Pharmacists Perceptions of Providing Colorectal Cancer Screening in Community-Based Practice.

BACKGROUND: Colorectal cancer (CRC) is the third most common diagnosed cancer in the United States. Kentucky pharmacists can be instrumental in the CRC early detection process through board authorized protocols (BAP): a regulatory approach managed by the Kentucky Board of Pharmacy that allows pharmacists to increase access to care while saving lives through early detection screening. Determining the barriers and successes of implementing CRC screening can improve access to education and care for patients. OBJECTIVE(S): This study aims to evaluate community pharmacists' perceptions of implementing a colorectal screening for patients via protocol and identify pharmacists' confidence and potential barriers such as cost, staff support, and patient need for colorectal screening in community pharmacy settings. METHODS: A survey was sent electronically to a convenience sample of pharmacists throughout Kentucky. The survey collected demographics, opinions regarding implementation of the colorectal cancer screening protocol, pharmacists' perceptions of knowledge, as well as the barriers and benefits associated with implementation of CRC services. RESULTS: 207 responses were received and of those 151 were from community-based pharmacists. 34% of pharmacists agreed or strongly agreed to offer CRC screening. Overwhelmingly, 81.3% of pharmacists reported need for additional training. There were no statistically significant differences in support among demographic factors; practice setting (p-value = 0.937), gender (p-value = 0.973), age (p-value = 0.568), years practicing (p-value = 0.870). In addition, the most common barriers reported were lack of reimbursement (97%), lack of willingness for patients to pay (98%), and time or workflow issues (97%). Most pharmacists stated that lack of trust in pharmacists was not a barrier (87%). CONCLUSIONS: Overall, 34% of pharmacists either agreed or strongly agreed to offer colorectal cancer screening via the board-approved protocol. However, overwhelmingly the pharmacists believe that there is a need for additional training and opportunities for additional training on board authorized protocols have increased drastically in Kentucky. Barriers such as lack of reimbursement, willingness to pay, and time or workflow issues are barriers that need to be overcome before implementation. Finding solutions to these barriers will increase pharmacist's support.

Impact of burnout and professional fulfillment on intent to leave among pediatric physicians: The findings of a quality improvement initiative.

BACKGROUND AND OBJECTIVES: Physician burnout is rampant, and physician retention is increasingly hard. It is unclear how burnout impacts intent to leave an organization. We sought to determine how physician burnout and professional fulfillment impact pediatric physicians' intent to leave (ITL) an organization. DESIGN AND METHODS: We performed 120, 1:1 semi-structured interviews of our pediatric faculty and used the themes therefrom to develop a Likert-scale based, 22-question battery of their current work experience. We created a faculty climate survey by combining those questions with a standardized instrument that assesses burnout and professional fulfillment. We surveyed pediatric and pediatric-affiliated (e.g. pediatric surgery, pediatric psychiatry, etc.) physicians between November 2 and December 9, 2022. We used standard statistical methods to analyze the data. An alpha-level of 0.05 was used to determine significance. RESULTS: A total of 142 respondents completed the survey, 129 (91%) were Department of Pediatrics faculty. Burnout was present in 41% (58/142) of respondents, whereas 30% (42/142) were professionally fulfilled. There was an inverse relationship between professional fulfillment and ITL, p < 0.001 for the trend. Among those who were not professionally fulfilled, the odds ratio of ITL in the next three years was 3.826 [95% CI 1.575-9.291], p = 0.003. There was a direct relationship between burnout and ITL, p < 0.001 for the trend. CONCLUSIONS: Among pediatric physicians, professional fulfillment is strongly, inversely related with ITL in the next three years. Similarly, burnout is directly related with ITL. These data suggest a lack of professional fulfillment and high burnout are strong predictors of pediatric physician turnover.

Effect modification of dosing strategy (AUC or trough) on AKI associated with vancomycin in combination with piperacillin/tazobactam or cefepime and meropenem.

