Implementation and impact of a fourth-year student pharmacist wellness series pilot on perceived stress and support.

BACKGROUND AND PURPOSE: A wellness program was piloted for student pharmacists in their advanced pharmacy practice experience (APPE) year. The purpose is to describe the program implementation and its impact on APPE students' perceived stress and perception of support by school personnel. EDUCATIONAL ACTIVITY AND SETTING: A three-session virtual wellness program was designed for APPE students. Attendance was optional for the pilot year. An online survey assessing demographics, perceived stress (measured by the validated Perceived Stress Scale [PSS]), factors contributing to stress, and perceived support before the first session and after the third session was sent to all APPE students. FINDINGS: Twenty (37%), 13 (24%), and 10 (18.5%) students attended the first, second, and third session, respectively. A total of 49 students completed the post-program survey. Of these, ten (20.4%) attended one session, ten (20.4%) attended two sessions, and two (4.1%) attended three sessions. Students reported moderate stress. Female students endorsed higher PSS scores and career-related stress. PSS scores were lower among students who attended at least one session vs. those who did not attend any sessions and were negatively correlated with total sessions attended. Attendees were likelier to feel supported by staff and preceptors and perceived that concerns were heard by administration and preceptors. SUMMARY: An APPE wellness program was successfully developed. Students who attended at least one session reported less stress and greater support from school personnel vs. those who did not attend any sessions. These findings are promising as wellness efforts are integrated into pharmacy training.

Advancing Pharmacist Collaborative Care within Academic Health Systems.

INTRODUCTION: The scope of pharmacy practice has evolved over the last few decades to focus on the optimization of medication therapy. Despite this positive impact, the lack of reimbursement remains a significant barrier to the implementation of innovative pharmacist practice models. SUMMARY: We describe the successful development, implementation and outcomes of three types of pharmacist collaborative care models: (1) a pharmacist with physician oversight, (2) pharmacist-interprofessional teams and (3) physician-pharmacist teams. The outcome measurement of these pharmacist care models varied from the design phase to patient volume measurement and to comprehensive quality dashboards. All of these practice models have been successfully funded by affiliated health systems or grants. CONCLUSIONS: The expansion of pharmacist services delivered by clinical faculty has several benefits to affiliated health systems: (1) significant improvements in patient care quality, (2) access to experts in specialty areas, and (3) the dissemination of outcomes with national and international recognition, increasing the visibility of the health system.

Uncertain Associations of Major Bleeding and Concurrent Use of Antiplatelet Agents and Chinese Medications: A Nested Case-Crossover Study.

Despite the evidence that some commonly used Chinese medications (CMs) have antiplatelet/anticoagulant effects, many patients still used antiplatelets combined with CMs. We conducted a nested case-crossover study to examine the associations between the concomitant use of antiplatelets and CMs and major bleeding using population-based health database in Taiwan. Among the cohort of 79,463 outpatients prescribed antiplatelets (e.g., aspirin and clopidogrel) continuously, 1,209 patients hospitalized with new occurring bleeding in 2012 and 2013 were included. Those recruited patients served as their own controls to compare different times of exposure to prespecified CMs (e.g., Asian ginseng and dong quai) and antiplatelet agents. The periods of case, control 1, and control 2 were defined as 1-4 weeks, 6-9 weeks, and 13-16 weeks before hospitalization, respectively. Conditional logistic regression analyses found that concurrent use of antiplatelet drugs with any of the prespecified CMs in the case period might not significantly increase the risks of bleeding over that in the control periods (OR = 1.00, 95% CI 0.51 to 1.95 and OR = 1.13, 95% CI 0.65 to 1.97). The study showed no strong relationships between hospitalization for major bleeding events and concurrent use of antiplatelet drugs with the prespecified CMs.

Evaluation of the effect of torsemide on warfarin dosage requirements.

Background According to drug interaction databases, torsemide may potentiate the effects of warfarin. Evidence for this drug-drug interaction, however, is conflicting and the clinical significance is unknown. Objective The aim of this study is to evaluate the impact of torsemide initiation on warfarin dosage requirements. Setting This study was conducted at the Veterans Affairs Healthcare System in San Diego, California. Method A retrospective cohort study was conducted using Veterans Affairs data from patients who were converted from bumetanide to torsemide between March 2014 and July 2014. Patients were also prescribed and taking warfarin during the observation period. Warfarin dosage requirements were evaluated to determine if any changes occurred within the first 3 months of starting torsemide. Main outcome measure The primary outcome was the average weekly warfarin dose before and after torsemide initiation. Results Eighteen patients met study inclusion criteria. The weekly warfarin dose before and after initiation of torsemide was not significantly different (34 ± 15 and 34 ± 13 mg, p > 0.05). Of those eighteen patients, only two experienced elevations in INR that required a decrease in warfarin dosage after torsemide initiation. Between those two patients, dosage reductions ranged from 5.3 to 18%. Conclusion These results indicated that most patients did not require any warfarin dosage adjustments after torsemide was initiated. The potential for interaction, however, still exists. While empiric warfarin dosage adjustments are not recommended when initiating torsemide, increased monitoring is warranted to minimize the risk of adverse effects.

