Retrospective, multicenter analysis of the safety and effectiveness of direct oral anticoagulants for the treatment of venous thromboembolism in obesity.

BACKGROUND: Direct oral anticoagulants (DOACs) are the preferred treatment for venous thromboembolism (VTE). However, DOAC use in patients with a BMI greater than 40 kg/m2 has not been well studied despite the growing prevalence of obesity, and current literature is often underpowered. METHODS: This multicenter, retrospective, observational study evaluated patients 18 years and older who received DOACs for acute VTE treatment. Patients receiving DOACs for recurrent VTE or for failure of another agent were excluded. The primary efficacy outcome was recurrent VTE and the primary safety outcome was major bleeding within 12 months (or one month after stopping anticoagulation therapy). A propensity score analysis was performed to balance patient characteristics and evaluate the primary endpoints by BMI group. Time-to-event outcomes were analyzed using weighted Kaplan-Meier curves. RESULTS: There were 165 patients with a BMI of at least 40 kg/m2 and 320 patients with a BMI less than 40 kg/m2. The majority received apixaban (373, 77%). Recurrent VTE occurred in 5 (3.0%) and 13 (4.1%) of patients in the higher and lower BMI groups, respectively (adjusted OR: 0.66; 95% CI: 0.16-2.69). Major bleeding occurred in 5 (3.0%) and 15 (4.7%) of patients in the higher and lower BMI groups, respectively (adjusted OR: 1.19; 95% CI: 0.36-3.92). CONCLUSION: There was no significant difference in VTE recurrence or major bleeding related to BMI among patients treated with DOACs. This study showed that DOACs may be a safe and effective VTE treatment option in patients with obesity.

De novo formation of an aggregation pheromone precursor by an isoprenyl diphosphate synthase-related terpene synthase in the harlequin bug.

Insects use a diverse array of specialized terpene metabolites as pheromones in intraspecific interactions. In contrast to plants and microbes, which employ enzymes called terpene synthases (TPSs) to synthesize terpene metabolites, limited information from few species is available about the enzymatic mechanisms underlying terpene pheromone biosynthesis in insects. Several stink bugs (Hemiptera: Pentatomidae), among them severe agricultural pests, release 15-carbon sesquiterpenes with a bisabolene skeleton as sex or aggregation pheromones. The harlequin bug, Murgantia histrionica, a specialist pest of crucifers, uses two stereoisomers of 10,11-epoxy-1-bisabolen-3-ol as a male-released aggregation pheromone called murgantiol. We show that MhTPS (MhIDS-1), an enzyme unrelated to plant and microbial TPSs but with similarity to trans-isoprenyl diphosphate synthases (IDS) of the core terpene biosynthetic pathway, catalyzes the formation of (1S,6S,7R)-1,10-bisaboladien-1-ol (sesquipiperitol) as a terpene intermediate in murgantiol biosynthesis. Sesquipiperitol, a so-far-unknown compound in animals, also occurs in plants, indicating convergent evolution in the biosynthesis of this sesquiterpene. RNAi-mediated knockdown of MhTPS mRNA confirmed the role of MhTPS in murgantiol biosynthesis. MhTPS expression is highly specific to tissues lining the cuticle of the abdominal sternites of mature males. Phylogenetic analysis suggests that MhTPS is derived from a trans-IDS progenitor and diverged from bona fide trans-IDS proteins including MhIDS-2, which functions as an (E,E)-farnesyl diphosphate (FPP) synthase. Structure-guided mutagenesis revealed several residues critical to MhTPS and MhFPPS activity. The emergence of an IDS-like protein with TPS activity in M. histrionica demonstrates that de novo terpene biosynthesis evolved in the Hemiptera in an adaptation for intraspecific communication.

Author Correction: An IDS-Type Sesquiterpene Synthase Produces the Pheromone Precursor (Z)-α-Bisabolene in Nezara viridula.

The original version of this article unfortunately contained a mistake. Under the heading "Insects" in "Methods and Materials" the sentence "A colony of N. viridula originated with field collections near Tifton, Georgia, USA" is incorrect.

