Impact of Pharmacist Intervention to Increase Compliance With Guideline-Directed Statin Therapy During an Acute Coronary Syndrome Hospitalization.

BACKGROUND: Despite evidence on poor adherence to guideline-directed statin therapy (GDST) following an acute coronary syndrome (ACS), little information has been published on pharmacist-led statin pilot programs for secondary prevention. OBJECTIVE: We sought to evaluate the impact of a pharmacist intervention (PI) on GDST during an ACS hospitalization. METHODS: A historical control (HC) group consisting of 125 ACS hospitalizations was retrospectively identified, with prospective data of 113 patients captured over 6 months in the PI group. The primary outcome of GDST was defined according to 2013 clinical guidelines and evaluated in all 238 qualifying patients. Secondary outcomes included number of interventions and use of logistic regression to investigate the relationship of ACS subtype with statin dose. RESULTS: On admission, GDST was ordered in 62.5% of the HC and 75.9% of the PI group. At discharge, the PI group had a higher rate of GDST relative to HC among all patients (86.7 % vs 77.4%, P = 0.06), and after exclusion of contraindications (84.8% vs 74.5%; P = 0.1), 10 patients required PI, accounting for an increase in GDST of 5.3%. Statin dose selection did not differ by ACS subtype (odds ratio = 0.79; 95% CI = 0.0.29-2.17; P = 0.18). CONCLUSION: PI did not significantly increase GDST. Increased compliance rates measured were primarily driven by higher baseline adherence and guideline incorporation over time.

Serial evaluation of loop diuretic efficiency following left ventricular assist device implantation.

More than 50% of heart failure (HF) patients require diuretic therapy after left ventricular assist device (LVAD). Although few data related to diuretic response (DR) exist in stage D patients, tubular sodium reabsorption may be clinically prognostic independent of estimated glomerular filtration rate (eGFR) and proteinuria within this cohort. We aimed to characterize DR serially before and after LVAD implantation in a stage D population. We conducted a prospective, observational cohort study of HF patients receiving diuretics with plans to undergo LVAD implantation. We measured urine sodium (UNa) and creatinine (UCr) at three points after diuretic therapy: pre-LVAD, post-LVAD prior to discharge, and as an outpatient. Prior to LVAD, patients (N = 19) had an average eGFR of 54.0 ± 18.0 mL/min/1.73 m2, spot UNa of 74.8 ± 28.0 mmol/L, and fractional excretion of sodium (FENa) of 3.1 ± 2.7%. Pre-LVAD, eGFR did not correlate with spot UNa nor FENa (p > 0.05 for both). LVAD implantation did not improve DR post-LVAD (mean change FENa per 40 mg IV furosemide 0.5 ± 1.0%; p = 0.84), and 90% of patients required loop diuretics at 90 days post-surgery. Improved hemodynamics following LVAD may not improve DR or tubular function; larger studies are needed to confirm our results and assess the utility of DR to predict post-LVAD outcomes.

choros: correction of sequence-based biases for accurate quantification of ribosome profiling data.

Ribosome profiling quantifies translation genome-wide by sequencing ribosome-protected fragments, or footprints. Its single-codon resolution allows identification of translation regulation, such as ribosome stalls or pauses, on individual genes. However, enzyme preferences during library preparation lead to pervasive sequence artifacts that obscure translation dynamics. Widespread over- and under-representation of ribosome footprints can dominate local footprint densities and skew estimates of elongation rates by up to five fold. To address these biases and uncover true patterns of translation, we present choros, a computational method that models ribosome footprint distributions to provide bias-corrected footprint counts. choros uses negative binomial regression to accurately estimate two sets of parameters: (i) biological contributions from codon-specific translation elongation rates; and (ii) technical contributions from nuclease digestion and ligation efficiencies. We use these parameter estimates to generate bias correction factors that eliminate sequence artifacts. Applying choros to multiple ribosome profiling datasets, we are able to accurately quantify and attenuate ligation biases to provide more faithful measurements of ribosome distribution. We show that a pattern interpreted as pervasive ribosome pausing near the beginning of coding regions is likely to arise from technical biases. Incorporating choros into standard analysis pipelines will improve biological discovery from measurements of translation.

Clinical Pharmacy Practice Patterns Among North Carolina Rural Hospitals.

INTRODUCTION: Rural hospitals are isolated without adequate funding needed to provide for clinical services offered at larger health systems. The purpose of this study is to determine the clinical pharmacy services available and desired by rural hospitals in North Carolina. METHODS: This prospective, cross-sectional, survey was distributed to a cohort of rural pharmacy directors and managers at rural hospitals across North Carolina. Data collected pertained to characteristics of the hospital and pharmacy, pharmacy director, clinical services, and responder impressions on their ability to maintain or enhance clinical services. Responses were summarized utilizing descriptive statistics and free-responses were coded for similar themes. RESULTS: Seventeen respondents (32.6%) completed the survey. Clinical activities varied, as did characteristics of the hospitals and staff. Improved patient care is the primary reason why hospital pharmacies expand their clinical participation (46.7%). Pharmacy directors believed growth of clinical activities was a long-term goal while reporting regulations, staff, and finances as barriers to growth. CONCLUSION: Clinical pharmacy services vary in NC rural hospitals. Directors exhibit a willingness to expand clinical responsibilities. Rural hospital pharmacy directors desire pharmacists to be active clinically in patient care, but face barriers in reaching that goal.