Piperacillin-tazobactam (TZP), cefepime (FEP), or meropenem (MEM) and vancomycin (VAN) are commonly used in combination for sepsis. Studies have shown an increased risk of acute kidney injury (AKI) with TZP and VAN compared to FEP or MEM. VAN guidelines recommend area under the curve (AUC) monitoring over trough (Tr) to minimize the risk of AKI. We investigated the association of AKI and MAKE-30 with the two VAN monitoring strategies when used in combination with TZP or FEP/MEM. Adult patients between 2015 and 2019 with VAN > 72 hours were included. Patients with AKI prior to or within 48 hours of VAN or baseline CrCl of ≤30 mL/min were excluded. Four cohorts were defined: FEP/MEM/Tr, FEP/MEM/AUC, TZP/Tr, and TZP/AUC. A Cox Proportional Hazard Model was used to model AKI as a function of the incidence rate of at-risk days, testing monitoring strategy as a treatment effect modification. Multivariable logistic regression was used to model MAKE-30. Overall incidence of AKI was 18.6%; FEP/MEM/Tr = 115 (14.6%), FEP/MEM/AUC = 52 (14.9%), TZP/Tr = 189 (26%), and TZP/AUC = 96 (17.1%) (P < 0.001). Both drug group [(TZP; P = 0.0085)] and monitoring strategy [(Tr; P = 0.0007)] were highly associated with the development of AKI; however, the effect was not modified with interaction term [(TZP*Tr); 0.085)]. The odds of developing MAKE-30 were not different between any group and FEP/MEM/AUC. The effect of VAN/TZP on the development of AKI was not modified by the VAN monitoring strategy (AUC vs trough). MAKE-30 outcomes were not different among the four cohorts.

Antibiotics for Patients With a Planned Re-Laparotomy for Intra-Abdominal Infection.

Background: Appropriate antimicrobial therapy for the management of intra-abdominal infection (IAI) continues to evolve based on available literature. The Study to Optimize Peritoneal Infection Therapy (STOP-IT) trial provided evidence to support four days of antibiotic agents in IAI post-source control but excluded patients with a planned re-laparotomy. This study aimed to determine the short- and long-term recurrent infection risk in this population. Patients and Methods: This is a single-center, retrospective, observational study of adult patients admitted to a quaternary medical center between January 1, 2016, and August 1, 2022, with IAI requiring planned laparotomy. Patients were designated as receiving five or less days of antibiotic agents (short course) or more than five days (long course) after source control. The primary outcome was IAI recurrence within 30 days. Results: Of the 104 patients who met inclusion criteria, 78 were included in analysis. Average age was 57 ± 13.3 years, 56% were male, 94% Caucasian, with a mean Acute Physiology and Chronic Health Evaluation (APACHE) II score of 17 ± 7.09. All other baseline characteristics and clinical severity markers were similar between the two groups. Regarding the primary outcome of IAI recurrence, there was no difference when comparing those who received short course versus those who received long course therapy (41.2% vs. 44.4%; p = 0.781). No differences were found between groups with respect to secondary outcomes. Conclusions: In patients admitted with IAI managed with planned re-laparotomy those who received short course antimicrobial therapy were not found to have an increase in IAI recurrence compared to those with longer courses of therapy.

Outcomes in Variceal Bleeding Associated With Continuous Octreotide in Patients With Delayed Endoscopy.

Background: Variceal hemorrhage treatment includes endoscopy within 12 hours of admission and octreotide therapy for 2-5 days post-endoscopy. Duration of pre-endoscopy octreotide can be prolonged when intervention is delayed. Objective: This study aimed to evaluate the impact of extended pre-endoscopy octreotide on rebleeding after endoscopy when comparing short vs long durations of post-endoscopy octreotide. Methods: This was a single center, retrospective cohort evaluating adult cirrhotic patients with esophageal variceal hemorrhage admitted between July 1, 2017 and June 30, 2020. Study groups included patients receiving octreotide ≥12 hours prior to endoscopy followed by ≤ 48 (short course) or >48 hours (standard course) after endoscopy. The primary outcome was post-endoscopy rebleeding, defined as hemoglobin decrease of ≥2 g/dL from baseline or the requirement of ≥1 unit of packed red blood cells. Results: Of the 169 patients included, 88 patients received short course octreotide after endoscopy, and 81 patients received standard course octreotide after endoscopy. Twenty-nine (33%) patients in the short course group and 43 (53.1%) in the standard course group experienced the primary endpoint (OR 2.3, 95% CI 1.24 - 4.29; P = .008). Conclusion: Extended pre-endoscopy octreotide may be beneficial in preventing rebleeding when intervention is delayed. Further studies are needed to determine the necessary octreotide duration in delayed endoscopy and varying bleeding risk.

