Predictors of Student Failure or Poor Performance on Advanced Pharmacy Practice Experiences.

Objective. To determine factors predictive of student failure or poor performance on advanced pharmacy practice experiences (APPEs) at a single pharmacy program. Methods. This retrospective cohort evaluated students entering the Doctor of Pharmacy (PharmD) program from 2012-2014 at St. Louis College of Pharmacy. Students who received a grade of F for one or more APPEs (failure group) were compared to all other students (non-failure group). A secondary evaluation compared students with a C or F on one or more APPEs (poor performers) to all other students (non-poor performers). Data were collected on didactic and experiential performance, identifiable professionalism issues from introductory pharmacy practice experiences (IPPEs), and academic honor code violations. Univariable and multivariable logistic regressions were performed to determine factors associated with APPE failure and poor performance. Results. A total of 669 students were analyzed. Twenty-eight students (4.2%) failed one or more APPEs and 81 students (12.1%) were identified as poor performers (grade of C or F). For the primary outcome, professional grade point average (GPA) of less than 2.7, practicum failure, IPPE professionalism issue(s), and pharmacotherapy course failure were identified for inclusion in the multivariable analysis. The IPPE professionalism issue(s) (HR 4.8 [95% CI 1.9-12.4]) and pharmacotherapy course failure (HR 4.2 [95% CI, 1.6-11.1]) were associated with APPE failure on multivariable regression. On the secondary analysis, the same variables were identified for multivariable regression, with professional GPA of less than 2.7 (HR 2.7 [95% CI 1.5-5]), IPPE professionalism issue(s) (HR 3.9 [95% CI 2.2-6.9]), and pharmacotherapy course failure (HR 2.0 [95% CI 1.1-3.7]) associated with poor performance. Conclusion. Poor academic performance and/or identified unprofessional behavior while completing IPPEs are associated with APPE failure and poor performance. Interventions should be aimed at identifying at-risk students and addressing risk factors prior to APPEs.

Use of Nonselective ß-Blockers in Patients With End-Stage Liver Disease and Select Complications.

Objective: To review the literature and recommendations for nonselective ß-blockers (NSBBs) in the setting of variceal bleeding prophylaxis and decompensated liver disease. Data Sources: Literature search of MEDLINE was performed (1988 to October 2019) using the following search terms: cirrhosis, advanced cirrhosis, ß-blocker, decompensation, prophylaxis. Abstracts, peer-reviewed publications, clinical practice guidelines, and product monographs were reviewed. Study Selection and Data Extraction: Relevant English language studies and those conducted in humans were considered for analysis and inclusion. Data Synthesis: Evidence that suggests that NSBBs are harmful in advanced cirrhosis is overshadowed by confounding variables and small patient populations. The majority of the available evidence suggests neutral or beneficial effects on mortality with continuation of NSBBs despite liver disease progression. Based on the available literature, guidelines, and expert consensuses, NSBBs can be considered within this patient population and may have a positive impact on the majority of these patients. Relevance to Patient Care and Clinical Practice: This review summarizes current place in therapy for NSBBs in the setting of cirrhosis and variceal bleeding prophylaxis. It also includes a discussion of the literature for use of NSBBs within the setting of different acute decompensations in which the data and recommendations for use are less clear. Conclusions: Recent evidence shows neutral or positive results for NSBB use in particular decompensation subgroups, which suggests that NSBBs can be used cautiously with close monitoring in patients with advanced cirrhosis. Questions still remain regarding optimal agent and dose and whether agents can be safely restarted after an acute decompensation episode.

Predictors of Treatment Failure Following De-escalation to a Fluoroquinolone in Culture-Negative Nosocomial Pneumonia.

