Publications by authors named "B A Sin"

72 Publications

β-blockers and ACE inhibitors are not a risk factor for severe systemic sting reactions and adverse events during venom immunotherapy.

Allergy 2021 Feb 19. Epub 2021 Feb 19.

Department of Dermatology and Venereology, Medical University of Graz, Graz, Austria.

Background: There is controversy whether taking β-blockers or ACE inhibitors (ACEI) is a risk factor for more severe systemic insect sting reactions (SSR) and whether it increases the number or severity of adverse events (AE) during venom immunotherapy (VIT).

Methods: In this open, prospective, observational, multicenter trial, we recruited patients with a history of a SSR and indication for VIT. The primary objective of this study was to evaluate whether patients taking β-blockers or ACEI show more systemic AE during VIT compared to patients without such treatment.

Results: In total, 1,425 patients were enrolled and VIT was performed in 1,342 patients. Of all patients included, 388 (27.2%) took antihypertensive (AHT) drugs (10.4% took β-blockers, 11.9% ACEI, 5.0% β-blockers and ACEI). Only 5.6% of patients under AHT treatment experienced systemic AE during VIT as compared with 7.4% of patients without these drugs (OR: 0.74, 95% CI: 0.43-1.22, p = 0.25). The severity of the initial sting reaction was not affected by the intake of β-blockers or ACEI (OR: 1.14, 95% CI: 0.89-1.46, p = 0.29). In total, 210 (17.7%) patients were re-stung during VIT and 191 (91.0%) tolerated the sting without systemic symptoms. Of the 19 patients with VIT treatment failure, 4 took β-blockers, none an ACEI.

Conclusions: This trial provides robust evidence that taking β-blockers or ACEI does neither increase the frequency of systemic AE during VIT nor aggravate SSR. Moreover, results suggest that these drugs do not impair effectiveness of VIT. (Funded by Medical University of Graz, Austria; Clinicaltrials.gov number, NCT04269629).
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http://dx.doi.org/10.1111/all.14785DOI Listing
February 2021

A Self-Reflection Program for Smoking Cessation in Adolescents: A Phenomenological Study.

Int J Environ Res Public Health 2020 02 8;17(3). Epub 2020 Feb 8.

Red Cross College of Nursing, Chung-Ang University, 84 Heukseok-ro, Dongjak-Gu, Seoul 156-756, Korea.

The study aimed to understand the experiences of adolescent smokers who participated in a self-reflection program for smoking cessation and to develop the theoretical basis for constructing similar programs. The program is unique from other smoking cessation programs in that it seeks to be creative and allow participants to establish an individualized vision for themselves. The participants, ten students from middle and high schools located in cities A and S, were interviewed right after the program ended. Data were collected from August to December 2019 and analyzed using a phenomenological approach to understand participant experiences in depth. The analysis revealed five major themes: 'Uniqueness of the Program,' 'Perception of Smoking Cessation,' 'Positive Reflection on Life,' 'Understanding Others,' and 'A Search for Hope and Vision in Life.' The findings revealed that their smoking behaviors were changed through self-reflection and enhancement of self-efficacy and that the program facilitated the formation of identity and vision for the future, which may indirectly strengthen the motivation for adolescent smokers to quit smoking. These findings suggest the need for a smoking cessation program that enhances self-concept and self-esteem. Moreover, it highlights the importance of follow-up research to ensure effectiveness and the need to develop programs with creative content.
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http://dx.doi.org/10.3390/ijerph17031085DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7037450PMC
February 2020

Comparing Nonopioids Versus Opioids for Acute Pain in the Emergency Department: A Literature Review.

Am J Ther 2019 Nov 13;28(1):e52-e86. Epub 2019 Nov 13.

Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, NY; and.

Background: Pain is the most common reason for patient visits in the emergency department (ED). Opioids have been long considered the standard of care for acute pain in the ED. Because of the opioid crisis, investigation and implementation of novel practices to manage pain is needed. The use of various nonopioids has been suggested as a plausible alternative to opioids, with emerging literature to support its use for acute pain in the ED.

Study Question: To evaluate the safety, efficacy, opioid-sparing effects of nonopioids in patients who present with acute pain in the ED.

Data Sources: We systematically searched PubMed and EMBASE (July 1970 to January 2019).

Study Design: Randomized controlled trials that evaluated nonopioids versus opioids in the ED were eligible. The clinical outcomes measured were change in pain scores compared with baseline, the incidence of adverse events, and use of rescue analgesia.

Results: Twenty-five randomized controlled trials that evaluated the use of nonopioids in 2323 patients [acetaminophen (APAP) (n = 651), diclofenac (n = 547), ketamine (n = 272), ketorolac (n = 225), lidocaine (n = 219), ibuprofen (n = 162), ibuprofen & APAP (n = 162), hydroxyzine & dihydroergotamine (n = 85)] met inclusion criteria. Four trials found significant greater reductions in pain scores, favoring nonopioids. In all trials, the duration of pain relief provided by nonopioids was not sustained over an extended period. Eighteen trials reported no significant differences in reduction of pain scores. Two trials reported improved pain reduction with opioids and one trial reported noninferiority.

Conclusions: Evidence from primary literature suggests that nonopioids could be a feasible alternative to opioids for management of acute pain in the ED as it is effective, safe, and decreases the need for rescue analgesia.
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http://dx.doi.org/10.1097/MJT.0000000000001098DOI Listing
November 2019

Intranasal Sufentanil Versus Intravenous Morphine for Acute Pain in the Emergency Department: A Randomized Pilot Trial.

J Emerg Med 2019 Mar 9;56(3):301-307. Epub 2019 Jan 9.

Department of Emergency Medicine, The Brooklyn Hospital Center, Brooklyn, New York.

