Scientists from McGill University and the Univeriste de Montreal discovered that Vitamin D, in its purest form, can counteract the effects of Crohn’s disease, a form of inflammatory bowel disease (IBD), (Journal of Biological Chemistry). It involves ongoing or chronic inflammation of the gastrointestinal tract. The Crohn’s-induced inflammation most often affects the intestines. However, it may also occur at the mouth and rectum, (ADAM Multimedia Encyclopedia).

The exact cause of Crohn’s disease was unknown until now. Now that scientists have extensively studied this disease, they now have a better understanding of how it affects the body. It has long been suspected that Crohn’s disease is linked to a malfunction of the body’s immune system response, but it was not clear how, (ADAM Multimedia Encyclopedia). That assumption wasn’t farfetched.

In fact, in the process of determining that Vitamin D has a direct effect on Crohn’s disease, the scientists realized that the innate immune system, which acts as the body’s first defense against microbial invaders was the part of the immune system that was directly involved with the disease. It is believed that the immune system is overreacting to normal bacteria in the intestines, (ADAM Multimedia Encyclopedia).

Findings from the study suggest, for the first time, that Vitamin D deficiency can directly contribute to Crohn’s disease. There is even a belief that people from northern countries who receive less sunlight necessary for the manufacture of Vitamin D by the human body, are susceptible to Crohn’s disease, (Journal of Biological Chemistry). According to ADAM Multimedia Encyclopedia, genetic predisposition and environmental factors seem to play a large role in a person getting Crohn’s disease.

The research team found that Vitamin D acts directly on the beta defensin 2 gene. This gene encodes for an antimicrobial peptide. Vitamin D also acts directly on the NOD2 gene, which alerts cells to the presence of invading microorganisms that enters the body, according to the research team. They said both Beta-defensin and NOD2 have been linked to Crohn’s disease, suggesting that if NOD2 is deficient or defective, it won’t be able to combat invading microbes in the intestinal track.

Vitamin D, in its active form is called “1, 25-dihydroxyvitamin D,” which is a hormone that binds to receptors of cells of the body, according to the researchers. Over-the-counter Vitamin D Supplements can adequately supply the body with enough Vitamin D, the team said.

The researchers argued that the Crohn’s-Vitamin D discovery can be put to the test, stating that siblings of people with Corhn’s disease who haven’t yet developed the disease might be well advised to make sure they are Vitamin D sufficient, and they can get enough Vitamin D in their systems by simply going to the pharmacy and buying Vitamin D supplements.

It is great to know that Vitamin D can help people defend themselves against Crohn’s disease or other inflammatory bowel diseases by them just buying Vitamin D supplements from the local pharmacy.

Spinal fusion has become a very common surgical procedure in the United States over the past 10 years. There are many diagnoses that range from fractures of the spine to severe degenerative disc disease that prevent patients from being able to stand or walk are best treated with a surgical remedy. This article is intended to provide a basic review of the many spinal fusion options that are available. It is best to talk to a fellowship-trained spine surgeon who will be able to give you a complete picture of all of the devices available that are recognized for quality and reliability or to help you rule out those that are not recommended.

As the number of spinal fusions has increased, the variety of procedures and hardware alternatives that are available has also increased. It may be easier to understand why there are so many types of fusions if you consider how fractures need to be fixed with fusion. With broken bones, there is usually little question about the wisdom of providing casts or plates and screws to stabilize bones that need to be realigned or stabilized. Spinal fusion provides the same stability for the spine as is used for other fractured bones. What is a spinal fusion? Screws and rods in the spine are used to keep bones from moving as the bone graft that is placed allows the stabilized bones to form a connection across a previously mobile disc space. The growth of bone between 2 previously mobile bones is called fusion.