Evaluation of a Pharmacist-Managed Diabetes Transitions of Care Medication Management Clinic.

PURPOSE: The purpose of this study was to determine the impact of a pharmacist-managed transitions of care (TOC) clinic on outcomes in a posthospitalization population with diabetes. METHODS: A retrospective single center cohort study utilized electronic health records to identify discharged patients followed by the inpatient endocrinology team. The primary outcome was 30-day readmission rates in the target population. Secondary outcomes include 90-day readmission rates, time to first follow-up, emergency department/urgent care encounters, change in A1C, retention with endocrinology, referrals for diabetes education, and types of interventions. The control group included patients prior to the initiation of the TOC clinic compared to patients seen in the TOC clinic, evenly matched by A1C. Readmission rates and other clinical data were queried up to 4 months after discharge. RESULTS: Patients in the TOC cohort had similar 30-day readmission rates compared to the non-TOC cohort and were found to have lower A1C values within 120 days of discharge. Overall, patients in the TOC cohort were more likely to have a follow-up appointment and had closer follow-up after discharge. CONCLUSION: This study highlights that although there was no difference in readmission rates, a pharmacist-managed diabetes TOC clinic may decrease time to follow-up and improve long-term diabetes outcomes.

Rural disparities in emergency department utilization for migraine care.

OBJECTIVE: To evaluate differences in emergency department (ED) utilization and quality of care for migraine in patients with rural and nonrural residences. BACKGROUND: Migraine is a significant problem in the United States with direct health-care utilization cost amounting to US $4.2 billion annually. A considerable portion of this cost is attributed to more than 4 million annual ED visits for migraine and headache. Previous research has documented health disparities among rural populations in other disease states, which can be influenced by factors such as socioeconomic status and health-care access. Given these associations, it was hypothesized that patients with rural residence in a national sample would have increased ED utilization for migraine compared to patients with nonrural residence. METHODS: This was a cross-sectional epidemiologic study to evaluate rural disparities in ED utilization and quality of care for migraine in the United States in 2019. ED encounter data were collected from the Healthcare Cost and Utilization Project (HCUP) Nationwide Emergency Department Sample (NEDS) and Kentucky State Emergency Department Database (KY-SEDD). The primary outcome was crude and age-adjusted rates of ED encounters for migraine per 10,000 population. ED encounters were included if they had a primary International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis code of G43.xx. ED encounters lacking sufficient data to classify into a geographic group were excluded. Secondary outcomes examined differences in quality of care, including mean ED charges and the proportion of encounters with medication administration, imaging, and nerve block service codes between groups. RESULTS: One hundred eighty-three thousand two hundred eleven national ED discharges were classified as rural patient encounters and 627,176 were classified as nonrural. The rural group had significantly higher crude and age-adjusted rates of ED utilization for migraine (crude: rural 39.8, 95% confidence interval [CI] 36.9-42.7; nonrural 22.2, 95% CI 21-23.5 and age-adjusted: rural 41.8, 95% CI 38.8-44.8; nonrural 23.4, 95% CI 22.1-24.7). Opioid utilization was higher in rural encounters (rural n = 26,764, 14.6%; nonrural n = 50,367, 8%; p < 0.001). A Kentucky sub-analysis found 5210 ED discharges were classified as Appalachian and 12,551 as non-Appalachian. The Appalachian group had significantly higher ED utilization rates for migraine compared to the non-Appalachian and national rural groups (crude: Appalachian 44.9, 95% CI 43.7-46.2; age-adjusted: Appalachian 47.4, 95% CI 46.1-48.8). The Kentucky Appalachian group also demonstrated significantly higher opioid analgesia use compared to the national rural group (Appalachian n = 1031, 19.8%; p < 0.001). CONCLUSION: This study suggests rural populations, particularly in Appalachia, may experience significantly higher ED utilization for migraine compared to nonrural patients. Moreover, rural populations were more likely to receive suboptimal migraine management with opioid analgesia. Multimodal health-care interventions should be developed to improve access to outpatient migraine care and further investigate potential risk factors in the rural population. With high ED utilization, the Appalachian population may benefit most from such an intervention.