Background: Patients in the United States frequently seek medical attention in the emergency department (ED) to address their pain. The intranasal (i.n.) route provides a safe, effective, and painless alternative method of drug administration. Sufentanil is an inexpensive synthetic opioid with a high therapeutic index and rapid onset of action, making it an attractive agent for management of acute pain in the ED.

Objective: The objective of our study was to evaluate the safety and efficacy of i.n. sufentanil as the primary analgesic for acute pain in the ED.

Methods: This was a single-center, prospective, randomized, double-blind, double-dummy, controlled trial that evaluated the use of i.n. sufentanil 0.7 μg/kg via mucosal atomizer device vs. intravenous morphine 0.1 mg/kg in adult patients who presented to the ED with acute pain. The primary outcome was patient's pain score at 10 min after administration of intervention. Secondary outcomes were adverse events, the need for rescue analgesia, and patient satisfaction after treatment.

Results: Thirty patients were enrolled in each group. There was no significant difference in pain scores at 10 min after administration of intervention (sufentanil: 2.0, interquartile range = 2.0-3.3 vs. morphine: 3.0, interquartile range = 2.0-5.3, p = 0.198). No serious adverse events were reported. Rescue analgesia was not requested in either group. No significant difference in median satisfaction scores was found.

Conclusion: The use of i.n. sufentanil at 0.7 μg/kg/dose resulted in rapid and safe analgesia with comparable efficacy to i.v. morphine for up to 30 min in patients who presented with acute pain in the ED.
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http://dx.doi.org/10.1016/j.jemermed.2018.12.002DOI Listing
March 2019

Implementation of an Advanced Pharmacy Practice Model in the Emergency Department.

J Pharm Pract 2020 Aug 13;33(4):481-490. Epub 2019 Jan 13.

Department of Pharmacy Services, The Brooklyn Hospital Center, Brooklyn, NY, USA.

Study Objective: The objective of this retrospective descriptive study was to quantify clinical activities performed by pharmacists in an advanced pharmacy practice model in the emergency department (ED).

Methods: Data from January 2015 to August 2017 extracted from the department of pharmacy's electronic documentation system and the hospital's electronic medical record were collected and reviewed. Cost savings was derived from the system with adaptation from the previous literature and had been validated by our institution's administration as an acceptable reflection of the impact for activity.

Results: The ED pharmacy team participated in a total of 4106 clinical activities that resulted in a cumulative cost avoidance of $5 387 679. Overall, the most common clinical activities that the pharmacy team provided included pharmacotherapy consult (63.3%) and response to medical emergencies (20.7%). A total of 16 219 medication orders placed by ED clinicians were prospectively reviewed and 379 interventions were accepted by ED clinicians. Turnaround times for medication verification in median (interquartile range [IQR]) for 2015, 2016, and 2017 were 2 minutes (1-6 minutes), 3 minutes (1-6 minutes), and 2 minutes (1-5 minutes), respectively. A total of 14 peer-reviewed publications, primarily based on pharmacy practice or use of pharmacotherapy for acute pain, were published by a research program led by the ED pharmacotherapist.

Conclusion: We created and implemented an advanced practice model tailored to our institution's needs. The model maximized opportunities for pharmacists to provide direct patient care, practice at the top of their license, and encouraged the safe and effective use of medications.
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http://dx.doi.org/10.1177/0897190018819412DOI Listing
August 2020

Cytokine genes show distinct polymorphism pattern in Hymenoptera venom allergy.

Allergy 2019 05 15;74(5):1020-1022. Epub 2019 Jan 15.

Division of Immunology & Allergy, School of Medicine, Ankara University, Ankara, Turkey.

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http://dx.doi.org/10.1111/all.13706DOI Listing
May 2019

Omalizumab in the treatment of eosinophilic granulomatosis with polyangiitis (EGPA): single-center experience in 18 cases.

World Allergy Organ J 2018 3;11(1):39. Epub 2018 Dec 3.

1Department of Chest Diseases, Division of Immunology and Allergy, School of Medicine, Ankara University, Ankara, Turkey.

Background: Data are limited regarding the effectiveness of omalizumab in patients with eosinophilic granulomatosis with polyangiitis (EGPA). Our aim was to evaluate the clinical and functional effectiveness of omalizumab in patients with EGPA in long-term follow-up.

Methods: This study was a retrospective chart review of patients with EGPA who were treated with omalizumab injections between May 2012 and April 2018. Once treatment with omalizumab was started, data were collected at various time points: baseline, the 16th week, 1st year, and annually until the last evaluation.

Results: Eighteen patients (16F/2M) with a mean age of 48.61 ± 11.94 years were included. Data were available for all patients for the first year, 12 patients for the second year, 10 patients for the third  year, 8 patients for the fourth  year and 5 patients for the fifth year. All patients were on mean dosage of 15.77 ± 7.6 mg/day oral corticosteroid (OCS) as daily bases for mean 8.61 ± 4 years besides high-dose inhaler corticosteroid/long-acting beta agonist. Antineutrophil cytoplasmic antibodies (ANCA) were positive in 2  patients, and 8 patients were diagnosed as having vasculitis by skin biopsy, one patient had polyneuropathy, and one patient had cardiac involvement.By considering the individual responses of patients and the level of improvement at the last evalulation, 10 (55.6%) patients responded completely, 1 responded partially, and 7 (38.9%) had no improvement. Omalizumab worked as a steroid-sparing agent in all patients and the daily OCS dose was reduced with a mean dosage of 6.28 mg/day at the end of the first year. The mean OCS reduction time for the whole group was 4 months. A reduction in asthma exacerbations/hospitalizations, improvement in forced expiratory volume in 1 second, and no decrease in the eosinophil count during treatment with omalizumab were also observed.

