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Objectives This study aimed to evaluate the impact of intravenous opioid product restrictions at an academic medical institution in an urban setting during the time of critical opioid shortages. We assessed the effect of ordering restrictions on inpatient opioid utilization measured by 1) changes in intermittent oral and injectable opioid product administration; 2) changes in total institutional opioid administration; and 3) changes in the utilization of individual restricted opioid agents. Methods This study is a single-center retrospective analysis by interrupted time series of institutional opioid utilization from 07/2017 to 06/2018. Utilization was quantified using milligrams of intravenous morphine equivalent administered or dispensed per admitted patient. Restrictions were grouped into 10 distinct phases, which informed the interruptions in linear regression models. Results Sequential restrictions during the study period led to shifts in use of individual agents but did not have a significant impact on overall total opioid utilization. "Soft" restrictions did not have a direct, statistically significant impact on medication use but did decrease utilization over time. In situations where a product was restricted with a "soft stop" followed by a "hard stop," the "hard stop" directly reduced usage. Conclusions Targeted ordering restrictions allowed the institution to redirect drug use according to clinical need without affecting the overall utilization. Clinical decision support led providers to choose therapeutically equivalent alternatives. The demonstrated effect of restrictions will guide institutions in the selection of "hard stop" or "soft stop" restrictions in response to future shortages. [ABSTRACT FROM AUTHOR]

Background In 2012, the US Food and Drug Administration approved a Risk Evaluation and Mitigation Strategy (REMS) programme including mandatory prescriber training and a patient/provider acknowledgement form to prevent fetal exposure to mycophenolate. Prior to the REMS, the teratogenic risk was solely mitigated via written information (black box warning, medication guide (MG period)). To date, there is no evidence on the effectiveness of the REMS. Methods We used a national private health insurance claims database to identify women aged 15-44 who filled ≥1 mycophenolate prescription. To compare fetal exposure during REMS with the MG period, we estimated the prevalence of pregnancy at treatment initiation in a pre/post comparison (analysis 1) and the rate of conception during treatment in a retrospective cohort study (analysis 2). Pregnancy episodes were measured based on diagnosis and procedure codes for pregnancy outcomes or prenatal screening. We used generalised estimating equation models with inverse probability of treatment weighting to calculate risk estimates. Results The adjusted proportion of existing pregnancy per 1000 treatment initiations was 1.7 (95% CI 1.0 to 2.9) vs 4.1 (95% CI 3.2 to 5.4) during the REMS and MG period. The adjusted prevalence ratio and prevalence difference were 0.42 (95% CI 0.24 to 0.74) and -2.4 (95% CI -3.8 to -1.0), respectively. In analysis 2, the adjusted rate of conception was 12.5 (95% CI 8.9 to 17.6) vs 12.9 (95% CI 9.9 to 16.9) per 1000 years of mycophenolate exposure time in the REMS versus MG periods. The adjusted risk ratio and risk difference were 0.97 (95% CI 0.63 to 1.49) and -0.4 (95% CI -5.9 to 5.0), respectively. Sensitivity analyses on the estimated conception date demonstrated robustness of our findings. Conclusion While the REMS programme achieved less pregnancies at treatment initiation, it failed to prevent the onset of pregnancy during treatment. Enhanced approaches to ensure effective contraception during treatment should be considered. [ABSTRACT FROM AUTHOR]

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Background: With an increasing prevalence of psychotropic polypharmacy, clinicians depend on drug-drug interaction (DDI) references to ensure safe regimens, but the consistency of such information is frequently questioned.Objectives: To evaluate the consistency of psychotropic DDIs documented in Clinical Pharmacology (CP), Micromedex (MM), and Lexicomp (LC) and summarize consistent psychotropic DDIs.Methods: In May 2016, we extracted severe or major psychotropic DDIs for 102 psychotropic drugs, including central nervous system (CNS) stimulants, antidepressants, an antimanic agent (lithium), antipsychotics, anticonvulsants, and anxiolytics-sedatives-hypnotics from CP, MM, and LC. We then summarized the psychotropic DDIs that were included in all 3 references and with evidence quality of "excellent" or "good" based on MM.Results: We identified 1496, 938, and 1006 unique severe or major psychotropic DDIs from CP, MM, and LC, respectively. Common adverse effects related to psychotropic DDIs include increased or decreased effectiveness, CNS depression, neurotoxicity, QT prolongation, serotonin syndrome, and multiple adverse effects. Among these interactions, only 371 psychotropic DDIs were documented in all 3 references, 59 of which had "excellent" or "good" quality of evidence based on MM.Conclusion: The consistency of psychotropic DDI documentation across CP, MM, and LC is poor. DDI documentations need standards that would encourage consistency among drug information references. The list of the 59 DDIs may be useful in the assessment of psychotropic polypharmacy and highlighting DDI alerts in clinical practice. [ABSTRACT FROM AUTHOR]

In Cuba is present, in the agro-industrial activities, a group of processes that begin with the crop of the product in the field and finish in the industry that processes them. Among these are the tobacco agro-industry, the citric fruits agro-industry, and the sugar agro-industry. A fundamental process in the sugar agro-industry constitutes the crop, benefit and transportation of the sugar cane. In this process, the sugar cane after been cut and hoisted for loading the vehicles that transport it to the mill, is transferred, by several means of transportation to the benefit centers, where a high percentage of the alien matters accompanying it is eliminated. Then, the transportation of the sugar cane takes place to the swing bolster of the sugar factory. This present article shows a procedure for the making of logistic decisions with multi-criteria approach in the chain of cut, hoisting-loading and transportation of the sugar cane. [ABSTRACT FROM AUTHOR]

The current situation of the Cuban Economy has made it possible to elevate its efficiency in order to get some meaningful incomes. In the sugar-cane industry, being one of the major branches, it has become necessary, to apply every mechanism aimed at ensuring its optimum operations in every sector. Being one of the fundamentals the chain of cut, boost and transportation of the sugar cane, which constitutes the link that ties the agriculture with the industry about the principal dalliance and the cost of process of obtaining sugar which acts on several criterions of role playing. This has therefore become necessary for the usage of the multi-objective optic for taking of decisions and precisely here, radicates the object of this present work. [ABSTRACT FROM AUTHOR]