Background: Little evidence exists for de-escalation of nosocomial pneumonia therapy without positive cultures. Objective: The purpose of this study was to identify potential predictors of treatment failure following de-escalation to a fluoroquinolone in culture-negative nosocomial pneumonia. Methods: The study involved a single-center, retrospective cohort of patients admitted with diagnosis of nosocomial pneumonia and positive chest radiography who received at least 24 hours of fluoroquinolone monotherapy following at least 24 hours of appropriate empirical antibiotics. Treatment failure was defined using a composite of all-cause death within 30 days of discharge, treatment re-escalation, or readmission for pneumonia within 30 days of discharge. The Cox proportional hazards model was used to analyze predictors of treatment failure. Duration of empirical antibiotics and significant univariable exploratory predictors were included in multivariable analysis. Results: Of 164 patients, 23 (14%) failed de-escalation. Duration of empirical antibiotics (68.5 ± 32.1 vs 65.8 ± 35 hours) was not associated with treatment failure in univariable (Hazard Ratio [HR] = 1.002 [95% CI = 0.991-1.013]) or multivariable analyses (HR = 1.003 [95% CI = 0.991-1.015]). Significant exploratory predictors on univariable analysis included active cancer, intensive care unit (ICU) admission at empirical initiation, APACHE II score, and steroid use ≥20-mg prednisone equivalent. ICU admission at empirical initiation (HR = 2.439 [95% CI = 1.048-5.676]) and steroid use ≥20-mg prednisone equivalent (HR = 2.946 [95% CI = 1.281-6.772]) were associated with treatment failure on multivariable analysis. Conclusion and Relevance: Duration of empirical antibiotics does not appear to influence failure of de-escalation to fluoroquinolone monotherapy in culture-negative nosocomial pneumonia.

Edoxaban: A Comprehensive Review of the Pharmacology and Clinical Data for the Management of Atrial Fibrillation and Venous Thromboembolism.

Historically, vitamin K antagonists have been the only class of oral anticoagulants available. Despite our experience with warfarin over the past 60 years, its use is associated with several pharmacokinetic and clinical disadvantages including unpredictable dosing, frequent monitoring, and delayed onset and offset. Edoxaban, an oral direct Xa inhibitor, may provide clinicians with an additional option in patients requiring chronic anticoagulation. This review examines the pharmacology and clinical data of edoxaban as a therapeutic alternative.

The potential role of newer gram-positive antibiotics in the setting of osteomyelitis of adults.

WHAT IS KNOWN AND OBJECTIVE: To summarize available literature regarding the potential role of linezolid, daptomycin, telavancin, tigecycline and ceftaroline for the treatment of osteomyelitis caused by resistant gram-positive organisms. METHODS: Literature was obtained through PubMed searches from January 1980 to October 2011 using the terms osteomyelitis, bone, linezolid, daptomycin, telavancin, tigecycline and ceftaroline. Results were limited to those published in English. All articles identified from the PubMed searches were evaluated. Any published data related to bone penetration (animal or human) or clinical outcomes in adult osteomyelitis of these agents were included in the review. RESULTS AND DISCUSSION: Animal models report bone concentrations of 2·3 mcg/dL (vertebral) for linezolid, 0·45 mcg/mL (tibiae) for daptomycin, 0·78 mcg/mL (tibiae) for tigecycline and 0·27 mcg/mL (tibiae) for telavancin; no data are available for ceftaroline. Human studies demonstrate bone concentrations of 4·6, 17·0 and 3·9 mcg/mL (sternal, metatarsal and cancellous bone respectively) for linezolid, 4·7 mcg/mL (metatarsal) for daptomycin and 0·078 mcg/mL (unspecified) for tigecycline; no data are available for telavancin and ceftaroline. Retrospective cohort data, and prospective/retrospective case series support the use of linezolid in this setting; however, side-effects may limit use. Retrospective and prospective cohort data support daptomycin use. A retrospective case series is available supporting the use of telavancin. No data are available supporting clinical effectiveness for ceftaroline or tigecycline in the setting of osteomyelitis. WHAT IS NEW AND CONCLUSION: Limited data are available evaluating the safety and efficacy of these agents in osteomyelitis in adults. Daptomycin and telavancin may be potential alternatives or second-line agents to vancomycin in selected patients. Linezolid, because of an increase in clinically important ADRs with prolonged use, should be reserved as a second- or third-line agent. Due to a lack of clinical data and poor bone penetration, along with concerns regarding outcomes in severe infections, tigecycline's potential is limited. Little data exist regarding ceftaroline use in osteomyelitis.