Assessing Cognitive Apprenticeship Impact on Clinical Reasoning in Third-Year Student Pharmacists.

OBJECTIVE: The objective of this study was to evaluate the impact of implementing a cognitive apprenticeship theory (CAT) model into a Doctor of Pharmacy course in improving clinical reasoning skills of third-year student pharmacists over time and preparing them for Advanced Pharmacy Practice Experiences (APPEs). METHODS: This was a single center, nonrandomized, observational before-and-after study from January 2022 through May 2022. Third-year student pharmacists enrolled in the Critical Care Integrated Drugs and Disease pharmacotherapy course at the University of Kentucky College of Pharmacy were administered a well-established and nationally recognized clinical patient case assessment on weeks 1 and 15 of the course. Students were asked to prioritize patient problems and provide recommendations for therapy, goals, and monitoring. Responses were then scored using a predefined case key. In addition, student pharmacists were asked to self-evaluate their confidence in APPE readiness on a 5-point Likert scale. RESULTS: Of the 136 student pharmacists enrolled in the course, 92 (68%) student pharmacists completed both week 1 and week 15 clinical cases and self-assessment surveys, provided informed consent, and were included. Cumulative clinical case scores were significantly increased from week 1 to week 15 (34.8 vs 39.7). In addition, significant improvement was seen in overall problem prioritization, overall recommendations, and self-perceived preparedness for APPE rotations. CONCLUSION: The use of a CAT model into a 15-week pharmacotherapy course improved comprehensive scores of clinical reasoning assessment in third-year student pharmacists and was associated with increased self-perceived confidence and readiness for APPEs.

A decade of change: The evolution of pharmacy services at U.S. cystic fibrosis centers.

INTRODUCTION: People with cystic fibrosis (pwCF) require a multidisciplinary care team due to disease complexity. The Cystic Fibrosis Foundation (CFF) notes that pharmacists are recommended, while other organizations consider pharmacists required. In 2016, the CFF initiated a grant program for CFF-accredited care centers and affiliate programs (CFF-ACCAP) to implement outpatient pharmacy services. The primary objective of this study was to compare surveys regarding pharmacy involvement in CFF-ACCAP pre- and post-grant implementation. METHODS: This was an IRB-approved, survey-based study. The surveys were distributed via the CF pharmacist-pharmacy technician and center director e-mail exchanges. RESULTS: There are currently 244 CFF-ACCAP and 158 pharmacists. Forty-two pharmacists completed the 2013 survey and 77 completed the 2023 survey. Practice site shifted from primarily the inpatient (58.5%) to outpatient settings (67.5%; p < .001). Most positions were created in the past 7 years (81%) with 50% currently or previously funded by the CFF grant program. CFF center director response decreased from 2013 to 2023 (106 vs. 48) but centers with a dedicated CF pharmacist increased from 2013 to 2023 (66%-86%; p = .014). In the 2023 survey, we received responses from 17 pharmacy technicians, who were newly included. Most of these technicians (64%) reported working in outpatient clinics. CONCLUSIONS: Since 2013, pharmacy presence has grown at CFF-ACCAP, partly due to the CFF grant program. Despite pharmacists not being required members of the multidisciplinary care team, their presence is notable in 65% of CFF-ACCAP centers, where they contribute significantly to improving the care provided for pwCF.

Association of vancomycin-induced acute kidney injury with trough versus AUC monitoring in patients receiving extended durations of therapy.

