Intellectual property: A primer for radiologists.

Typically the creative product of the mind, intellectual property often forms the basis of a new product, service line, or company. Intellectual property law is complicated and nuanced, and poorly understood by many physicians, innovators, and entrepreneurs. Successfully navigating the process of intellectual property protection is critical in facilitating the translation of innovation into clinical practice. We define intellectual property and common terms used in intellectual property law and offer justification for the importance of intellectual property protections. We additionally highlight resources to assist radiologists with intellectual property protection and outline basic guidelines to successfully initiate discussions around intellectual property with third party vendors and consultants. SUMMARY: Proactive intellectual property protection is critically important for radiologist innovators seeking to bring new ideas to the marketplace.

Evaluation and optimization of take-home naloxone in an academic medical center.

With the United States in the midst of an opioid overdose epidemic, efforts to reduce overdose deaths have increased. Expanding access to the opioid antagonist naloxone can combat the epidemic. A pilot project in a psychiatric hospital resulted in the development of a screening tool in the electronic medical record (EMR) to help pharmacists identify adult inpatients at high risk of opioid overdose. Pharmacists can facilitate these patients being discharged with take-home naloxone. The purpose of this project was to optimize the screening tool for nonpsychiatric adult inpatient areas. Prior to implementation, a team of pharmacists familiar with the screening tool and take-home naloxone met with stakeholders to assess need for modification of the tool, determine barriers to implementation, and provide insight into the new service. In addition to expanding the tool into nonpsychiatric areas, a morphine-equivalents calculator was developed to identify patients receiving at least 100 mg of morphine equivalents per day to capture an additional at-risk population. Four short educational videos were developed to provide training to pharmacists. Initial performance of the screening tool was evaluated in general medicine patients over a 5-day period. Out of 44 admissions, 8 (18.2%) screened positive. The majority of those patients (5/8, 62.5%) screened positive for morphine equivalents greater than 100 mg. Anecdotally, the educational videos have been well received by pharmacy staff. Opioid overdose risk factors can be applied to nonpsychiatric inpatients for screening purposes in the EMR. Educational videos can be used to disseminate information to pharmacists on take-home naloxone and opioid overdose.

Thiamine Prescribing and Wernicke's Encephalopathy Risk Factors in Patients With Alcohol Use Disorders at a Psychiatric Hospital.

BACKGROUND: Alcohol use disorder (AUD) is the leading cause of thiamine deficiency and can lead to Wernicke's encephalopathy (WE). WE has a higher prevalence of development in patients with AUD, and current recommendations emphasize parenteral administration of thiamine. Our objective was to characterize thiamine utilization in patients with AUD who were prescribed thiamine and evaluate if those who received oral thiamine had risk factors for the development of WE. METHODS: This retrospective chart review enrolled adults admitted to a psychiatric hospital from October 2014 through September 2015 diagnosed with AUD as per the International Classification of Diseases, Ninth Edition (ICD-9). The cohort was divided on the basis of route of thiamine administration (nonparenteral vs. parenteral) and was then screened retrospectively for risk factors for WE. Descriptive data and measures of central tendency were utilized to assess the objectives. RESULTS: The majority of patients were white male individuals, with a mean age of 48 years. Of the 226 patients, 201 (89%) were prescribed oral thiamine. Of the first 100 patients who received oral thiamine, 36% had risk factors for WE, with the most common risk factor being malnutrition. A χ analysis revealed that WE risk factors did not influence route of thiamine administration (χ=2.148, df=1, P=0.143). No patients were diagnosed with WE during their admission; however, 8 patients received parenteral thiamine at a treatment dose indicated for WE. CONCLUSIONS: Parenteral thiamine is underutilized in patients with AUD and risk factors for WE. Education is needed to enhance thiamine prescribing and evaluation of risk factors for WE in this population. A thiamine prescribing protocol has been developed for further thiamine optimization.

Ketamine for the Acute Management of Excited Delirium and Agitation in the Prehospital Setting.

