To identify potential risk factors for the development of osteonecrosis of the jaw (ONJ) in patients receiving bisphosphonates, we conducted a MEDLINE search. We identified 44 English-language published case reports and case series describing 481 patients with bisphosphonate-related ONJ. Our review of these reports indicated that ONJ occurs more frequently in patients receiving intravenous bisphosphonates (453 patients [94.2%]) than in patients receiving oral bisphosphonates (28 patients [5.8%]). Most patients who developed ONJ had cancer (451 patients [93.8%]), with multiple myeloma being the most common diagnosis, followed by breast, prostate, and lung cancers. Nearly one third of patients had a history of glucocorticoid use. The inciting event (reported in 449 patients) preceding the diagnosis of ONJ was a tooth extraction or other surgical or invasive dental procedure in 309 patients (68.8%), whereas 93 patients (20.7%) developed ONJ spontaneously. Guidelines for the prevention and treatment of bisphosphonate-associated ONJ have been developed but are largely based on anecdotal evidence. Patients receiving bisphosphonates must be counseled on the risks and benefits of therapy. Further studies will help to elucidate the pathophysiology, frequency, and risk factors for development of bisphosphonate-associated ONJ.

Objectives Patients with febrile neutropenia are at high risk of morbidity and mortality from infectious causes. Decreasing time to antibiotic (TTA) administration is associated with improved patient outcomes. We sought to reduce TTA for children presenting to the Emergency Department (ED) with fever and neutropenia. Methods In a prospective cohort study with historical comparison, TTA administration was evaluated in patients with neutropenia presenting to the Children’s of Alabama ED. A protocol was established to reduce delays in antibiotic administration and increase the percentage of patients who receive treatment within 60 minutes of presentation. One hundred pre-protocol patient visits between August 2010 and December 2011 were evaluated and 153 post-protocol visits were evaluated between August 2012 and September 2013. We reviewed individual cases to determine barriers to rapid antibiotic administration. Results Antibiotics were administered in 96.9 ± 57.8 minutes in the pre-protocol patient group and only 35% of patients received antibiotics within 60 minutes of presentation and 70% received antibiotics within 120 minutes. After implementation of the protocol, TTA for neutropenic patients was decreased to 64.3 ± 28.4 minutes (p < 0.0001) with 51.4% receiving antibiotics within 60 minutes and 93.2% within 120 minutes. Conclusion Implementing a standard approach to patients at risk for neutropenia decreased TTA. There are numerous challenges in providing timely antibiotics to children with febrile neutropenia. Identified delays included venous access (time to effect of topical anesthetics, and difficulty obtaining access), physicians waiting on laboratory results, and antibiotic availability.

Introduction:In patients who are immunocompromised, fever may indicate a life-threatening infection. Prompt time to antibiotic administration in febrile patients at risk for neutropenia has been identified by national and international panels as a key benchmark of quality care in emergent situations. A quality improvement initiative to improve health care provided in a pediatric emergency department (ED) is described.Methods:A clinical pathway was previously initiated in a pediatric ED with a goal of improving time to antibiotics for febrile neutropenia patients. An agreed upon pathway and order set being initiated. Improvements were seen but not to the desired level. This project involved an improvement cycle that focused on nonvalue added time in the workflow.Results:Percent of patients receiving antibiotics within the goal time of 1 hour increased from 40% to 80% with the intervention. Process measures including arrival to ED bed time, ED bed to antibiotic order time and antibiotic order time to delivery time were followed.Conclusion:Clinical guidelines, order sets and detailed understanding of the actual workflow at the point of care delivery can be instrumental in achieving the goals of reducing time to antibiotics.

Objective. To design, deliver, and evaluate the impact of a required course on student knowledge acquisition and ability to evaluate contemporary public health issues. Design. A 2-credit course was implemented using asynchronous, online delivery. Learning activities included literature retrieval and assessment, analytic writing, quizzes, and creation of a group wiki evaluating a current public health issue. Course topics included health care reform, social determinants of health, health disparities, evidence-based medicine, end-of-life care, patient safety, and research ethics. Assessment. Strong student performance on assessments indicated an ability to use higher-order cognitive domains. Online delivery provided students with the flexibility to complete assignments at their convenience, allowed participation by all students, and encouraged self-directed learning. Conclusion. Completion of a required, online, asynchronous course with a public health focus allowed pharmacy students to increase their knowledge of and ability to evaluate contemporary ethical, social, cultural, and governmental issues affecting pharmacy practice.