Objective: Vancomycin therapy is associated with an increased risk of acute kidney injury (AKI). Previous studies suggest that area under the curve (AUC) monitoring reduces the risk of AKI, but literature is lacking to support this in patients receiving longer durations of vancomycin therapy. Design: Retrospective cohort study. Method: Patients ≥18 years old, admitted between August 2015 and July 2017 or October 2017 and September 2019, and received at least 14 days of intravenous (IV) vancomycin therapy were included in the study. Our primary outcome was the incidence of AKI between trough monitoring and AUC monitoring groups using Kidney Disease Improving Global Outcomes criteria. Secondary outcomes included inpatient mortality, median inpatient length of stay, and median intensive care unit length of stay. Results: Overall, 582 patients were included in the study, with 318 patients included in the trough monitoring group and 264 included in the AUC monitoring group. The median duration of vancomycin therapy was 23 days (interquartile range, 16-39). Patients within the trough monitoring group had a higher incidence of AKI compared to the AUC monitoring group (45.6% vs 28.4%, p < 0.001). Furthermore, logistic regression analysis showed that AUC monitoring was associated with a 54% lower incidence of AKI (OR 0.46, 95% CI [0.31-0.69]). All-cause inpatient mortality was numerically higher in the trough monitoring group (12.9% vs 8.3%, p = 0.078). Conclusions: In patients who received at least 14 days of IV vancomycin therapy, AUC monitoring was associated with a lower incidence of AKI.

Association of Elevated Serum Aldosterone Concentrations in Pregnancy with Hypertension.

Emerging evidence indicates a previously unrecognized, clinically relevant spectrum of abnormal aldosterone secretion associated with hypertension severity. It is not known whether excess aldosterone secretion contributes to hypertension during pregnancy. We quantified aldosterone concentrations and angiotensin peptides in serum (using liquid chromatography with tandem mass spectrometry) in a cohort of 128 pregnant women recruited from a high-risk obstetrics clinic and followed prospectively for the development of gestational hypertension, pre-eclampsia, superimposed pre-eclampsia, chronic hypertension, or remaining normotensive. The cohort was grouped by quartile of aldosterone concentration in serum measured in the first trimester, and blood pressure, angiotensin peptides, and hypertension outcomes compared across the four quartiles. Blood pressures and body mass index were greatest in the top and bottom quartiles, with the top quartile having the highest blood pressure throughout pregnancy. Further stratification of the top quartile based on increasing (13 patients) or decreasing (19 patients) renin activity over gestation revealed that the latter group was characterized by the highest prevalence of chronic hypertension, use of anti-hypertensive agents, pre-term birth, and intrauterine growth restriction. Serum aldosterone concentrations greater than 704 pmol/L, the 75th percentile defined within the cohort, were evident across all categories of hypertension in pregnancy, including normotensive. These findings suggest that aldosterone excess may underlie the development of hypertension in pregnancy in a significant subpopulation of individuals.

Cardiometabolic risk factors in South American children: A systematic review and meta-analysis.

BACKGROUND: Cardiometabolic risk factors (impaired fasting glucose, abdominal obesity, high blood pressure, dyslipidemia) cluster in children, may predict adult disease burden, and are inadequately characterized in South American children. OBJECTIVES: To quantify the burden of cardiometabolic risk factors in South American children (0-21 years) and identify knowledge gaps. METHODS: We systematically searched PubMed, Google Scholar, and the Latin American and Caribbean Health Sciences Literature via Virtual Health Library from 2000-2021 in any language. Two independent reviewers screened and extracted all data. RESULTS: 179 studies of 2,181 screened were included representing 10 countries (n = 2,975,261). 12.2% of South American children experienced obesity, 21.9% elevated waist circumference, 3.0% elevated fasting glucose, 18.1% high triglycerides, 29.6% low HDL cholesterol, and 8.6% high blood pressure. Cardiometabolic risk factor definitions varied widely. Chile exhibited the highest prevalence of obesity/overweight, low HDL, and impaired fasting glucose. Ecuador exhibited the highest prevalence of elevated blood pressure. Rural setting (vs. urban or mixed) and indigenous origin protected against most cardiometabolic risk factors. CONCLUSIONS: South American children experience high rates of obesity, overweight, and dyslipidemia. International consensus on cardiometabolic risk factor definitions for children will lead to improved diagnosis of cardiometabolic risk factors in this population, and future research should ensure inclusion of unreported countries and increased representation of indigenous populations.

Evaluation of an Empiric Vancomycin Dosing Protocol on Goal Troughs and Acute Kidney Injury in a Neonatal Intensive Care Unit.