Standard fusion technique: Initially, fusion of the vertebral bones was done by laying bone graft between the bones, to provide a scaffolding across which the native bone cells could grow. As the patient’s bone cells move across the bone graft, they are able to incorporate the bone graft into the patient’s own bone structure, forming a complete connection called a fusion. Bone graft is of primary importance in allowing the vertebral bones to fuse across a previously mobile segment. Studies of patient’s with fusions done with bone graft alone have shown a relatively good rate of incorporation when patients are placed in back braces for 3 months or more. Because of the inconvenience and discomfort of the bracing, pedicle screws and rods have been added to provide an internal support that obviates the need for external supports. Internal screws and rods have increased successful fusion rates, as well as allowed patients to become mobile very quickly after the spinal fusion.

Interbody fusion cages: As the skill of the surgeon’s has grown when applying screws and rods to the spine, we have, in turn, looked for better ways to gain improved results. Now, we are able to put bone graft around the back of the spine, as well as into the disc spaces. With these improved grafting methods, we are able to safely access the lumbar disc from the back of the spine. Adding bone graft to the disc increases the surface area for healing and should improve the overall success rate of the spinal fusion. Interbody grafting can be done from several different approaches, as access to the disc space can be achieved from multiple directions.

XLIF: This acronym stands for extreme lateral interbody fusion. XLIF is a newer device designed to provide a carrier for bone graft and support to the disc space. It is placed through an incision on the patient’s flank. By making an incision on the patient’s side, the abdominal contents can be moved out of the way for a good view of the spine. Unfortunately, there are some significant nerves in the front of the spine that are very sensitive to being moved. This type of access to the spine can lead to weakness in one leg because of the sensitivity of these nerves. At this time, there are no long-term studies that demonstrate success of this procedure.

AxiaLif: This is another fusion device that has received some attention, due to its being touted as the “least invasive spine fusion”. This device is placed across the lowest disc space by access from the front of the sacrum (a large, triangular bone at the base of the spine, inserted like a wedge between the two hip bones). By placing instruments through a small incision near the rectum towards the spine, the disc is accessed through a series of cannulas (hollow surgical tubes) and drills. This allows the disc material to be removed from the disc space. After the disc material is removed, bone grafting can be placed into the hole that is created. This disc space is then supported by a tapered screw placed into the bones. So far, this device has had minimal post-surgical study and is most likely best done in conjunction with standard screw and rod fusion techniques.

Flexible Rods: There has been some recent excitement around rod and screw systems that are so-called “non-fusion” fusion devices. This confusing name infers that, although the intent of the screws and rods is for the bones to not move, these devices are designed to allow some movement. As was discussed earlier in this article, fusion is the solid connection of bones that had previously moved. The idea of these flexible rods is to provide “enough” stability to allow the bones to fuse together, but not enough to change the forces in the spine. This is termed a “soft-fusion”. At this point, there is no concensus as to how much or how little support is needed to achieve this goal. It is known that current screw and rod systems provide enough support to allow a fusion to occur while providing complete immobility of the vertebrae. Other than this complete connection, the amount of support less than complete immobility has not been defined and at this point is still under investigation.

Disc Replacement: Disc replacement was developed as an alternative to fusion and is suggested for those discs that have ruptured, but in which the bone structure is still good. If only the disc has gone bad, removal of the disc leaves a space that we normally fill with bone graft to promote fusion in the neck or lower back. With the development of the disc replacement, the space that is left from disc removal can be filled with a device that allows motion, rather than fusion. This is a complete reversal in the approach to disc removal; from complete immobility to complete mobility. Disc replacement is intended to maintain the motion in the spine. This reconstruction of the spine should maintain the forces across the discs in the spine to prevent the other discs from deteriorating any more rapidly than their normal degenerative process. Disc replacement in the lumbar spine has met with some success in well-selected patients. It has not been a panacea for all patients with low back pain or degenerative disc disease. Disc replacement in the cervical spine has had good success, as most neck fusions are done for bad discs with the bones being in good condition.

