Community pharmacy-based SOAP notes documentation.

There is still scarce and sparse evidence regarding documentation of the subjective, objective, assessment and plan (SOAP) note in community pharmacies despite its long implementation history in clinical and academia settings. Hence, we aimed to document and maintain SOAP notes for individual patients visiting community pharmacies for their health problems. We conducted a community-based cross-sectional study at 2 community pharmacies in Nepal from July to December 2019. We recruited 400 patients from all age groups suffering from any health problem using simple random sampling. Patients' subjective complaints were retrieved from their respective prescriptions and verified by interviewing them. Data were collected on the standard format of the SOAP notes and all data related to patients' subjective and objective evaluations, and assessments and plans were descriptively analyzed with R programming 4.0.3. Drug interaction profile was checked with the Medscape Drug Interaction Checker. A total of 87 (21.8%) patients aged 42 to 51 years participated in the research, out of whom 235 (58.8%) were female, 208 (52%) illiterate, 359 (89.8%) were facing mild polypharmacy, and 40 (9.9%) were suffering from joint, leg, ankle, and knee pain. There were 41 minor (11.4%), 130 major (32.7%), and 3 severe (0.9%) drug interaction cases (i.e., medication-related problems), with 11 (2.8%) occurring between amlodipine and metformin, which required close monitoring. There were 226 (56.5%) cases with follow-up planned for the patients when necessary. This novel approach in documenting SOAP notes at community pharmacies during dispensing would be an extended form of the same being applied in clinical settings. Hence, this would open a new arena for the community pharmacists to expand their professionalism beyond the clinical and academia by documenting patients' complex disease and medication profiles in their documentation.

Overlapping Drug-Eluting Stent Is Associated with Increased Definite Stent Thrombosis and Revascularization: Results from 15,561 Patients in the AUTHENTIC Study.

PURPOSE: This study was to analyze the incidence of definite stent thrombosis (ST) after the implantation of drug-eluting stents (DESs) and cutoff value of overlapping length for predicting definite ST. An overlapping stent is associated with a high rate of clinical events after DES implantation compared with a non-overlapping stent. However, the rates of definite ST and clinical outcomes from a large patient population remain underreported. METHODS: A total of 15,561 patients with 24,183 lesions who underwent DES implantation from January 2005 to February 2017 were retrospectively included in 5 tertiary hospitals in China. The main endpoint was the incidence of definite ST after procedures. RESULTS: With a median of 1932 (IQR = 1194-2929) days, clinical follow-up was available in 7484 patients in the overlap group and in 8077 patients in the non-overlap group. The rates of definite ST were 3.1% in the overlap group and 1.2% in the non-overlap group (HR: 2.67 (95% CI: 2.11-3.38), p < 0.001). Of the 24,183 treated lesions, the incidences of definite ST were 2.4% in the overlap group and 0.9% in the non-overlap group (HR: 2.96 (95% CI: 2.38-3.69), p < 0.001). Stent overlap was associated with a higher rate of target lesion revascularization (TLR) (9.4%) compared with stent non-overlap (6.4%, p < 0.001). The length of overlapping stent ≥ 2.93 mm strongly correlated with definite ST. CONCLUSION: The present study shows that overlapping DES increases definite ST and revascularization in patients during long-term follow-up. In addition, the longer overlapping zone was associated with worse clinical outcomes.

Optical coherence tomography predictors of target vessel myocardial infarction after provisional stenting in patients with coronary bifurcation disease.