Rational Use of Second-Generation Antipsychotics for the Treatment of ICU Delirium.

Delirium, described as an acute neuropsychiatric syndrome, occurs commonly in critically ill patients and leads to many negative outcomes including increased mortality and long-term cognitive deficits. Despite the lack of clinical data supporting the use of antipsychotics for the management of intensive care unit (ICU) delirium, pharmacological interventions are often needed to control acutely agitated patients. Given that the most current guidelines do not advocate the use of haloperidol for either the prevention or treatment of ICU delirium due to a lack of evidence, second-generation antipsychotics (SGAs) have been commonly used as alternatives to haloperidol for ICU patients with delirium. Nonetheless, the evidence supporting the use of SGAs to treat ICU delirium remains limited. This review is designed to assess the available clinical evidence and highlights the different neuropharmacological and safety properties of SGAs in order to guide the rational use of SGAs for the treatment of ICU delirium.

Changes in medication regimen complexity and the risk for 90-day hospital readmission and/or emergency department visits in U.S. Veterans with heart failure.

BACKGROUND: Heart failure (HF) hospitalization is associated with multiple medication modifications. These modifications often increase medication regimen complexity and may increase the risk of readmission and/or emergency department (ED) visit. OBJECTIVES: To determine the association between changes in medication regimen complexity (MRC) during hospitalization of patients with heart failure and the risk of readmission or ED visit at 90 days. Secondary objectives include examining the association between changes in MRC and time to readmission as well as the relationship between number of medications and MRC. METHODS: This was a retrospective cohort study that included U.S. Veterans hospitalized with heart failure. MRC was quantified using the medication regimen complexity index (MRCI). The change in MRCI was the difference between admission MRCI and discharge MRCI recorded during the index hospitalization. Demographic and clinical data were collected to characterize the study population. Patient data for up to one year after discharge was recorded to identify hospital readmissions and ED visits. RESULTS: A total of 174 patients were included in the analysis. Sixty-two patients (36%) were readmitted or had an ED visit at 90 days from the index hospitalization. The mean change (SD) in MRCI during the index hospitalization among the cohort was 4.7 (8.3). After multivariate logistic regression analysis, each unit increase in MRCI score was associated with a 4% lower odds of readmission or ED visit at 90 days but this finding was not statistically significant (OR 0.955; 95% CI 0.911-1.001). In the cox proportional hazard model, the median time to hospital readmission or ED visit was 214 days. Each unit increase in MRCI score was associated with a modest but non-significant increase in probability of survival from readmission or ED visit (HR 0.978; 95% CI 0.955, 1.001). CONCLUSION: Changes in medication regimen complexity that occur during hospitalization may also be associated with optimization of medical therapy and do not necessarily portend worse outcomes in patients with HF.

Recent advances in the development of specific antidotes for target-specific oral anticoagulants.

Warfarin, a vitamin K antagonist, has been the only orally available anticoagulant for > 60 years. During the past decade, the U.S. Food and Drug Administration has approved several target-specific oral anticoagulants (TSOACs) for the prophylaxis and treatment of arterial and venous thromboembolism and stroke prevention in patients with nonvalvular atrial fibrillation. These new agents have several advantages over warfarin including more predictable pharmacokinetics and pharmacodynamics, fewer food and drug interactions, and lack of need for routine coagulation monitoring. However, unlike warfarin, currently no antidotes are available to reverse the anticoagulant effect of TSOACs. Specific antidotes for TSOACs may not be needed in most situations due to their short half-life, yet the absence of antidotes for these agents is a concern, especially in emergent situations such as life-threatening major bleeding or nonelective major surgery. Several specific antidotes for TSOACs including idarucizumab, andexanet alfa, and aripazine have been developed and have shown promise in early clinical trials evaluating their efficacy and safety. In this narrative review, the progress made in developing specific antidotes for TSOACs is summarized based on the latest available preclinical and clinical data.

A case of profound neutropenia and agranulocytosis associated with off-label use of ceftaroline.