Improved training, including advanced specialty training in fellowship programs, as well as improved implants, has decreased most surgical procedure times to 2 hours or less. Historically, older techniques have been known to take 4-6 hours for the operation alone. By decreasing operative times, surgeons have seen decreased complications from the anesthesia, as well as decreased risks of infection and blood loss. Most surgeries under 2 hours will not require a blood transfusion.

A well-informed patient, who understands the benefits and the risks of their surgery, can fully participate in the choices that need to be made about their surgery. If you have been told that you need a spine fusion, ask questions and do your research. It is appropriate to ask your surgeon about their experience performing spinal fusions, how many of the fusion procedures they perform, how long the operation will take and the likelihood of needing a blood transfusion. Selecting a well-qualified surgeon can help ensure the best outcome for you and the success of your spinal fusion.

Prescription Verification Strategies

A very simple schematic of the prescription filling process consists of. There are 3 steps of this simplified prescription filling process where various medication bar code scanning verification strategies may be utilized to ensure that the correct physical selection of the medication for a prescription has occurred. They are;

1) As part of the prescription Label Printing process

2) When the Counting/Pouring/Labeling of the Selected Medication occurs

3) During the Final Check of the Finished Prescription

Bar code scanning is more accurate and faster than the human eye at comparing all 11 digits of the NDC number, for example;

a. It doesn’t see an 8 when it really is a 3, etc.

b. All 11 digits of the NDC number need to be compared; just comparing the middle 4 digits of an NDC number can lead to errors because those 4 digits are not unique to just one drug product. The same 4 digit number can represent at least two different products from two different manufacturers. It is the addition of the 5 digit manufacturer code plus the 4 digit product code that makes a unique 9 digit medication ID number. The addition of the last two digits then just makes it a unique 11 digit number containing a container size ID.

It is important to remember that the pharmacy environment is usually

- Very dynamic

- Prescriptions may be prepared in several locations within the pharmacy

- These locations may move as the Rx volume changes throughout the day

- Personnel are typically constantly interrupted by phones calls, staff or patient questions, insurance issues etc.

This type of environment produces a prescription that is often being prepared in several interrupted steps and of course, interruptions can lead to errors.

Let’s examine in more detail these 3 steps of the prescription filling process where various medication bar code scanning verification strategies are often applied.

1) As part of the prescription Label Printing process

a. The strategy here usually consists of verifying that the proper stock medication container is selected before the prescription label is printed.

b. Typically a two step process.

i. First a prescription order tag or receipt, identifying a new or refill prescription order, is scanned to locate the information of the prescription being prepared

ii. Then the stock medication container is scanned.

The computer compares the stock container’s bar coded ID information to the ID of the medication, usually the NDC number, on file for the prescription. When they match the prescription label is printed.

Pro’s

1) Identifies an error before it is made.

2) May be able to document in the prescription processing software that this verification scan was completed.

3) It requires almost no training to use.

4) Bar code scanning is more accurate and faster than the human eye at comparing all 11 digits of the NDC number.

Con’s

1) Has to be built into the prescription processing software’s functionality.

2) Can become a bottle neck. Depending on pharmacy volume this may require multiple prescription label printers or / and verification workstations so that this step does not slow down the prescription filling workflow.

3) Multiple patient Rx labels will often be printed before a single prescription is completed, leading to mix ups when the medications are actually counted/poured/labeled

4) Often requires twice the number of labels to be printed,

a. First an Rx or transaction number bar code that is scanned to tell the system which prescriptions medication is to be verified.

b. Second the actual prescription label for the patient’s container.

5) Typically only allows for a medications selection to be verified one time. This may be an issue when;

a. There is not enough in the verified container to fill the prescription and another container(s) needs to be verified to finish filling the prescription at that time. There may be no way to scan additional stock containers with this method.

b. Short fill - not enough medication is in stock to completely fill the prescription. The balance of the prescription will be filled at a later date. There may be no way to scan the new stock containers with this method.