Conclusions: Omalizumab improved asthma control in some patients with EGPA with uncontrolled asthma by reducing asthma exacerbations and oral steroid requirement. However, more data are needed before recommending widespread use of omalizumab in patients with EGPA.
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http://dx.doi.org/10.1186/s40413-018-0217-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6276141PMC
December 2018

Recognition of Sympathetic Crashing Acute Pulmonary Edema (SCAPE) and use of high-dose nitroglycerin infusion.

Am J Emerg Med 2018 08 10;36(8):1526.e5-1526.e7. Epub 2018 May 10.

The Brooklyn Hospital Center, Brooklyn, NY, United States.

Sympathetic Crashing Acute Pulmonary Edema (SCAPE), or flash pulmonary edema, is the extreme end of the acute pulmonary edema spectrum. A sympathetic surge occurs as a result of decreased systemic perfusion resulting in further increases in afterload, causing the patient to decompensate. Patients can decompensate quickly, therefore patients require rapid interventions. The use of high-dose nitroglycerin (HDN) has been a topic of interest as it is believed to achieve preload and afterload reduction. However, its use continues to be controversial due to concerns of drug induced hypotension, syncope or paresthesia. Although there are Free Open Access Medical Education (FOAM) based podcasts as well as few studies to suggest the use of HDN, the evidence is limited by statistical flaws, incomplete dosing parameters and inconsistent methods of administration. In order to address these limitations, a protocol at our ED was created to ensure the safe and effective use of HDN. Here, we present a case of HDN use for the management of SCAPE based on this protocol.
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http://dx.doi.org/10.1016/j.ajem.2018.05.013DOI Listing
August 2018

Opioid-Induced Hyperalgesia in the Nonsurgical Setting: A Systematic Review.

Am J Ther 2019 May/Jun;26(3):e397-e405

Department of Emergency Medicine, The Brooklyn Hospital Center, Brooklyn, NY.

Background: Opioid-induced hyperalgesia (OIH) is a phenomenon that causes an increased pain sensitization and perception of pain to noxious stimuli secondary to opioid exposure. While this clinical effect has been described in the surgical setting, it is unclear if OIH occurs in the nonsurgical setting.

Study Question: To review the available literature which evaluated OIH in nonsurgical settings.

Data Sources: A comprehensive literature search was performed using PubMed (January 1946-July 2017) using a variety of keywords for OIH. This review included randomized controlled trials with objectives to identify OIH in the nonsurgical setting. The clinical outcomes of interest were identification of OIH, adverse events, and impact of OIH on opioid consumption.

Results: The search identified 8 studies that fulfilled the criteria. Six studies enrolled healthy male volunteers, 1 study used chronic low-back patients, and another used heroin-dependent treatment-seeking adults. Studies used various opioids and dosages, including remifentanil, alfentanil, fentanyl, morphine, methadone, and buprenorphine. Three primary experimental pain induction models were used to evaluate for OIH. Measured outcomes included hyperalgesia area, pain threshold, and pain tolerance. All 5 studies that used the electrical stimulation model identified OIH as a significant outcome. However, only 2 of 5 studies using the cold pressor model and 1 of 3 studies using the heat pressor model identified OIH. None of the trials explored clinical outcomes, such as effects on opioid consumption.

Conclusions: Most included studies identified OIH as a significant outcome within the nonsurgical setting. However, due to conflicting conclusions and various limitations, the clinical impact of OIH could not be assessed. Clinicians should monitor for effects of OIH in the nonoperative setting because there is insufficient evidence from the available literature to conclude that OIH is consistently observed in this setting.
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http://dx.doi.org/10.1097/MJT.0000000000000734DOI Listing
November 2019

Intravenous Lidocaine for Intractable Renal Colic Unresponsive to Standard Therapy.

Am J Ther 2019 Jul/Aug;26(4):e487-e488

Department of Emergency Medicine, The Brooklyn Hospital Center, Brooklyn, NY.

Clinical Features: Renal colic is defined as a flank pain radiating to the groin caused by kidney stones in the ureter (urolithiasis). Renal colic is a frequent cause of Emergency Department visits. Most renal colic cases present as acute distress and severe back and/or abdominal pain that require prompt treatment with analgesics.

Therapeutic Challenge: Nonsteroidal anti-inflammatory drugs and opioids are traditionally used for renal colic in the Emergency Department. This trend of practice is based on clinical experience and expert opinion. Consensus guidelines that provide evidence-based approach for the management of renal colic are limited. One consensus guideline from Europe provides a systematic approach for the management of pain with the use of nonsteroidal anti-inflammatory drugss and opioids. However, no guidance is provided on how to manage patients who do not respond to these agents.

Solution: Intravenous lidocaine 120 mg in 100 mL normal saline was infused over 10 minutes for pain management for intractable renal colic unresponsive to standard therapy. Three minutes after initiation of lidocaine infusion, the patient reported numeric pain rating scale 1/10. At 5 minutes, the reported numeric pain rating scale was 0/10 and remained for 60 minutes after initiation of lidocaine infusion. No adverse events were reported during or after the infusion, and no subsequent analgesia was required.
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http://dx.doi.org/10.1097/MJT.0000000000000729DOI Listing
December 2019

The use of intranasal analgesia for acute pain control in the emergency department: A literature review.

Am J Emerg Med 2018 Feb 20;36(2):310-318. Epub 2017 Nov 20.

Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, NY, United States; SUNY Downstate Medical Center, Brooklyn, NY, United States.

Background: Traditional routes for administration of pain medications include oral (PO), intravenous (IV), or intramuscular routes (IM). When these routes are not feasible, the intranasal (IN) route may be considered. The objectives of this evidence-based review were: to review the literature which compared the safety and efficacy of IN analgesia to traditional routes and to determine if IN analgesia should be considered over traditional routes for acute pain control in the ED.

Methods: The MEDLINE and EMBASE databases from July 1970 to July 2017 were searched. Randomized controlled trials (RCT) that evaluated the use of IN analgesia for acute pain in the ED were included. Methodological quality of the trials was assessed using the Grading of Recommendations Assessment, Development, and Evaluation criteria.

