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ObjectiveTo determine whether there was an increase in payments for neurologist-prescribed drugs, we performed a retrospective analysis of prescription claims in the Medicare Part D Prescriber Public Use Files from 2013 to 2017.MethodsWe included claims prescribed by providers with the taxonomy “neurology” and included drugs present in all 5 years. Drugs were designated in 2013 as generic (GEN), brand name only (BNO), and brand name prescribed even though a generic equivalent is available (BNGE). To observe payment trends, the percentage change in the per claim payment was compared between drug classes.ResultsWe included 520 drugs, of which 322 were GEN, 61 were BNO, and 137 were BNGE, representing 90,716,536 claims and generating payments of $26,654,750,720. While the number of claims from 2013 to 2017 increased only 7.6%, the total payment increased 50.4%. Adjusted for inflation, claim payments for GEN drug increased 0.6%, compared to significant increases in BNO and BNGE drugs of 42.4% and 45.0% (ptrend < 0.001). The percentage of overall GEN claims increased from 81.9% to 88.0%, BNO increased from 4.9% to 6.2%, and BNGE decreased from 13.3% to 5.8%. Neuroimmunology/multiple sclerosis drugs represented >50% of the total payments despite being only 4.3% of claims.ConclusionsPayments for neurologist-prescribed brand name, but not generic, drugs in Medicare Part D increased consistently and well above inflation from 2013 to 2017. Unless the overall trend stabilizes or is reversed or high cost-to-claim drugs are addressed, this trend will place an increasing burden on the neurologic Medicare budget.

Background Intravenous (IV) tissue plasminogen activator (tPA) utilization in acute ischemic stroke (AIS) requires weight-based dosing and a standardized infusion rate. In our regional network, we have tried to minimize tPA dosing errors. We describe the frequency and types of tPA administration errors made in our comprehensive stroke center (CSC) and at community hospitals (CHs) prior to transfer. Methods Using our stroke quality database, we extracted clinical and pharmacy information on all patients who received IV tPA from 2010-11 at the CSC or CH prior to transfer. All records were analyzed for the presence of inclusion/exclusion criteria deviations or tPA errors in prescription, reconstitution, dispensing, or administration, and for association with outcomes. Results We identified 131 AIS cases treated with IV tPA: 51% female; mean age 68; 32% treated at the CSC, and 68% at CHs (including 26% by telestroke) from 22 CHs. tPA prescription and administration errors were present in 64% of all patients (41% CSC, 75% CH, P P Conclusion Despite focus on minimization of tPA administration errors in AIS patients, such errors were very common in our regional stroke system. Although an association between tPA errors and stroke outcomes was not demonstrated, quality assurance mechanisms are still necessary to reduce potentially dangerous, avoidable errors.

Uremic bleeding syndrome is a recognized consequence of renal failure and can result in clinically significant sequelae. Although the pathophysiology of the condition has yet to be fully elucidated, it is believed to be multifactorial. This article is a review of both the normal hemostatic and homeostatic mechanisms that operate within the body to prevent unnecessary bleeding, as well as an in-depth discussion of the dysfunctional components that contribute to the complications associated with uremic bleeding syndrome. As a result of the multifactorial nature of this syndrome, prevention and treatment options can include one or a combination of the following: dialysis, erythropoietin, cryoprecipitate, desmopressin, and conjugated estrogens. Here, these treatment options are compared with regard to their mechanism of action, and onset and duration of efficacy. An extensive review of the clinical trials that have evaluated each treatment is also presented. Lastly, we have created an evidence-based treatment algorithm to help guide clinicians through most clinical scenarios, and answered common questions related to the management of uremic bleeding.

BACKGROUND: Utilization of systemic IV tPA in acute ischemic stroke (AIS) requires weight-based dosing and a standardized infusion rate. We describe the frequency and types of tPA administration errors made in a comprehensive stroke center (CSC) and at stroke receiving facilities prior to transfer. METHODS: Using a prospectively-collected stroke quality database, all patients included received IV tPA from 2010-11 either at the CSC or prior to transfer (“drip-and-ship”). Retrospective data collection included pharmacy, air transport, and nursing records. RESULTS: We identified 131 tPA-treated AIS cases: 51% female; mean age 68 years; 33% treated at CSC; and 67% treated pre-transfer (including 16% by telestroke) from 22 facilities. Treatment of stroke mimics was more common at the CSC (12% vs 9%, p=NS). Pre-tPA blood pressure was more frequently not recorded in transfers (64% vs 7%, p 60 minutes (14%), total dose >90mg (5%), suspension/discontinuation of infusion (5%), or delayed tPA delivery to bedside (4%). Body weight discrepancies between institutions were frequent among transfers (42%). Parenchymal hematomas (PH) occurred in 7.5% of all patients (or 6.2% with tPA errors, 9.1% without errors); in-hospital death occurred in 10.7% overall (or 9.2% with errors, 12.1% without errors). PH, mortality and mRS did not differ between CSC-treated patients and transferred patients nor between those with and without errors. See table. CONCLUSION: tPA errors were very common in our large, regional stroke system, particularly among patients treated as “drip-and-ships”. Though in this study errors were not associated with outcomes, CSCs should include tPA dosing/administration education and quality assurance mechanisms within their systems in order to reduce avoidable, systematic errors.

*Guidelines have been published for management of chronic systolic heart failure to reduce patient morbidity and mortality. Objective: A quality review of the heart failure medical therapy for a community family medicine residency program clinic and a multidisciplinary heart failure specialty clinic was performed to compare adherence to ACC/AHA heart failure guidelines, with regard to medications and in titrating to recommended target doses. Methods: The study was a retrospective chart review and data collected included name and dose of any ACEI, beta-blocker, ARB, or other medication addressed in the guidelines. Results: Specialty clinic patients had significantly lower systolic blood pressures and ejection fractions. Significantly more patients were prescribed beta-blockers in the specialty clinic population (98% vs 80%, p

Purpose. A case of rhabdomyolysis associated with the use of Hydroxycut is reported. Summary. An 18-year-old Caucasian man arrived at an urgent care center complaining of bilateral leg pain and weakness. His creatine kinase (CK) concentration was 13,220 IU/L. He was diagnosed with rhabdomyolysis and instructed to go to the emergency room. He admitted to decreased urine output for four to five days before hospital admission. He had no significant past medical history, and his medications before symptom onset included Hydroxycut four caplets by mouth daily, naproxen sodium 220 mg by mouth as needed for pain, dextroamphetamine saccharate–amphetamine salts (Adderall) 15 mg by mouth once five days prior for a school examination, and hydrocodone–acetaminophen and cyclobenzaprine for pain. His social history revealed a recent increase in his exercise regimen, and his last alcoholic beverage was consumed five days prior. Upon admission, laboratory tests revealed elevated concentrations of CK, serum creatinine (SCr), aspartate transaminase, alanine transaminase (ALT), and alkaline phosphatase. The patient was diagnosed with rhabdomyolysis and treated with intravenous hydration. The patient’s leg tenderness was reduced, and he was discharged with instructions to stop Hydroxycut, increase fluid intake, avoid alcohol consumption, and limit physical activity for the next week. Two weeks after hospital discharge, the patient’s CK and liver enzyme values returned to normal, excluding ALT and SCr, which remained slightly elevated, and his lower-extremity tenderness fully resolved. Conclusion. An 18-year-old Caucasian man with no significant medical history developed rhabdomyolysis possibly associated with the ingestion of Hydroxycut in addition to his increased exercise regimen.

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