2) When the Counting/Pouring/Labeling of the selected medication occurs Three scenarios

I. The verification occurs at workstations primarily dedicated to verification

II. The use of portable verification bar code scanners

III. A combination of 1 & 2

Scenario I - The verification occurs at verification workstations

a) Typically uses location specific computer workstations with attached bar code scanners

b) A two step process of scanning an Rx, Transaction or NDC number bar code on the patient label and then scanning the stock medication selected. At some point the NDC number assigned to the patient and the stock containers bar code is compared. The workstation then responds with an indication of whether the correct product has been selected. If it is correct then the medication is counted/poured/labeled.

Pro’s

1) Identifies an error before it is made.

2) May be able to document in the software that the verification scan was completed.

3) Bar code scanning is more accurate and faster than the human eye at comparing all 11 digits of the NDC number when the workstation uses the process of comparing NDC numbers.

Con’s

1) Often only allows a prescription to be verified once.

2) Can become a bottle neck. Requires enough physical workstations so that verification does not slow down the prescription filling workflow.

3) Doesn’t take into account the stop and start nature of prescription filling, have to keep going back to a verification workstation when the prescription filling is interrupted.

4) Not portable, number of verification workstations limited by the space requirement of the workstations that can fit into the workstation prescription preparation area.

Scenario II - The use of portable NDC number verification bar code scanners

a) A two step process that typically consists of scanning

1) A NDC number bar code on the patient label and then

2) The NDC number containing bar code of the stock medication selected. The scanner compares all of the digits of the two NDC numbers and responds with an indication of whether the correct product has been selected. If it is correct then the medication may be counted/poured/labeled. The scanner may or may not communicate with the prescription processing software.

Pro’s

1) Identifies an error before it is made.

2) Allows the same prescription to be verified as many times as needed for its completion as is needed to have a complete verification scan, count/pour, and label process without interruption.

3) Doesn’t require a live communication, wired or wireless, to the prescription processing software. The NDC numbers required to make the verification match are in the bar codes on the patients label and the manufacturers container, thus, eliminating the need for a live communication with the prescription processing software.

4) May be carried to where every a prescription is being prepared. The staff is not locked to a limited number of physical verification workstations when the volume increases.

5) May be able to document in the software that this scan was completed if a synching connection to the prescription processing system is available.

6) More verification scanners can be added without the concerns of workstation space requirements.

7) It fits into the current workflow of the individual person, so the reluctance to use is minimized.

It requires almost no training to use.

9) Bar code scanning is more accurate and faster than the human eye at comparing all 11 digits of the NDC number.

10) No problem scanning multiple stock containers when more than one is required to fill the prescription.

11) No problem scanning new stock containers when a short fill occurs and the balance is filled at a later date.

Scenario III - A combination of I & II

Pro’s

1) Adding the portable scanners over comes the space requirements of prescription verification workstations.

2) Allows for verifying a single prescription as many times as is needed to have a complete Verification, Count/Pour, and Label process without interruption.

3) During the Final Check of the Finished Prescription

a. Typically a prescription or transaction number bar code is scanned at the final check station to display on the computers screen a;

i. Copy of the original prescription

ii. Color image of the medication

then a visual comparison by a pharmacist of what is on the screen with the actual prescription label and medication is done.

Con’s

1) Errors are made before an attempt is made to catch them

2) Inefficient means of catching that the wrong medication has been selected. Catching it at the final check before bagging means that the prescription needs to cycle back through the filling process, be corrected and then go through the Final Check process again. Of course this assumes that all of the errors will be caught.

3) Once a prescription has been prepared incorrectly the odds are increased that one of the errors will be dispensed to a patient. It is best to catch the error before the prescription is prepared.

4) The human eye is not as accurate and is slower than a bar code scanner at comparing all 11 digits of the NDC number, for example it doesn’t see an 8 when it really is a 3 etc.

As you review your prescription filling process for accuracy and efficiency improvements I hope that you find this information helpful. The appropriate combination of these methods may be the best means you have of increasing efficiency and minimizing human error when dispensing prescriptions.