Results: Eleven randomized controlled trials (RCT) met the inclusion criteria. Four trials found significant reductions in pain scores, favoring IN analgesia. However, in all of the trials, pain relief was not sustained. Three trials reported superior pain reduction with comparators and three trials reported no statistical significance. One trial described effective pain relief with IN analgesia but did not provide data on statistical analysis.

Conclusion: Eleven randomized controlled trials with various methodological flaws revealed conflicting conclusions. There is limited evidence to support the use of the IN analgesia over traditional routes for acute pain in the ED. The IN route may be a good alternative in scenarios where IV access is not feasible, patients are refusing injectable medications, or a fast onset of pain relief is needed.
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http://dx.doi.org/10.1016/j.ajem.2017.11.043DOI Listing
February 2018

Omalizumab in non-allergic Asthma: A report of 13 cases.

J Asthma 2018 07 12;55(7):756-763. Epub 2017 Sep 12.

a Division of Immunology and Allergy, Department of Chest Diseases, School of Medicine , Ankara University , Ankara , Turkey.

Background: There are limited data regarding the effectiveness of omalizumab in patients with non-allergic asthma.

Objective: To evaluate the clinical and functional effectiveness of omalizumab in patients with non-allergic asthma.

Methods: The study was a single-center, retrospective chart review of patients with non-allergic asthma who were treated with add-on omalizumab between February 2014 and March 2016. After omalizumab was started, data of the asthma control test (ACT), pulmonary function test, and daily oral corticosteroid (OCS) dosage were collected at baseline, 16 weeks, 1 year, 2 and 3 years (if available). The number of exacerbations/hospitalizations were collected 1 year prior to and 6 months/1 year after omalizumab. To calculate the total daily dosage of OCS in milligrams, data for 6 months/1 year prior and after omalizumab treatment were recorded.

Results: Thirteen patients were included. After omalizumab, the mean ACT was significantly increased at 16 weeks (n = 13, p = 0.002), 1 year (n = 7, p = 0.006), and 2 years (n = 5, p = 0.006). The mean daily OCS dose was significantly decreased at 16 weeks (n = 13, p = 0.001), 1 year (n = 7, p = 0.006), and 2 years (n = 5, p = 0.04). The mean number of exacerbations and hospitalizations were decreased at the 6th month (n = 13; p = 0.001, p = 0.005) and 1st year (n = 7; p = 0.01, p = 0.02). The mean total quantity of OCS decreased 42% from 1.4 to 0.8 g in the six-month period prior to and post-omalizumab treatment (n = 6, p = 0.02) and decreased 76% from 3.8 to 0.9 g at 1 year in the pre vs. post-omalizumab treatment comparison (n = 7, p = 0.01). Six (46.2%) patients responded perfectly and seven (53.8%) partially responded to treatment.

Conclusion: Omalizumab can be effective in non-atopic severe asthma.
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http://dx.doi.org/10.1080/02770903.2017.1362427DOI Listing
July 2018

EAACI guidelines on allergen immunotherapy: Hymenoptera venom allergy.

Allergy 2018 04 5;73(4):744-764. Epub 2017 Dec 5.

Food Allergy Referral Centre Veneto Region Department of Women and Child Health, Padua General University Hospital, Padua, Italy.

Hymenoptera venom allergy is a potentially life-threatening allergic reaction following a honeybee, vespid, or ant sting. Systemic-allergic sting reactions have been reported in up to 7.5% of adults and up to 3.4% of children. They can be mild and restricted to the skin or moderate to severe with a risk of life-threatening anaphylaxis. Patients should carry an emergency kit containing an adrenaline autoinjector, H -antihistamines, and corticosteroids depending on the severity of their previous sting reaction(s). The only treatment to prevent further systemic sting reactions is venom immunotherapy. This guideline has been prepared by the European Academy of Allergy and Clinical Immunology's (EAACI) Taskforce on Venom Immunotherapy as part of the EAACI Guidelines on Allergen Immunotherapy initiative. The guideline aims to provide evidence-based recommendations for the use of venom immunotherapy, has been informed by a formal systematic review and meta-analysis and produced using the Appraisal of Guidelines for Research and Evaluation (AGREE II) approach. The process included representation from a range of stakeholders. Venom immunotherapy is indicated in venom-allergic children and adults to prevent further moderate-to-severe systemic sting reactions. Venom immunotherapy is also recommended in adults with only generalized skin reactions as it results in significant improvements in quality of life compared to carrying an adrenaline autoinjector. This guideline aims to give practical advice on performing venom immunotherapy. Key sections cover general considerations before initiating venom immunotherapy, evidence-based clinical recommendations, risk factors for adverse events and for relapse of systemic sting reaction, and a summary of gaps in the evidence.
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http://dx.doi.org/10.1111/all.13262DOI Listing
April 2018

The Use of Intravenous Lidocaine for the Management of Acute Pain Secondary to Traumatic Ankle Injury: A Case Report.

J Pharm Pract 2018 Feb 15;31(1):126-129. Epub 2017 Mar 15.