An IDS-Type Sesquiterpene Synthase Produces the Pheromone Precursor (Z)-α-Bisabolene in Nezara viridula.

Insects use a wide range of structurally diverse pheromones for intra-specific communication. Compounds in the class of terpenes are emitted as sex, aggregation, alarm, or trail pheromones. Despite the common occurrence of terpene pheromones in different insect lineages, their origin from dietary host plant precursors or de novo biosynthetic pathways often remains unknown. Several stink bugs (Hemiptera: Pentatomidae) release bisabolene-type sesquiterpenes for aggregation and mating. Here we provide evidence for de novo biosynthesis of the sex pheromone trans-/cis-(Z)-α-bisabolene epoxide of the Southern green stink bug, Nezara viridula. We show that an enzyme (NvTPS) related to isoprenyl diphosphate synthases (IDSs) of the core terpene metabolic pathway functions as a terpene synthase (TPS), which converts the general intermediate (E,E)-farnesyl diphosphate (FPP) to the putative pheromone precursor (+)-(S,Z)-α-bisabolene in vitro and in protein lysates. A second identified IDS-type protein (NvFPPS) makes the TPS substrate (E,E)-FPP and functions as a bona fide FPP synthase. NvTPS is highly expressed in male epidermal tissue associated with the cuticle of ventral sternites, which is in agreement with the male specific release of the pheromone from glandular cells in this tissue. Our study supports findings of the function of similar TPS enzymes in the biosynthesis of aggregation pheromones from the pine engraver beetle Ips pini, the striped flea beetle Phyllotreta striolata, and the harlequin bug Murgantia histrionica, and hence provides growing evidence for the evolution of terpene de novo biosynthesis by IDS-type TPS families in insects.

Heart Failure in Older People Part 1: Disease State Review and Lifestyle Interventions.

The care for patients with heart failure (HF) has evolved greatly over the past decade. While new guidelines have provided more clarity on categorization and staging, and novel agents have been approved for use, there are still questions surrounding the optimal strategies as they relate to diet and exercise. Additionally, overall health care costs have increased for patients, driven in part by medication therapy. Given the myriad comorbidities associated with the diagnosis of HF, senior care pharmacists are positioned to positively impact the care for patients with HF, regardless of setting. As the guidelines continue to evolve, addressing a wider spectrum of the disease, including iron deficiency, mental health, and pain, so must the pharmacist's role in caring for patients with HF. Senior care pharmacists engaged in the management of older people with HF must be especially attuned to the unique and individualized care each patient needs, offering guidance and education in balancing treatment modalities across all aspects of care. In this three-part series, we will explore a number of areas central to the management of HF. This first section will focus on the cost of treatment, pathophysiology, and non-pharmacologic management. Series two and three will address guideline-directed medication therapy and special population management, respectively.

Ancient origin and conserved gene function in terpene pheromone and defense evolution of stink bugs and hemipteran insects.

Insects use diverse arrays of small molecules such as metabolites of the large class of terpenes for intra- and inter-specific communication and defense. These molecules are synthesized by specialized metabolic pathways; however, the origin of enzymes involved in terpene biosynthesis and their evolution in insect genomes is still poorly understood. We addressed this question by investigating the evolution of isoprenyl diphosphate synthase (IDS)-like genes with terpene synthase (TPS) function in the family of stink bugs (Pentatomidae) within the large order of piercing-sucking Hemipteran insects. Stink bugs include species of global pest status, many of which emit structurally related 15-carbon sesquiterpenes as sex or aggregation pheromones. We provide evidence for the emergence of IDS-type TPS enzymes at the onset of pentatomid evolution over 100 million years ago, coinciding with the evolution of flowering plants. Stink bugs of different geographical origin maintain small IDS-type families with genes of conserved TPS function, which stands in contrast to the diversification of TPS genes in plants. Expanded gene mining and phylogenetic analysis in other hemipteran insects further provides evidence for an ancient emergence of IDS-like genes under presumed selection for terpene-mediated chemical interactions, and this process occurred independently from a similar evolution of IDS-type TPS genes in beetles. Our findings further suggest differences in TPS diversification in insects and plants in conjunction with different modes of gene functionalization in chemical interactions.