PURPOSE: A case of profound neutropenia and agranulocytosis associated with the off-label use of ceftaroline is reported. SUMMARY: A 67-year-old Caucasian man arrived at the emergency room with right shoulder pain and weakness that radiated to his right chest, back, and right arm. A review of symptoms was notable for two days of burning with urination associated with decreased urinary output and decreased appetite. Multiple tests revealed the presence of methicillin-resistant Staphylococcus aureus (MRSA) septic arthritis, which was treated with an off-label dosage of ceftaroline (600 mg intravenously every eight hours). At the start of ceftaroline therapy, the patient's baseline absolute neutrophil count (ANC) was 6640 cells/µL and decreased to 816 cells/µL by day 19, eventually falling to 0 cells/µL on day 21 of therapy. Ceftaroline was then discontinued due to the suspicion that the neutropenia was secondary to maturation arrest of the bone marrow. The patient was switched to i.v. daptomycin to finish a six-week course of antibiotics. Interventional radiology placed a drain in the patient's right shoulder during the hospital stay, with symptom improvement. His white blood cell count continued to increase after ceftaroline discontinuation, reaching 6.5×10(3) cells/µL with a differential of 56.6% segmented neutrophils and 28.4% lymphocytes after nine days off of ceftaroline. CONCLUSION: A 67-year-old man developed profound neutropenia and agranulocytosis after three weeks of high-dose ceftaroline therapy for the treatment of MRSA septic arthritis. His neutropenia resolved after ceftaroline discontinuation and treatment with an alternative antibiotic.

Clinical inertia in type 2 diabetes: A retrospective analysis of pharmacist-managed diabetes care vs. usual medical care.

BACKGROUND: Evidence suggests that patients with type 2 diabetes (T2DM) suffer from a high rate of "clinical inertia" or "recognition of the problem but failure to act." OBJECTIVE: THE AIM OF THIS STUDY IS TO QUANTIFY THE RATE OF CLINICAL INERTIA BETWEEN TWO MODELS OF CARE: Pharmacist-Managed Diabetes Clinic (PMDC) vs. Usual Medical Care (UMC). METHODS: Patients in a university based medical clinic with type 2 diabetes (T2DM) were analyzed in this retrospective cohort study. Patients were exposed to either PMDC or UMC. The difference in days to intervention in response to suboptimal laboratory values and time to achieve goal hemoglobin A1c (A1c), systolic blood pressure (SBP) and low-density lipoprotein (LDL) was compared in the two models of care. RESULTS: A total of 113 patients were included in the analysis of this study, 54 patients were in the PMDC and 59 patients were in the UMC group. Median time (days) to intervention for A1c values >7% was 8 days and 9 days in the PMDC and UMC groups, respectively (p>0.05). In patients with baseline A1c values >8%, median time to achieving A1c<7% was 259 days vs. 403 days in the PMDC and UMC groups, respectively (p<0.05). Median time to goal SBP was 124 days in the PMDC group and 532 days in the UMC group (p<0.05). Median time to goal LDL was 412 days in the PMDC group vs. 506 days in the UMC group (p<0.05). CONCLUSIONS: Rates of clinical inertia, defined as time to intervention of suboptimal clinical values, did not differ significantly between patients enrolled in a PMDC compared to patients with UMC with respect to A1c, SBP and LDL. Participation in PMDC, however, was associated with achieving goal A1c, SBP, and LDL levels sooner compared to UMC.

Syndrome of inappropriate antidiuretic hormone associated with aripiprazole.

PURPOSE: A probable case of aripiprazole-induced syndrome of inappropriate antidiuretic hormone (SIADH) is reported. SUMMARY: A 65-year-old Caucasian man arrived in the emergency department (ED) with dizziness, headache, abdominal pain, nausea, and vomiting. There had been no recent additions or changes to the patient's medication regimen except for an increase in the daily dose of aripiprazole (from 10 to 20 mg) about two months prior. On admission, the patient's serum sodium concentration was 108 meq/L, prompting discontinuation of aripiprazole use and fluid restrictions. Over the next 72 hours, the serum sodium level increased to a near-normal concentration (127 meq/L), and the man was discharged back to a nursing facility. Three days later, the patient was readmitted to the ED with recurrent symptoms and a serum sodium concentration of 118 meq/L, a serum osmolality of 254 mOsm/kg, a urine osmolality of 575 mOsm/kg, and a urine sodium concentration of 101 meq/L. It was learned that aripiprazole use had been inappropriately resumed at the nursing facility. Aripiprazole was again discontinued, and fluid restrictions were imposed, with subsequent abatement of hyponatremia over four days. Application of the adverse drug reaction probability scale of Naranjo et al. in this case yielded a score of 7, indicating probable aripiprazole-associated SIADH. CONCLUSION: A 65-year-old man developed severe hyponatremia after an aripiprazole dosage increase. Hyponatremia resolved promptly with the discontinuation of aripiprazole. After discharge from the hospital, the patient inadvertently received aripiprazole again and was subsequently readmitted with another episode of severe hyponatremia.