5 Pediatric Emergency Department, The Brooklyn Hospital Center, Brooklyn, NY, USA.

Sports-related injuries are a frequent cause of visits to the emergency department (ED) across the United States. A majority of these injuries affect the lower extremities with the ankle as the most frequently reported site. Most sports-related injuries are not severe enough to require inpatient hospitalization; however, they often lead to acute distress and pain which require prompt treatment with analgesics. Approximately 22% of patients who presented to the ED required pharmacotherapy for acute pain management. Opioids have been traditionally used for the management of severe acute pain in the ED; however, there are growing concerns for opioid overuse and misuse. As a result, there is growing controversy regarding the appropriate selection of analgesic agents, optimal dosing, and need for outpatient therapy which has contributed to changes in prescribing patterns of opioids in the ED. Lidocaine, a class 1b antiarrhythmic, has been utilized as an analgesic agent. Its use has been documented for the management of intractable chronic pain caused by cancer, stroke, neuropathies, or nephrolithiasis. However, literature describing the use of intravenous lidocaine for the management of acute pain secondary to trauma is limited to a single case series. This case report describes the use of intravenous lidocaine in a 17-year-old male who presented to the ED in acute distress secondary to ankle dislocation and fracture. This report serves to describe additional clinical experience with intravenous lidocaine for the management of acute pain secondary to ankle fracture in the emergency department.
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http://dx.doi.org/10.1177/0897190017696954DOI Listing
February 2018

The Feasibility and Impact of Prospective Medication Review in the Emergency Department.

J Pharm Pract 2018 Feb 13;31(1):22-28. Epub 2017 Mar 13.

6 Emergency Medicine, The Brooklyn Hospital Center, Brooklyn, NY, USA.

Objective: We evaluated the feasibility and impact of prospective medication review (PMR) in the emergency department (ED).

Methods: This was a retrospective cohort study of all nonadmitted ED patients who were prescribed medication orders by ED clinicians from September 2014 to September 2015 to determine the time intervals utilized during each step of the medication use process and quantify the number of interventions conducted by the pharmacist and cost avoidance accrued from the interventions.

Results: A total of 834 medication orders were included for evaluation. The median time for order verification, order verification to dispense, and dispense to administration were 3 minutes (interquartile range [IQR] = 1-7 minutes), 20 minutes (IQR = 7-45 minutes), and 10 minutes (IQR = 6-16 minutes). The median time interval for order verification was longer during the overnight pharmacy shift (median = 5 minutes, IQR = 2-9 minutes) compared to the day and evening shifts (median = 3 minutes, IQR = 1-6 minutes). A total of 563 interventions were recommended by the pharmacists and accepted by ED clinicians. These interventions equated to US$47 585 worth of cost avoidance.

Conclusion: The PMR is a feasible process that resulted in safe and effective use of medications without causing delays to patient care.
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http://dx.doi.org/10.1177/0897190017696948DOI Listing
February 2018

[Attitudes of adult asthma patients towards influenza vaccination].

Tuberk Toraks 2016 Dec;64(4):269-274

Department of Immunology and Allergy, Faculty of Medicine, Ankara University, Ankara, Turkey.

Introduction: It is known that viral infections trigger exacerbations in asthma patients.There are conflicting reports on whether influenza vaccine is preventive or not. In this study, we aimed to evaluate asthmatic patient's attitude towards influenza vaccine and to determine which factors affect this attitude.

Materials And Methods: A questionnaire involving data about demographic information, co-morbidities, frequency of viral upper respiratory tract infections, subject's influenza vaccination status and attitude towards vaccination had been filled for our outpatient clinic asthma patients and also for healthy controls. Results were evaluated separately for the two groups and then compared to each other.

Result: For the study; 108 asthma patients (91 female, 17 male) and 110 non-asthmatic controls (64 female, 46 male) were enrolled. In asthma group, vaccination rates were significantly higher in the previous year (40.7%) and nearly half of them stated that they do regularly have influenza shots every year. Contrast to this find; half of the patients in the control group stated that they do not need to vaccinate themselves and 26.2% said that they don't believe influenza vaccine has any preventive effect. Also in the asthma group, this ratio was similar to the control group (20.3%). In asthma group, 66.7% of the patients who had side effects at their previous shots did not want to vaccinate themselves this year (p= 0.02). More than a half of the patients (53.1%) whom did not have shots had an episode of viral upper respiratory tract infection this year and this rate was significantly lower in the vaccinated group (p= 0.00). This result highlights the preventive effect of vaccination.

Conclusions: We found that asthma patients' knowledge on influenza infection and vaccine were insufficient and also their belief towards the preventive features of the vaccination was low. Informing and encouraging patients about preventive medicine through various activities and meetings would be crucial.
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December 2016

The Use of Ketamine for Acute Treatment of Pain: A Randomized, Double-Blind, Placebo-Controlled Trial.

J Emerg Med 2017 May 6;52(5):601-608. Epub 2017 Mar 6.

Department of Emergency Medicine, The Brooklyn Hospital Center, Brooklyn, New York.

Background: Pain is one of the most common reasons for emergency department (ED) visits in the United States. Ketamine is a sedative with N-methyl-D-aspartate (NMDA) receptor antagonism. Recent literature has suggested that the use of subdissociative dose ketamine (SDDK) may be safe and effective for acute pain.

Objective: The objective of our study was to evaluate ketamine in subdissociative doses as an adjunct for acute pain in the ED.

Methods: This was a single-center, prospective, randomized, double-blind, placebo-controlled trial that evaluated the use of SDDK in adult patients who presented to the ED with acute pain. Patients received ketamine 0.3 mg/kg via intravenous piggyback over 15 min or placebo. Morphine 0.1 mg/kg intravenous push was administered with the study interventions. The primary outcome was the patient's pain score 15 min after initiation of the intervention. Secondary outcomes included adverse events, consumption of rescue analgesia, patient's length of stay, and patient satisfaction with treatment.

Results: Thirty patients were enrolled in each group. Median pain scores in patients who received ketamine were lower than in controls at 15 min (3.5 [interquartile range {IQR} 1.0-7.3 vs. 6.0 [IQR 4.0-9.0], respectively; p = 0.018). No serious adverse events occurred. No difference was detected in the amount of rescue analgesia used or in length of stay. Patients who received ketamine reported a higher mean satisfaction score with their pain management (8.57 [standard deviation {SD} 2.1]) than patients who received placebo (6.05 [SD 2.6]; p = 0.01).