OBJECTIVE: Review the efficacy and safety of an updated empiric vancomycin dosing protocol in a neonatal intensive care unit (NICU). METHODS: Retrospective chart review including neonates with postmenstrual age (PMA) less than 40 weeks without renal dysfunction who received vancomycin per protocol at a single institution's NICU before and after implementation of an updated dosing protocol. The primary outcome is the proportion of initial therapeutic troughs. Secondary outcomes include average trough, achievement of a therapeutic trough, number of days before attainment of a therapeutic trough, and proportion of acute kidney injury (AKI) during therapy. RESULTS: The 2 groups were similar in gestational age, race, birth weight, PMA, and weight at time of vancomycin initiation. The post-implementation group had a higher proportion of initial therapeutic troughs (33.0% vs 55.1%) and a lower proportion of a subtherapeutic (58.7% vs 43.8%) and supratherapeutic (8.3% vs 1.1%) initial troughs (p = 0.002). The median trough was not different (9.20 vs 10.50 mg/L; p = 0.092). There was no difference in the proportions of achieving a therapeutic trough throughout therapy (69% vs 76%; p = 0.235); however, the post-implementation group achieved a therapeutic trough 1 day earlier (3 vs 2 days; p < 0.001). There was no difference in proportions of AKI developing between the pre-implementation vs post-implementation groups (10.1% vs 5.6%; p = 0.251). CONCLUSIONS: Implementation of an updated vancomycin dosing protocol yielded a higher percentage of initial therapeutic vancomycin troughs and patients reached the therapeutic range 1 day earlier without increasing the proportion of AKI.

Activation of the Renin-Angiotensin-Aldosterone System Is Attenuated in Hypertensive Compared with Normotensive Pregnancy.

Hypertension during pregnancy increases the risk of adverse maternal and fetal outcomes, but the mechanisms of pregnancy hypertension are not precisely understood. Elevated plasma renin activity and aldosterone concentrations play an important role in the normal physiologic adaptation to pregnancy. These effectors are reduced in patients with pregnancy hypertension, creating an opportunity to define the features of the renin-angiotensin-aldosterone system (RAAS) that are characteristic of this disorder. In the current study, we used a novel LC-MS/MS-based methodology to develop comprehensive profiles of RAAS peptides and effectors over gestation in a cohort of 74 pregnant women followed prospectively for the development of gestational hypertension and pre-eclampsia (HYP, 27 patients) versus those remaining normotensive (NT, 47 patients). In NT pregnancy, the plasma renin activity surrogate, (PRA-S, calculated from the sum of Angiotensin I + Angiotensin II) and aldosterone concentrations significantly increased from the first to the third trimester, accompanied by a modest increase in the concentrations of angiotensin peptide metabolites. In contrast, in HYP pregnancies, PRA-S and angiotensin peptides were largely unchanged over gestation, and third-trimester aldosterone concentrations were significantly lower compared with those in NT pregnancies. The results indicated that the predominant features of pregnancies that develop HYP are stalled or waning activation of the RAAS in the second half of pregnancy (accompanied by unchanging levels of angiotensin peptides) and the attenuated secretion of aldosterone.

Evaluation of adjusted international normalized ratio goal in patients with HeartMate 3 left ventricular assist devices.

BACKGROUND: The HeartMate3 left ventricular assist device (HM3 LVAD) has shown a low incidence of thrombosis, but bleeding risk is as high as 43%. We aim to describe the impact of lower international normalization ratio (INR) goal on clinical outcomes. METHODS: In February 2019, our tertiary care institution lowered INR goal in HM3 patients from manufacturer recommendations to 1.8-2.2 and retrospectively analyzed the data. Two cohorts were compared: patients with lower INR goal upon implant (De novo) and those with subsequently lowered INR goal (Adjusted). The Adjusted group also served as its own historical control. Both groups continued aspirin 81 milligrams daily per manufacturer recommendations. The primary outcomes were incidences of bleed and thrombosis events within 12 months. Secondary outcomes included survival free of disabling stroke or reoperation to remove or replace the device and Rosendaal time in therapeutic range (TTR) over 12 months. RESULTS: Thirty-one patients were evaluated for inclusion with 26 meeting criteria. Within 12 months, incidence of bleeding events was 25% and 28.6% in the De novo and Adjusted groups, respectively. Incidence of thrombotic events within 12 months was 0% in the De novo group and 7.1% in the Adjusted group. Twelve-month survival free of disabling stroke or reoperation to remove or replace the device was higher over 12 months for patients in the De novo group (91.7% vs. 78.6%). Median 12-month TTR was 36%, which was primarily attributable to subtherapeutic deviations. CONCLUSIONS: A lower INR goal may be safe when initiated De novo following implantation of the HM3. This study informs the need for larger prospective studies.