Traditional first-line therapy in the prehospital setting for the acutely agitated patient includes an antipsychotic in combination with a benzodiazepine. Recently, interest has grown regarding the use of ketamine in the prehospital setting as an attempt to overcome the limitations of the traditional medications and provide a more safe and effective therapy. This review provides an overview of the pharmacology of ketamine, evaluates the literature regarding ketamine use for prehospital agitation, and proposes an algorithm that may be used within the prehospital setting. A literature review was conducted to identify articles utilizing ketamine in the prehospital setting. The review was limited to English-language articles identified in Embase (1988-June 2017) and the U.S. National Library of Medicine (1970-June 2017). References of all pertinent articles were also reviewed. Ten articles were identified including 418 patients receiving ketamine for agitation. The most commonly utilized route for administration was intramuscular (IM), with five of the seven IM administration studies using a ketamine dose of 5 mg/kg. Ketamine administered in this fashion was efficacious to achieve proper sedation during transport and did not require repeat dosing. Three studies applied a ketamine protocol to outline dosing and the management of ketamine adverse events. The most common adverse events identified were respiratory-related events and hypersalivation. Ketamine has a role for agitation management in the prehospital setting; however, emergency personnel education and ketamine protocols should be utilized to aid in safe and effective pharmacotherapy and provide guidance on the management of adverse events. Future prospective comparative studies, with protocolized standard ketamine regimens, are needed to further delineate the role of ketamine in agitation management and identify accurate adverse event incidence rates.

Drug-Induced Vitamin B12 Deficiency: A Focus on Proton Pump Inhibitors and Histamine-2 Antagonists.

OBJECTIVE: To review primary literature of gastric acid suppressive agents and vitamin B12 deficiency. DATA SYNTHESIS: From the published articles, proton pump inhibitors (PPIs) are associated with a higher risk of inducing vitamin B12 deficiency than histamine-2 receptor antagonists (H2RAs). Literature suggests that there is an increased risk of developing vitamin B12 deficiency in patients who are exposed to extended durations of therapy with PPIs. There are, however, some conflicting data in elderly patients suggesting that the PPI use for more than 3 years does not increase the risk of vitamin B12 deficiency. No evidence was found to support the extended use of H2RA monotherapy causing vitamin B12 deficiency. The inconsistency of results reported could be due to the differing patient populations studied, such as Zollinger-Ellison syndrome (ZES) and elderly patients. Overall, the lack of consistent evidence shows the need for more research in this area. CONCLUSION: To investigate the clinical significance of vitamin B12 deficiency caused by acid suppression with PPIs and H2RAs, longer prospective studies are needed. These studies should focus on patient-centered outcomes to accurately determine the extended usage of PPI and H2RA and the true effects on vitamin B12 deficiency.

General pharmacokinetic/pharmacodynamic concepts of mood stabilizers in the treatment of bipolar disorder.

INTRODUCTION: Mood stabilizers are the recommended treatment for patients who receive a diagnosis of bipolar disorder. Because of the necessity of mood stabilizer treatment in patients with bipolar disorder and the extent of pharmacokinetic and pharmacodynamic principles involved, the purpose of this review is to summarize the pharmacokinetic principles of lithium in addition to the pharmacodynamics of lithium, carbamazepine, lamotrigine, and valproic acid/valproate. METHODS: Practice guidelines, review articles, and clinical trials were located using online databases PubMed, CINAHL, IDIS, and Medline. Search terms included at least one of the following: bipolar disorder, carbamazepine, lamotrigine, lithium, mood stabilizers, pharmacokinetics, pharmacodynamics, valproate, and valproic acid. Online clinical databases Dynamed® and Lexicomp® were also used in the study. RESULTS: Mood stabilizers collectively possess distinct qualities that are closely regarded before, during, and after therapeutic initiation. Individual patient characteristics, coupled with these observed traits, add to the complexity of selecting the most optimal neurologic agent. Each medication discussed uniquely contributes to both the maintenance and restoration of overall patient well-being. DISCUSSION: Introduction of mood stabilizers into drug regimens is often done in the presence of an array of mitigating factors. Safety and efficacy measures are commonly used to gauge desired results. Careful monitoring of patients' responses to selected therapies is paramount for arriving at appropriate clinical outcomes.

Is combination therapy appropriate for hypothyroidism?

Levothyroxine is the first-line drug for treating hypothyroidism. This article reviews the literature on combination therapy using levothyroxine and liothyronine, and found that only one study produced beneficial outcomes; other studies reported increased adverse reactions among participants. Levothyroxine should remain the drug of choice for hypothyroidism. Adequate trials with homogenous populations and large sample sizes are needed to determine whether combination therapy can be recommended for patients with hypothyroidism.