Conclusion: When used as an adjunct, SDDK administered at 0.3 mg/kg over 15 min resulted in safe and effective analgesia for ≤30 min in patients who presented with acute pain in the ED.
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http://dx.doi.org/10.1016/j.jemermed.2016.12.039DOI Listing
May 2017

Allergen immunotherapy for insect venom allergy: a systematic review and meta-analysis.

Allergy 2017 Mar 25;72(3):342-365. Epub 2017 Jan 25.

Allergy and Respiratory Research Group, The University of Edinburgh, Edinburgh, UK.

Background: The European Academy of Allergy and Clinical Immunology (EAACI) is in the process of developing the EAACI Guidelines on Allergen Immunotherapy (AIT) for the management of insect venom allergy. To inform this process, we sought to assess the effectiveness, cost-effectiveness and safety of AIT in the management of insect venom allergy.

Methods: We undertook a systematic review, which involved searching 15 international biomedical databases for published and unpublished evidence. Studies were independently screened and critically appraised using established instruments. Data were descriptively summarized and, where possible, meta-analysed.

Results: Our searches identified a total of 16 950 potentially eligible studies; of which, 17 satisfied our inclusion criteria. The available evidence was limited both in volume and in quality, but suggested that venom immunotherapy (VIT) could substantially reduce the risk of subsequent severe systemic sting reactions (OR = 0.08, 95% CI 0.03-0.26); meta-analysis showed that it also improved disease-specific quality of life (risk difference = 1.41, 95% CI 1.04-1.79). Adverse effects were experienced in both the build-up and maintenance phases, but most were mild with no fatalities being reported. The very limited evidence found on modelling cost-effectiveness suggested that VIT was likely to be cost-effective in those at high risk of repeated systemic sting reactions and/or impaired quality of life.

Conclusions: The limited available evidence suggested that VIT is effective in reducing severe subsequent systemic sting reactions and in improving disease-specific quality of life. VIT proved to be safe and no fatalities were recorded in the studies included in this review. The cost-effectiveness of VIT needs to be established.
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http://dx.doi.org/10.1111/all.13077DOI Listing
March 2017

Does the medical diagnosis of occupational asthma coincide with the legal diagnosis?

J Asthma 2017 Nov 5;54(9):930-937. Epub 2017 Jan 5.

a Department of Chest Diseases, Division of Allergy and Clinical Immunology , Ankara University School of Medicine , Ankara , Turkey.

Objective: The incidence of occupational asthma (OA) is increasing worldwide. In this study, we first aimed to document the rate of diagnosis of OA among patients who were referred to our clinic from the Social Security Institution and the factors that affected diagnosis; secondly, we aimed to assess the consistency of the medical and legal diagnoses.

Methods: The study involved 132 consecutive patients who were referred to our clinic for the evaluation of OA between 2010 and 2015. Detailed workplace history, the tools used in the diagnosis such as peak expiratory flow (PEF) monitoring and bronchial provocation tests, and the final medical diagnosis were recorded from case files.

Results: Asthma was diagnosed in 75% (n = 99) of the patients. Among them, 22.2% were diagnosed as having OA. The diagnosis was confirmed by serial PEF measurements, non-specific bronchial hyperreactivity assessment or both of the tests both at work and off-work periods. OA diagnosis was mostly established in active workers (72.7%). The legal diagnosis period was completed in 54.5% of these 22 patients, and 50% (n = 11) were officially diagnosed as having OA with a 91.6% concordance with medical diagnosis.

Conclusion: This study verifies the importance of diagnosing asthma correctly as a first step in the evaluation of OA. Diagnostic tests other than specific provocation tests could be preferential in patients who still work in the same field. We believe that cooperation with the patient's occupational physician and adequate recognition of the work environment will improve the consistency of legal and medical diagnoses.
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http://dx.doi.org/10.1080/02770903.2016.1277541DOI Listing
November 2017

Intravenous Acetaminophen for Renal Colic in the Emergency Department: Where Do We Stand?

Am J Ther 2017 Jan/Feb;24(1):e12-e19

1Division of Pharmacy Practice, Arnold and Marie Schwartz College of Pharmacy, LIU Pharmacy, Brooklyn, NY; 2Department of Pharmacy, Division of Pharmacotherapy, The Brooklyn Hospital Center, Brooklyn, NY; 3Arnold and Marie Schwartz College of Pharmacy, LIU Pharmacy, Brooklyn, NY; 4Drug Regulatory Affairs M.S. Program, Arnold and Marie Schwartz College of Pharmacy, LIU Pharmacy, Brooklyn, NY; and 5Department of Emergency Medicine, The Brooklyn Hospital Center, Brooklyn, NY.

Background: The efficacy, safety, opioid-sparing effects, and cost-benefit analyses of intravenous (IV) acetaminophen (APAP) in treating renal colic remain controversial.

Study Question: To evaluate the safety, efficacy, opioid-sparing effects, and cost-benefits of IV APAP in patients who present with renal colic in the emergency department (ED).

Data Sources: We systematically searched PubMed (January 1970 to April 2016).

Study Design: Randomized controlled trials which evaluated IV APAP for renal colic in the ED were eligible. The clinical outcomes measured were change in pain scores from baseline, incidence of adverse events, use of rescue analgesia, and cost-benefits. Forest plots were constructed using the Mantel-Haenszel method in a random effect model to changes in pain scores from the baseline to designated intervals.

Results: The analysis suggested a difference in pain reduction favoring IV APAP over morphine. IV APAP had a significant effect in pain reduction than IV morphine (difference in mean pain score reduction = 7.5 in a 100-point visual analog scale (VAS); 95% confidence interval [CI], 1.99-13.00; P = 0.008). There was mild-to-moderate study heterogeneity (I = 42%). No difference was observed when IV APAP was compared with intramuscular piroxicam for pain reduction (difference in mean pain score reduction = 0.17 in a VAS reduction ≥50% VAS; 95% CI, -0.22 to 0.57) and to intramuscular diclofenac (difference in mean pain score reduction = 0.00 in a numeric rating scale reduction ≥50%; 95% CI, -0.12 to 0.12). The analysis for nonsteroidal anti-inflammatory drugs versus IV APAP revealed no difference (difference in mean pain score reduction = 0.01 in a 100-point VAS; 95% CI, -0.10 to 0.13; P = 0.80).