Syndrome of inappropriate antidiuretic hormone associated with moxifloxacin.

PURPOSE: A possible case of moxifloxacin-induced syndrome of inappropriate antidiuretic hormone (SIADH) is reported. SUMMARY: A 66-year-old Caucasian woman with stage II chronic obstructive pulmonary disease (COPD) arrived at the emergency department from an outpatient clinic complaining of worsening shortness of breath, headache, body aches, and dizziness. Five days before her arrival at the hospital, the patient was seen in an outpatient clinic with symptoms of COPD exacerbation and was given a corticosteroid taper of prednisone 40 mg daily and moxifloxacin 400 mg daily. The patient was hospitalized, and her serum sodium concentration was 110 meq/L. Moxifloxacin was continued on admission, and the patient was admitted to the intensive care unit for frequent neurologic examination, serial serum sodium measurements, and fluid restriction. Her laboratory test results were consistent with SIADH. Fluid restriction at 1 L/day initially corrected her serum sodium concentration to 119 meq/L, but increases in serum sodium plateaued by day 2 of admission (119-122 meq/L). Moxifloxacin was discontinued on hospital day 3. At discharge, on hospital day 5, her serum sodium concentration had increased to 131 meq/L. She was restarted on her home medications and followed up in an outpatient clinic one week later. After multiple etiologies were ruled out, drug-induced SIADH associated with moxifloxacin was the most likely diagnosis for this patient. Clinicians should be aware of this potential adverse drug effect when assessing patients with hyponatremia or SIADH. CONCLUSION: A 66-year-old woman developed severe hyponatremia after receiving moxifloxacin for five days for treatment of COPD exacerbation.

Interventions to improve guideline compliance following coronary artery bypass grafting.

BACKGROUND: Lifestyle modification and appropriate medical therapy improve long-term outcomes following coronary artery bypass grafting (CABG). Our institutional experience suggested that evidence-based recommendations were not being followed postdischarge after CABG. We undertook this study to document our rate of compliance with evidence-based guidelines and to correct deficiencies in our discharge practices. METHODS: Seven evidence-based interventions were studied after CABG: (1) institution of beta-blocker therapy, (2) angiotensin-converting enzyme (ACE) inhibitor therapy, (3) aspirin, (4) lipid-lowering therapy, (5) smoking cessation intervention, (6) heart-healthy diet therapy, and (7) physical activity recommendations. The rate of compliance with guidelines in 50 control patients was measured at discharge. A multidisciplinary team including cardiac surgeons, nurses, dieticians, physical therapists, and clinical pharmacists evaluated the guideline compliance in the control group and developed interventions to assure guideline compliance at the time of discharge. A subsequent study group of 50 patients was then assessed prospectively to measure the guideline compliance after institution of intervention programs. The multidisciplinary team agreed on predefined acceptable compliance limits as follows: (1) >80% of patients receive ACE inhibitors at discharge, (2) 100% of patients receive beta-blockers, aspirin, and lipid-lowering agents at discharge, and (3) 100% of patients receive lifestyle modification counseling at discharge. Compliance with guidelines was defined as documentation in the medical record of provision of medications and lifestyle counseling at the time of discharge. RESULTS: In the control group, the rate of guideline compliance was surprisingly low. Rates of compliance with guidelines increased significantly after the multidisciplinary interventions were undertaken. CONCLUSIONS: We conclude that compliance with guidelines known to improve long-term outcome is suboptimal after CABG. A multidisciplinary intervention program can improve compliance with currently accepted guidelines and quality indicators in patients following CABG.

"Collateral damage": antibiotics and the risk of Clostridium difficile infection.

Patients undergoing orthopedic surgery are at increased risk for infection, and antimicrobial use continues to be required. Antimicrobial selection, however, is an important consideration given the increasing incidence and severity of C. difficile infection described in the literature. When choosing antimicrobials for prophylaxis and treatment, evaluate patients for risk factors that may predispose them to C. difficile infection. Patients receiving multiple antibiotics or broad-spectrum antibiotics, women, patients with concurrent proton pump inhibitor use, and those with renal failure are at increased risk. Choice of antibiotics should be evaluated for their potential or likelihood to cause C. difficile infection. When a number of these risk factors are present, avoiding the use of high-risk antibiotics may be warranted.