BACKGROUND: Provisional side branch (SB) stenting is correlated with target vessel myocardial infarction (TVMI) in patients with coronary bifurcation lesions. However, the mechanisms underlying this association remain unknown. OBJECTIVES: To determine the correlation between SB lesion length with vulnerable plaques and TVMI using optical coherence tomography (OCT). BACKGROUND: The correlation between SB lesion length with vulnerable plaques and TVMI is unknown. METHODS: A total of 405 patients with 405 bifurcation lesions who underwent preprocedure OCT imaging of both the main vessel (MV) and the SB were enrolled. Patients were divided into long SB lesion (SB lesion length ≥10 mm) and short SB lesion (SB lesion length <10 mm) groups according to quantitative coronary analysis; they were also stratified by the presence of vulnerable plaques identified by OCT. The primary endpoint was the occurrence of TVMI after provisional stenting at 1-year follow-up. RESULTS: In total, 178 (43.9%) patients had long SB lesions. Vulnerable plaques were predominantly localized in the MV and were more frequently in the long SB lesion group (42.7%) than in the short SB lesion group (24.2%, p < .001). At 1-year follow-up after provisional stenting, there were 31 (7.7%) TVMIs, with 21 (11.8%) in the long SB lesion group and 10 (4.4%) in the short SB lesion group (p = .009). Multivariate regression analysis showed that long SB lesion length (p = .011), absence of vulnerable plaques in the polygon of confluence (p = .001), and true coronary bifurcation lesions (p = .004) were the three independent factors of TVMI. CONCLUSIONS: The presence of long SB lesion with MV vulnerable plaques predicts the increased risk of TVMI after provisional stenting in patients with true coronary bifurcation lesions. Further studies are warranted to identify the best stenting techniques for coronary bifurcation lesions with long SB lesions.

Anatomical features and clinical outcome of a honeycomb-like structure in the coronary artery: reports from 16 consecutive patients.

BACKGROUND: Recanalization of thrombus in coronary artery tree is defined as a honeycomb-like structure. However, the anatomic features and appropriate treatment of honeycomb-like structure still remain largely unclear. METHODS AND RESULTS: Between 2014 July and 2017 December, 17 honeycomb-like structure in 16 patients based on optical coherence tomography and intravascular ultrasound were included. Fractional flow reserve was measured for patients who had thrombolysis in myocardial infarction flow grade 3. Angiographic and optical coherence tomography/intravascular ultrasound-derived variables were studied. Clinical events (until to 2018 December) were collected. Honeycomb-like structures mostly involved left anterior descending artery (68.8%) and localized at proximal-mid (88.2%) segment of vessels. Eight patients had a side branch ≥ 2 mm in diameter taking from honeycomb-like structure. Only one patient had a normal fractional flow reserve. Fifteen patients underwent implantation of a stent. Stent implantation was associated with side branch compromise or closure (4 in each). Of 4 patients with side branch closure, all had a creatine kinase myocardial band > 5 times increase in hospital, with 3 deaths and 1 target lesion revascularization during follow-up. CONCLUSIONS: Despite the presence of recanalization, most honeycomb-like structure lesion have a positive fractional flow reserve. Further study is required to address how to protect a large side branch taking from honeycomb-like structure.

A review in enormity of OCT and its enduring understanding of vulnerable plaque in coronary bifurcation lesion.

Optical coherence tomography (OCT) has emerged as one of the most promising tools to assist the optimization of percutaneous coronary intervention (PCI). Its ability to provide unique information on the plaque at high risk for rupture, plaque composition, the thickness of the fibrous cap, the presence of macrophage and thrombi has not only assisted simple PCI but also in many complex bifurcation lesions PCI. OCT has helped to provide valuable anatomic information to optimize stent implantation and adapt PCI strategy in individual patients. This review article summarizes the current role of OCT as an imaging technology and prediction of vulnerable plaque, its site and composition at the coronary bifurcation lesions for supporting the clinical decision.

Response of Red Blood Cell Folate to Supplementation in Nonpregnant Women is Predictable: A Proposal for Personalized Supplementation.