Conclusions: In this meta-analysis, we found that data on the efficacy, safety, opioid-sparing effects, and cost-benefit analyses of IV APAP for renal colic were weak. Based on the available data, IV APAP should not be considered as an alternative to opioids or nonsteroidal anti-inflammatory drugs for the primary management of renal colic in the ED.
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http://dx.doi.org/10.1097/MJT.0000000000000526DOI Listing
February 2017

Authors' Response.

Consult Pharm 2015 Nov;30(11):628

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November 2015

Quality-of-life in insect venom allergy: validation of the Turkish version of the "Vespid Allergy Quality of Life Questionnaire" (VQLQ-T).

Springerplus 2016 10;5:583. Epub 2016 May 10.

Division of Immunology and Allergy, Department of Pulmonary Diseases, School of Medicine, Ankara University, Ankara, Turkey.

Purpose: "Vespid Allergy Quality of Life Questionnaire (VQLQ)" has been used to assess psychological burden of disease. The aim of this study was to evaluate validity, reliability and responsiveness to interventions of the Turkish version.

Methods: The Turkish language Questionnaire (VQLQ-T) was administered to 81 patients with bee allergy and 65 patients with vespid allergy from different groups to achieve cross-sectional validation. To establish longitudinal validity, the questionnaire was administered to 36 patients treated with venom immunotherapy.

Results: The cross-sectional validation in patients with vespid venom allergy showed a correlation coefficient of 0.97 (Cronbach α). Spearman's correlation coefficient of the pretreatment VQLQ-T score with Expectation of Outcome (EoO) questionnaire score was 0.55 (p < 0.001). After treatment, correlation between VQLQ-T score and EoO score was 0.64 (p = 0.003) in these patients. The cross-sectional instrument validation for non-beekeepers with bee venom allergy yielded a correlation coefficient of 0.96 (Cronbach α). Spearman's correlation coefficient between pretreatment VQLQ-T score and EoO score was 0.47 (p < 0.001) and after treatment, correlation between VQLQ-T score and EoO score was 0.78 (p = 0.008) in these patients. These findings indicate cross-sectional validity of VQLQ-T. In the longitudinal validation, there was a positive correlation between EoO and VQLQ-T with a correlation coefficient of 0.562 (p < 0.001). While mean (±SD) VQLQ-T score was 5.27 (±1.29) in pretreatment, it was 2.78 (±1.01) after treatment (p < 0.001). The correlation between the mean change in VQLQ-T score and the mean change in EoO score was 0.42 (p = 0.011).

Conclusions: The Turkish version of VQLQ-T enables measurement of Quality of Life (QoL) in patients with either vespid or bee venom allergy. Furthermore, responsiveness of this instrument demonstrates the questionnaire's ability to detect changes over time.
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http://dx.doi.org/10.1186/s40064-016-2246-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4864742PMC
June 2016

Intranasal Ketamine in Subdissociative Doses for a 2-Year-Old.

Am J Ther 2017 Jul/Aug;24(4):e497-e498

1Division of Pharmacy Practice LIU Pharmacy (Arnold and Marie Schwartz College of Pharmacy) Brooklyn, NY 2Emergency Department Clinical Pharmacy Educator Emergency Medicine Clinical Research Program The Brooklyn Hospital Center Brooklyn, NY 3LIU Pharmacy (Arnold and Marie Schwartz College of Pharmacy) Brooklyn, NY 4Department of Pharmacy Services The Brooklyn Hospital Center Brooklyn, NY 5Pediatric Emergency Department The Brooklyn Hospital Center Brooklyn, NY.

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http://dx.doi.org/10.1097/MJT.0000000000000458DOI Listing
February 2019

Immunologic alterations and efficacy of subcutaneous immunotherapy with Dermatophagoides pteronyssinus in monosensitized and polysensitized patients.

Ann Allergy Asthma Immunol 2016 Mar;116(3):244-251.e2

Division of Immunology and Allergic Diseases, Department of Chest Diseases, Ankara University, School of Medicine, Ankara, Turkey. Electronic address:

Background: There is a continuing debate about whether monoallergen subcutaneous immunotherapy (SCIT) is able to modulate immune and clinical responses toward main causal allergen in polysensitized patients.

Objective: To investigate short-term immunologic changes and clinical effectiveness of SCIT with Dermatophagoides pteronyssinus in monosensitized and polysensitized patients who have rhinitis with or without asthma.

Methods: Nineteen monosensitized and 24 polysensitized patients participated in this prospective, self-placebo-controlled, interventional study. Cluster immunotherapy with D pteronyssinus was administered after 2 months of placebo in both groups. Immunologic parameters, including CD203c expression on basophils after allergen stimulation, total IgE, specific IgE, and specific IgG4, were evaluated at baseline, after placebo, and after immunotherapy. Clinical effectiveness was assessed using monthly symptom-medication scores, visual analog scale, quality-of-life questionnaire, and nasal allergen provocation test.

Results: At baseline, polysensitized patients had higher CD203c expression on basophils than monosensitized patients (P = .007). Activated basophils expressing CD203c, total IgE, and specific IgG4 were significantly increased after immunotherapy compared with baseline and placebo in the polysensitized group (P < .025). After immunotherapy, specific IgE and D pteronyssinus-induced CD203c expression were significantly higher in polysensitized than monosensitized patients (P < .05). The total symptom scores and the Mini Rhinoconjunctivitis Quality of Life Questionnaire scores in polysensitized patients and the visual analog scale scores in both groups were lower after immunotherapy compared with baseline and placebo (P < .025). Titrated nasal allergen provocation test with D pteronyssinus increased after immunotherapy in the monosensitized group (P < .05).