Impact of in utero drug exposure on neonates requiring ECMO: A retrospective cohort study.

The incidence of in utero drug exposure (IUDE) and neonatal extracorporeal membrane oxygenation (ECMO) utilization have both increased over the past decade. However, there are no studies to date that examine the impact that IUDE has on neonates requiring ECMO. In this retrospective cohort study, we compared the clinic course and outcomes of neonates who were placed on ECMO with IUDE vs. neonates without IUDE. Analysis included data extracted from medical records from all neonatal ECMO runs between January 2014 and January 2021 at the University of Kentucky Children's Hospital. A total of 56 neonatal patients were placed on ECMO during this time period and there were a total of 57 ECMO runs. Nearly one-third of neonates (16) had documented IUDE. There were no differences in gestational age, length of ECMO run, survival to discharge, or number of major complications while on ECMO in the neonates with IUDE compared to those without. In contrast, greater use of sedative and analgesic adjuvant medications during ECMO was required for IUDE-ECMO cases (p < 0.01). Trending results indicated that post-ECMO feeding complications and total hospitalization length were also greater in the IUDE-ECMO group. These findings illustrate the complex influence of prenatal drug exposures on neonatal patient care and warrant the development of clinical care strategies optimized for this unique patient group.

Body mass index percentiles versus body composition assessments: Challenges for disease risk classifications in children.

Background: Identifying at-risk children with optimal specificity and sensitivity to allow for the appropriate intervention strategies to be implemented is crucial to improving the health and well-being of children. We determined relationships of body mass indexes for age and sex percentile (BMI%) classifications to actual body composition using validated and convenient methodologies and compared fat and non-fat mass estimates to normative cut-off reference values to determine guideline reliability. We hypothesized that we would achieve an improved ability to identify at-risk children using simple, non-invasive body composition and index measures. Methods: Cross-sectional study of a volunteer convenience sample of 1,064 (537 boys) young children comparing Body Fat Percentage (BF%), Fat Mass Index (FMI), Fat-Free Mass Index (FFMI), determined via rapid bioimpedance methods vs. BMI% in children. Comparisons determined among weight classifications and boys vs. girls. Results: Amongst all subjects BMI% was generally correlated to body composition measures and indexes but nearly one quarter of children in the low-risk classifications (healthy weight or overweight BMI%) had higher BF% and/or lower FFMI than recommended standards. Substantial evidence of higher than expected fatness and or sarcopenia was found relative to risk status. Inaccuracies were more common in girls than boys and girls were found to have consistently higher BF% at any BMI%. Conclusions: The population studied raises concerns regarding actual risks for children of healthy or overweight categorized BMI% since many had higher than expected BF% and potential sarcopenia. When body composition and FMI and FFMI are used in conjunction with BMI% improved sensitivity, and accuracy of identifying children who may benefit from appropriate interventions results. These additional measures could help guide clinical decision making in settings of disease-risks stratifications and interventions.

Fixed mindset and imposter phenomenon: Determining the correlation and prevalence among pharmacy students.

INTRODUCTION: To determine the prevalence of fixed vs. growth mindsets and imposter phenomenon (IP) scores among pharmacy students at one institution, identify variables that explained variance in fixed mindsets and IP, and determine if a correlation exists. METHODS: A survey was developed and administered to first- to fourth-year students at the University of Kentucky College of Pharmacy. The survey included demographic questions, the Clance Imposter Phenomenon Scale (CIPS), and the Implicit Theories of Intelligence Scale (ITIS). Descriptive and inferential statistical analyses were conducted to determine the prevalence of IP and fixed vs. growth mindsets, identify variables that explained variance in CIPS and ITIS scores, and investigate if a correlation exists. RESULTS: Pharmacy students reported a high rate of IP experiences; mean (SD) CIPS score of 67.2 (14). Thirty percent of students reported at least moderate IP experiences and 68.2% reported frequent or intense IP experiences. The majority of students (59.6%) reported a growth mindset. Gender was the only tested variable that explained variance in CIPS or ITIS scores, as male gender respondents had lower CIPS score as compared to those reporting female gender (63.27 vs 68.87, p=.006). A correlation was found between lower ITIS and higher CIPS scores (r = -0.221, P < .001). CONCLUSIONS: Pharmacy students surveyed exhibited a high rate of IP and growth mindsets. Understanding that fixed mindsets and high rates of IP are correlated can help educators make informed decisions regarding targeted interventions, with the goal to improve overall student wellbeing.