SCOPE: We modeled red blood cell (RBC)-folate response to supplementation and developed personalized folate supplementation concepts. METHODS AND RESULTS: The changes of RBC-folate were modeled in a time- (4 or 8 weeks) and dose- (400 or 800 µg d-1 folate) dependent manner. Post-supplementation RBC-folate levels were predicted from folate-loading capacities (= measured RBC-folate - [baseline RBC-folate × RBC-survival]). The prediction equations were validated in 119 participants. The median increase of RBC-folate was higher in the 800 µg d-1 than in the 400 µg d-1 group (275 vs 169 nmol L-1 after 4 weeks, and 551 vs 346 nmol L-1 after 8 weeks). Medians (interquartile range) of RBC-folate loading were (4 weeks: 299 (160) vs 409 (237) nmol L-1 ) and (8 weeks: 630 (134) versus 795 (187) nmol L-1 ) in the 400 and 800 µg d-1 group, respectively. The individual measured and predicted RBC-folate values (after 4 weeks/400 µg d-1 = 25 + 1.27 × baseline RBC-folate) and (after 4 weeks/800 µg d-1 = 65 + 1.41 × baseline RBC-folate) did not differ significantly. The measured and predicted concentrations showed high agreement in the validation cohort. CONCLUSIONS: The models can guide nutritional recommendations in women when baseline RBC-folate concentrations are measured and the time to pregnancy between 4 and 8 weeks.

Models for the red blood cell lifespan.

The lifespan of red blood cells (RBCs) plays an important role in the study and interpretation of various clinical conditions. Yet, confusion about the meanings of fundamental terms related to cell survival and their quantification still exists in the literature. To address these issues, we started from a compartmental model of RBC populations based on an arbitrary full lifespan distribution, carefully defined the residual lifespan, current age, and excess lifespan of the RBC population, and then derived the distributions of these parameters. For a set of residual survival data from biotin-labeled RBCs, we fit models based on Weibull, gamma, and lognormal distributions, using nonlinear mixed effects modeling and parametric bootstrapping. From the estimated Weibull, gamma, and lognormal parameters we computed the respective population mean full lifespans (95 % confidence interval): 115.60 (109.17-121.66), 116.71 (110.81-122.51), and 116.79 (111.23-122.75) days together with the standard deviations of the full lifespans: 24.77 (20.82-28.81), 24.30 (20.53-28.33), and 24.19 (20.43-27.73). We then estimated the 95th percentiles of the lifespan distributions (a surrogate for the maximum lifespan): 153.95 (150.02-158.36), 159.51 (155.09-164.00), and 160.40 (156.00-165.58) days, the mean current ages (or the mean residual lifespans): 60.45 (58.18-62.85), 60.82 (58.77-63.33), and 57.26 (54.33-60.61) days, and the residual half-lives: 57.97 (54.96-60.90), 58.36 (55.45-61.26), and 58.40 (55.62-61.37) days, for the Weibull, gamma, and lognormal models respectively. Corresponding estimates were obtained for the individual subjects. The three models provide equally excellent goodness-of-fit, reliable estimation, and physiologically plausible values of the directly interpretable RBC survival parameters.

Intra-Spinal Bone Marrow Mononuclear Cells Transplantation Inhibits the Expression of Nuclear Factor-κB in Acute Transection Spinal Cord Injury in Rats.

OBJECTIVE: To assess the effect of bone marrow mononuclear cells (BMMNCs) transplantation in the expression of nuclear factor-κB (NF-κB) in spinal cord injury (SCI) in rats. METHODS: BMMNCs were isolated from tibia and femur by a density gradient centrifugation. After establishment of acute transection SCI, rats were divided into experiment (BMMNCs), experiment control (0.1 M PBS infused) and sham surgery groups (laminectomy without any SCI). Locomotor function was assessed weekly for 5 weeks post-injury using BBB locomotor score and urinary bladder function daily for 4 weeks post-injury. Activity of NF-κB in spinal cord was assessed by immunohistochemistry and reverse transcriptase polymerase chain reaction. RESULTS: At each time point post-injury, sham surgery group had significantly higher Basso, Beattie, Bresnahan locomotor and urinary bladder function scores than experiment and experiment control group (p<0.05). At subsequent time interval there were gradual improvement in both experiment and experiment control group, but experiment group had higher score in comparison to experiment control group (p<0.05). Comparisons were also made for expression of activated NF-κB positive cells and level of NF-κB messenger RNA in spinal cord at various time points between the groups. Activated NF-κB immunoreactivity and level of NF-κB mRNA expression were significantly higher in control group in comparison to experiment and sham surgery group (p<0.05). CONCLUSION: BMMNCs transplantation attenuates the expression of NF-κB in injured spinal cord tissue and thus helps in recovery of neurological function in rat models with SCI.