Conclusion: This study indicates that monosensitized and polysensitized patients have distinct humoral response and basophil behavior to SCIT. However, a single-allergen immunotherapy corresponding to the most clinically troublesome allergy in polysensitized patients can lead to early clinical efficacy comparable to that seen in monosensitized patients.

Trial Registration: clinicaltrials.gov Identifier: NCT01795846.
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http://dx.doi.org/10.1016/j.anai.2016.01.002DOI Listing
March 2016

Allergen immunotherapy for insect venom allergy: protocol for a systematic review.

Clin Transl Allergy 2015 16;6. Epub 2016 Feb 16.

Allergy and Respiratory Research Group, The University of Edinburgh, Edinburgh, UK.

Background: The European Academy of Allergy and Clinical Immunology (EAACI) is in the process of developing the EAACI Guidelines for Allergen Immunotherapy (AIT) for the Management of Insect Venom Allergy. We seek to critically assess the effectiveness, cost-effectiveness and safety of AIT in the management of insect venom allergy.

Methods: We will undertake a systematic review, which will involve searching international biomedical databases for published, in progress and unpublished evidence. Studies will be independently screened against pre-defined eligibility criteria and critically appraised using established instruments. Data will be descriptively and, if possible and appropriate, quantitatively synthesised.

Discussion: The findings from this review will be used to inform the development of recomendations for EAACI's Guidelines on AIT.
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http://dx.doi.org/10.1186/s13601-016-0095-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4754882PMC
February 2016

Hydrochlorothiazide Induced Lichen Planus in the Emergency Department.

J Pharm Pract 2017 Apr 9;30(2):266-269. Epub 2016 Jul 9.

3 Department of Emergency Medicine, The Brooklyn Hospital Center, Brooklyn, NY, USA.

Lichen planus (LP) is a mucocutaneous inflammatory disease that involves papulosquamous eruption of the skin, scalp, nails, and mucous membranes. This uncommon condition has a higher prevalence in African Americans and females. Women accounts for 50% of cutaneous LP (CLP) and 60% to 75% of oral LP (OLP) cases. Diagnosis is centered around clinical presentation. Patient evaluation requires a comprehensive physical examination to identify any potential sites of involvement. LP is usually described by the "Six P's": planar, purple, polygonal, pruritic, papules, and plaques. Drug-induced LP, or lichenoid drug reactions, is uncommon and usually indiscernible from other forms of LP. Lichenoid drug reactions exhibit parakeratosis, dermal infiltrates of eosinophils, or perivascular lymphocytic infiltrates affecting the reticular dermis. An extended time interval between the initiation of drug to the onset of symptoms usually does not exclude potential diagnosis of a lichenoid drug reaction. We describe a case of hydrochlorothiazide-induced LP without prolonged exposure to sunlight diagnosed in the emergency department (ED). In this case, a pharmacist-conducted medication reconciliation played an integral role in accurately recognizing this adverse drug reaction. Our case report adds to the limited available literature on the topic, most of which originated more than 30 years ago.
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http://dx.doi.org/10.1177/0897190016630879DOI Listing
April 2017

The Use of Intravenous Acetaminophen for Acute Pain in the Emergency Department.

Acad Emerg Med 2016 05 13;23(5):543-53. Epub 2016 Apr 13.

The Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, NY.

Objectives: Acetaminophen (APAP) is a mainstay for pain management worldwide. The intravenous (IV) formulation has been widely used in Europe for more than 20 years in adults and children. In the United States, IV APAP obtained full approval from the Food and Drug Administration in 2010. There is emerging literature to suggest the use of IV APAP for pain reduction in the emergency department (ED). This evidence-based review examines the evidence pertaining to the use of IV APAP for acute pain control in the ED.

Methods: The MEDLINE and EMBASE databases were searched. Randomized controlled trials (RCTs) that described or evaluated the use of IV APAP for acute pain in the ED were included. Duplicate articles, unpublished reports, abstracts, review articles, and non-English literature were excluded. The primary outcome of interest in this review was the difference in pain score between IV APAP and active comparator or placebo from baseline to a cutoff time specified in the original trials. Secondary outcome measures were the incidence of adverse events and reduction in the amount of adjuvant analgesics consumed by patients who received IV APAP. Methodologic quality of the trials was assessed using the Grading of Recommendations Assessment, Development, and Evaluation criteria.

Results: Fourteen RCTs with various methodologic flaws, which enrolled a total of 1,472 patients, met the inclusion criteria. The level of evidence for the individual trials ranged from very low to moderate. In three of the 14 trials, a significant reduction in pain scores was observed in patients who received IV APAP. The first trial found a significant reduction in mean pain scores when IV APAP was compared to IV morphine at 30 minutes after drug administration (4.7 ± 2.3 vs. 2.9 ± 2.2). In the second trial, patients who received IV APAP reported of lower pain scores (31.7 ± 18 mm, 95% confidence interval [CI] = 8.2 to 25.2 mm) compared to those who received IV morphine (48.3 ± 14.1 mm, 95% CI = 8.2 to 25.2 mm), 15 minutes after drug administration. A third trial found a significant reduction (p = 0.005) in the mean pain scores when IV APAP was compared to intramuscular piroxicam at 90 minutes after drug administration. In the remaining eight trials, pain scores were not statistically different when IV APAP was compared to other pain medications. The incidence of side effects associated with IV APAP was very low.

Conclusions: Fourteen RCTs with various methodologic flaws provided limited evidence to support the use of IV APAP as the primary analgesic for acute pain control in patients who present to the ED.
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http://dx.doi.org/10.1111/acem.12921DOI Listing
May 2016