Outcomes in patients with spontaneous bacterial peritonitis utilizing first-line or alternative agents for secondary prophylaxis.

PURPOSE: The American Association for the Study of Liver Diseases guidelines recommend ciprofloxacin as a first-line option for spontaneous bacterial peritonitis (SBP) prophylaxis, citing literature that is over 30 years old. There is insufficient data and guidance for prophylaxis in cases of fluoroquinolone treatment failure or intolerance. This study aimed to evaluate outcomes in patients whose antimicrobial prophylaxis was switched from first-line therapies to an alternative agent versus those who were not switched following recurrent SBP. METHODS: This study was an institutional review board-approved retrospective chart review of patients admitted to University of Kentucky HealthCare from 2014 through 2020. Patients included were 18 years of age or older with a diagnosis of recurrent SBP. The primary outcome examined was SBP recurrence rate following initial prophylaxis failure. Additional analyses targeted secondary outcomes, including 6-month mortality, development of SBP complications, development of an adverse drug reaction, and development of multidrug-resistant pathogens. RESULTS: Fifty-three patients were identified with recurrent SBP and divided into 2 cohorts: 25 patients were switched from their original prophylactic agent while 28 patients continued on the same agent after SBP recurrence. Patients in the switch group had lower rates of recurrence (52% vs 100%). Additionally, these patients had lower 6-month mortality rates (24% vs 57.1%; P = 0.015). Thirteen patients in the no-switch group and 3 patients in the switch group required intensive care on a subsequent admission (46.4% vs 12%; P = 0.008). There were no significant differences between the groups in rates of other SBP complications. CONCLUSION: Patients switched from their original prophylactic agent had lower rates of SBP recurrence with significantly lower 6-month mortality rates.

Use and Cost Analysis of Comprehensive Respiratory Panel Testing in a Pediatric Emergency Department.

OBJECTIVES: Fever and respiratory infections are among the leading causes of pediatric emergency department visits and hospitalizations. Although typically self-resolving, clinicians may perform diagnostic tests to determine microbial etiologies of these illnesses. Although comprehensive respiratory viral panels can quickly identify causative organisms, cost to the hospital and patient may be significant. The objective of this study was to analyze the financial impact of comprehensive respiratory viral panel use in relation to associated clinical outcomes. METHODS: This study was a single-center, retrospective chart review of pediatric emergency department patients who were evaluated between October 1, 2016, and April 30, 2018, with International Classification of Diseases, Tenth Revision (ICD-10) code diagnoses of acute upper respiratory infection, fever unspecified, and/or bronchiolitis. Our primary outcome was the effect of comprehensive respiratory viral panel testing and results on the total health care charge to patients. Secondary outcomes were the effect of comprehensive respiratory viral panel testing and results on emergency department length of stay and antimicrobial use. RESULTS: A total of 5766 visits were included for primary analysis, with 229 (4%) undergoing comprehensive respiratory viral panel testing. Of these, 163 had a positive result (71%) for at least 1 organism. The total cost was significantly higher in the group that underwent comprehensive respiratory viral panel testing ($643.39 [$534.18-$741.15] vs $295.15 [$249.72-$353.92]; P < 0.001). There was no decrease in emergency department length of stay or significant change in antimicrobial use associated with comprehensive respiratory viral panel use. CONCLUSIONS: This study demonstrates that the utilization of comprehensive respiratory viral panels in pediatric emergency department patients with bronchiolitis, unspecified fever, and/or acute upper respiratory infection adds significant cost to patient care without a decrease in their length of stay or antimicrobial use. Further studies are needed to determine the appropriate targeted use of comprehensive respiratory viral panels.