Comparison of clinical outcomes of Chinese men and women after coronary stenting for coronary artery disease: a multi-center retrospective analysis of 4,334 patients.

The outcome differences between Chinese male and female patients within one-year follow-up after percutaneous coronary intervention (PCI) with stent remain unclear. The present study was aimed to compare clinical outcomes in such two populations. From May 1999 to December 2009, 4,334 patients with acute myocardial infarction (MI), unstable angina, stable angina, or silent ischemia, who underwent PCI, were registered at our centers. Among these, 3,089 were men and 1,245 were women. We compared these groups with respect to the primary outcomes of MI and secondary outcomes including a composite of major adverse cardiac events (MACE) including cardiac death, MI, target lesion revascularization, target vessel revascularization (TVR), stent thrombosis (ST), definite ST and probable ST at one-year follow-up. Chinese male patients had a higher MACE rate (13% vs. 10.7%, P  =  0.039), mainly led by TVR (9.09% vs. 6.98%, P = 0.024) at one year, which was significantly different than female patients. Chinese male and female patients showed a significant difference on MACEs. However, there was no significant difference with respect to MI between these groups.

Control-relevant erythropoiesis modeling in end-stage renal disease.

Anemia is prevalent in end-stage renal disease (ESRD). The discovery of recombinant human erythropoietin (rHuEPO) over 30 years ago has shifted the treatment of anemia for patients on dialysis from blood transfusions to rHuEPO therapy. Many anemia management protocols (AMPs) used by clinicians comprise a set of experience-based rules for weekly-to-monthly titration of rHuEPO doses based on hemoglobin (Hb) measurements. In order to facilitate the design of an AMP using model-based feedback control theory, we present a physiologically relevant erythropoiesis model and demonstrate its applicability using clinical data.

Frequency of Blood Culture Isolates and their Antibiogram in a Teaching hospital.

INTRODUCTION: Bloodstream infections are associated with significant patient morbidity and mortality. Antimicrobial susceptibility patterns should guide the choice of empiric antimicrobial regimens for patients with bacteremia. METHODS: Blood sample received from the patient attending Nepal Medical College and Teaching Hospital from March, 2012 - August, 2012 were subjected to culture. Isolate identification and antimicrobial susceptibility testing was done by standard microbiological method. RESULTS: Out of the total 2,766 blood samples, 368 (13.3%) showed bacterial growth. The percentage of neonatal septicemia was 368 (13.3%). Staphylococcus aureus (28%) was the most common isolates followed by Salmonella enterica Serotype Typhi (22%), Coagulase negative Staphylococci (9.5%), Salmonella enterica Serotype Paratyphi ((7.6%) and Klebsiella pneumoniae (7.6%). 26.3% of the isolates of Staphylococcus aureus were oxacillin resistant. Most of the gram positive organisms were susceptible to amikacin and vancomycin and showed high level resistance to cefuroxime and cotrimoxazole. Out of 109 isolates of typhoid bacilli, 95.3% were resistant to nalidixic acid,79% to ciprofloxacin and 60.5% to ofloxacin. More than 50% of the isolates of Klebsiella pneumoniae and Escherichia coli showed resistance to cephalosporins and cotrimoxazole. Acinetobacter sp. showed high resistance (more than 60%) to ceftriaxone and ofloxacin. More than 20% of the isolates of Pseudomonas aeruginosa were resistant to ciprofloxacin and amikacin. CONCLUSIONS: Ongoing surveillance for antimicrobial susceptibility remains essential, and will enhance efforts to identify resistance and attempt to limit its spread.

Two-year clinical outcomes after coronary drug-eluting stent placement in Chinese men and women: a multicenter, prospective registry study.

