanted. In a 5-to 7-year follow-up study, all but one of the hips that had been operated upon could be evaluated. In 10 cases reoperation was performed because of loosening of the stem (3 infections, 7 aseptic loosenings). In the remaining 51 endoprostheses in 45 patients, 2 were described as in poor shape. In 3 cases, an X-ray film demonstrated potential loosening of the stem. Because there is a 9.8% loosening rate of the stem, the indication for implantation has been restricted. We had no problems at all with the RM acetabular components.

Cardiac allograft prolongation in mice treated with combined posttransplantation total-lymphoid irradiation and anti-L3T4 antibody therapy.

Neonatal cardiac allograft survival was examined in mice treated with anti-L3T4 antibody, posttransplantation total lymphoid irradiation (TLI) or a combination of both therapies. Independently, both posttransplantation TLI and short-course antibody treatment allowed minimal prolongation. However, synergistic prolongation in graft survival was observed with the combination (synergistic) therapy. Fluorescence-activated cell sorter analysis of peripheral blood lymphocytes from animals treated with combined anti-L3T4 and posttransplantation TLI additionally revealed "synergy" with respect to the degree of peripheral lymphocyte depletion.

[Treatment of femur shaft fractures in children with Ender nails]. / Die Behandlung von Femurschaftfrakturen beim Kind mit Endernägeln.

Ender-nailing is a proved method in the treatment of sub- and pertrochanteric fractures in old people. In special cases Ender-nailing can be useful in the treatment of other types of fractures. 3 cases of Ender-nailing of femoral shaft fractures in childhood are reported.

[Pyoderma gangraenosum as an orthopedic problem case]. / Das Pyoderma gangraenosum als orthopädischer Problemfall.

A problematic case of pyoderma gangraenosum in a patient with colitis ulcerosa mimicing an empyema of the knee joint is reported.