Use of Tissue Plasminogen Activator Alteplase Purge Solution in an Impella 5.5 Heart Pump.

Standardized Impella purge solutions have traditionally consisted of 5-40% dextrose with or without unfractionated heparin as a means of anticoagulation. Such a solution serves to create a pressure barrier preventing entry of blood into the pump's motor housing with heparin providing adequate purge pathway patency in the event of this occurring. We present a case of tissue plasminogen activator (tPA, Activase) utilization in lieu of the recommended purge solution due to concern for thrombus formation of the purge pathway in a 51-year-old male with cardiogenic shock status-post Impella 5.5 heart pump placement for hemodynamic support while awaiting heart transplantation. The purge solution was successfully administered for 48 hours without complication and a reduction in average purge pressure with increase in purge flow rate was observed.

Design of Thermoresponsive Polyamine Cross-Linked Perfluoropolyether Hydrogels for Imaging and Delivery Applications.

Perfluorocarbons are versatile compounds with applications in 19F magnetic resonance imaging (MRI) and chemical conjugation to drugs and pH sensors. We present a novel thermoresponsive perfluorocarbon emulsion hydrogel that can be detected by 19F MRI. The developed hydrogel contains perfluoro(polyethylene glycol dimethyl ether) (PFPE) emulsion droplets that are stabilized through ionic cross-linking with polyethylenimine (PEI). Specifically, PFPE ester undergoes hydrolysis upon contact with aqueous PEI solution, resulting in an ionic bond between the PFPE acid and charged PEI amino groups. Due to the ionic nature of the PFPE/PEI bond, potassium buffer is required to preserve the hydrogel's pH and rheological and emulsion droplet stability. The presence of the surface cross-linked PFPE droplets does not affect the hydrogel's rheological behavior, drug loading, or drug release, and the hydrogel is nontoxic. We propose that the presented hydrogel can be adapted to a broad range of biomedical imaging and delivery applications.

Nonmodal Clinical Decision Support and Antimicrobial Restriction Effects on Rates of Fluoroquinolone Use in Uncomplicated Infections.

BACKGROUND: Medication alert overrides remain persistently high over the past decade, influenced by factors such as "alert fatigue" and lack of provider acceptance. OBJECTIVE: We compared the aggregate rate of fluoroquinolone (FQ) prescribing for the treatment of acute sinusitis, acute bronchitis, and uncomplicated urinary tract infections (UTIs) in adult inpatients prior to (historical control group) and after (prospective intervention group) implementation of a program requiring indication when ordering FQ antibiotics in combination with a nonmodal best-practice alert regarding the latest U.S. Food and Drug Administration (FDA) recommendations. We then compared rates of prescribing among provider type, severity of infection, and patient age. METHODS: Qualified orders were defined as new FQ orders for acute sinusitis, acute bronchitis, and uncomplicated UTI for adult inpatients between July 2016 through September 2016 (control) or November 2016 through January 2017 (intervention). The primary endpoint was a provider-initiated FQ order for a target indication. Secondary endpoints included FQ orders by provider type and patient age. Rates of FQ use among the target indications were compared between groups by chi-square test of independence with Yates' correction in the analysis of the primary endpoint and Fisher's exact test for secondary endpoints. RESULTS: FQ prescribing for acute bronchitis, and uncomplicated UTI occurred at a rate of 86/350 (24.6%) and 62/394 (15.7%) in the control and experimental groups, respectively (p = 0.0035). No patients receiving FQ qualified for a diagnosis of acute sinusitis. CONCLUSION: A program combining FQ restriction in combination with nonmodal messaging may have decreased the rate of prescribing for acute bronchitis and uncomplicated UTI, although the contributions of each individual element could not be rigorously assessed.

Accurate design of translational output by a neural network model of ribosome distribution.

Synonymous codon choice can have dramatic effects on ribosome speed and protein expression. Ribosome profiling experiments have underscored that ribosomes do not move uniformly along mRNAs. Here, we have modeled this variation in translation elongation by using a feed-forward neural network to predict the ribosome density at each codon as a function of its sequence neighborhood. Our approach revealed sequence features affecting translation elongation and characterized large technical biases in ribosome profiling. We applied our model to design synonymous variants of a fluorescent protein spanning the range of translation speeds predicted with our model. Levels of the fluorescent protein in budding yeast closely tracked the predicted translation speeds across their full range. We therefore demonstrate that our model captures information determining translation dynamics in vivo; that this information can be harnessed to design coding sequences; and that control of translation elongation alone is sufficient to produce large quantitative differences in protein output.

Impact of Standardized Simulated Patients on First-Year Pharmacy Students' Knowledge Retention of Insulin Injection Technique and Counseling Skills.

Objective. To compare pre- and post-intervention test scores assessing insulin injection technique and counseling skills among P1 students with (intervention) or without (control) simulated patients, and to compare counseling checklist and knowledge retention test scores between groups. Methods. This study utilized cluster randomization. In addition to traditional instruction, the intervention group counseled a simulated patient on the use of insulin using the teach-back method. Test score changes from baseline were analyzed via two-sample t-test. Results. The intervention group exhibited a significantly greater increase in knowledge test scores from baseline compared to the control group. Similar changes were seen in post-instruction counseling checklist scores and knowledge retention test scores from baseline. Conclusion. Simulated patient interactions, when added to traditional coursework within a P1 skills lab, improve student counseling aptitude and knowledge retention scores.