BACKGROUND: Previous studies have reported a discrepancy in baseline characteristics and outcomes after percutaneous coronary intervention between men and women. However, this finding has never been verified in the Chinese population. The present study analyzed two-year clinical outcomes after placement of coronary drug-eluting stents in Chinese men and women. METHODS: From January 2005 to December 2010, a total of 3804 Chinese patients (2776 men, 1028 women) who underwent drug-eluting stent implantation were studied prospectively. The primary endpoint was the composite major adverse cardiac event (MACE) rate, including myocardial infarction, cardiac death, and target vessel revascularization at two years. Stent thrombosis served as the safety endpoint. Propensity score matching was used to compare the adjusted MACE rate between the two groups. RESULTS: At two-year follow-up, unadjusted rates of myocardial infarction, non-ST segment elevation myocardial infarction, target vessel revascularization, and MACE were significantly different between men (6.84%, 4.6%, 13.1%, and 21.7%, respectively) and women (3.8% [P = 0.001], 2.0% [P < 0.001] 10.3% [P = 0.025], and 16.3% [P < 0.001], respectively). After propensity score matching, there were no significant differences in composite MACE and individual endpoints at two years between the genders. CONCLUSION: Despite all the unfavorable risk factor clustering in women and complex coronary disease in men, the two-year clinical outcomes after coronary stent placement were comparable between Chinese women and men.

A semimechanistic model of the time-course of release of PTH into plasma following administration of the calcilytic JTT-305/MK-5442 in humans.

JTT-305/MK-5442 is a calcium-sensing receptor (CaSR) allosteric antagonist being investigated for the treatment of osteoporosis. JTT-305/MK-5442 binds to CaSRs, thus preventing receptor activation by Ca(2+) . In the parathyroid gland, this results in the release of parathyroid hormone (PTH). Sharp spikes in PTH secretion followed by rapid returns to baseline are associated with bone formation, whereas sustained elevation in PTH is associated with bone resorption. We have developed a semimechanistic, nonpopulation model of the time-course relationship between JTT-305/MK-5442 and whole plasma PTH concentrations to describe both the secretion of PTH and the kinetics of its return to baseline levels. We obtained mean concentration data for JTT-305/MK-5442 and whole PTH from a multiple dose study in U.S. postmenopausal women at doses of 5, 10, 15, and 20 mg. We hypothesized that PTH is released from two separate sources: a reservoir that is released rapidly (within minutes) in response to reduction in Ca(2+) binding, and a second source released more slowly following hours of reduced Ca(2+) binding. We modeled the release rates of these reservoirs as maximum pharmacologic effect (Emax ) functions of JTT-305/MK-5442 concentration. Our model describes both the dose-dependence of PTH time of occurrence for maximum drug concentration (Tmax ) and maximum concentration of drug (Cmax ), and the extent and duration of the observed nonmonotonic return of PTH to baseline levels following JTT-305/MK-5442 administration.

A mathematical model of parathyroid hormone response to acute changes in plasma ionized calcium concentration in humans.

A complex bio-mechanism, commonly referred to as calcium homeostasis, regulates plasma ionized calcium (Ca(2+)) concentration in the human body within a narrow range which is crucial for maintaining normal physiology and metabolism. Taking a step towards creating a complete mathematical model of calcium homeostasis, we focus on the short-term dynamics of calcium homeostasis and consider the response of the parathyroid glands to acute changes in plasma Ca(2+) concentration. We review available models, discuss their limitations, then present a two-pool, linear, time-varying model to describe the dynamics of this calcium homeostasis subsystem, the Ca-PTH axis. We propose that plasma PTH concentration and plasma Ca(2+) concentration bear an asymmetric reverse sigmoid relation. The parameters of our model are successfully estimated based on clinical data corresponding to three healthy subjects that have undergone induced hypocalcemic clamp tests. In the first validation of this kind, with parameters estimated separately for each subject we test the model's ability to predict the same subject's induced hypercalcemic clamp test responses. Our results demonstrate that a two-pool, linear, time-varying model with an asymmetric reverse sigmoid relation characterizes the short-term dynamics of the Ca-PTH axis.