Impact of antibiotic choice on readmission in adults experiencing an acute COPD exacerbation.

PURPOSE: The impact of antibiotic therapy in managing acute chronic obstructive pulmonary disease (COPD) exacerbations requiring hospitalization remains unclear. We conducted a study to assess the impact of antibiotic therapy on the rate of 30-day readmission after discharge from a hospital stay for an acute COPD exacerbation. Additional study outcomes analyzed included the effects of antibiotic therapy on hospital length of stay, in-hospital mortality, 90-day and 12-month readmission rates, and time to next COPD exacerbation. METHODS: The study was an institutional review board-approved, retrospective, observational review of adult patients at a tertiary academic medical center. The medical records of patients 18 years of age or older who were hospitalized for an acute COPD exacerbation between January 2008 and December 2014 were evaluated. Included patients were stratified by receipt of guideline-appropriate, guideline-inappropriate, or no antibiotic therapy. Nonparametric data were analyzed using the Kruskal-Wallis test (nonparametric) and categorical data via χ 2 test, respectively. RESULTS: Three hundred twenty-five subjects were included; there were no significant differences in baseline characteristics in the 3 study groups. Sixty-eight percent of patients (n = 223) received antibiotics. The percentage of patients readmitted within 30 days did not differ between cohorts: 11.9% (appropriate therapy) vs 13.2% (nonappropriate therapy) vs 12.2% (no antibiotics) (P = 0.95 for all comparisons). Additionally, no detectable differences in 90-day or 12-month readmission rate, length of hospital day, or in-hospital mortality were found. However, a trend toward increased time to next COPD exacerbation was noted in those receiving antibiotics vs no antibiotics (352 days vs 192 days, P = 0.07). CONCLUSION: Treatment of COPD exacerbations with antibiotics did not impact readmission rates, length of hospital stay, in-hospital mortality, or time to next exacerbation. More investigation is warranted to assess the effect of antibiotics on time to next exacerbation, as well as comparative effectiveness between antibiotic classes.

Doripenem monohydrate, a broad-spectrum carbapenem antibiotic.

BACKGROUND: Doripenem monohydrate, a broad-spectrum carbapenem antibiotic, has been approved by the US Food and Drug Administration for the treatment of complicated intra-abdominal infections (cIAIs) and complicated urinary tract infections (cUTIs). OBJECTIVE: This article reviews available information on doripenem in the management of patients with complicated bacterial infections, including its chemistry, spectrum of activity, resistance mechanisms, pharmacokinetics, pharmacodynamics, drug interactions, therapeutic efficacy, tolerability, and dosing and administration. Also discussed are pharmacoeconomic considerations associated with doripenem. METHODS: Pertinent English-language literature was identified from searches of MEDLINE (1996-October 2008) and BIOSIS (1993-October 2008). Search terms included, but were not limited to, doripenem, S-4661, spectrum of activity, resistance, pharmacology, pharmacokinetics, pharmacodynamics, adverse events, and therapeutic use. Additional publications were found by searching the reference lists of identified articles and reviewing abstracts from meetings of the Interscience Conference on Antimicrobial Agents and Chemotherapy (2003-2007). RESULTS: Doripenem is a parenteral carbapenem antibiotic with in vitro activity against gram-positive, gram-negative, and anaerobic organisms. It is stable against a wide variety of beta-lactamases, including extended-spectrum and AmpC beta-lactamases; it is, however, inactivated by organisms that produce class A enzymes, KPC enzymes, class B metallo-beta-lactamases, and class D enzymes. Doripenem is eliminated primarily in the urine (68%-80% unchanged). It should be used cautiously in patients receiving valproic acid, as combined use may lead to a precipitous decline in serum concentrations of valproic acid. A large Phase III study in the treatment of cIAIs found doripenem noninferior to meropenem (clinical cure rates, 83.9% and 85.9%, respectively; difference, -2.1; 95% CI, -9.8 to 5.6). A Phase III study in the treatment of cIAIs, including pyelonephritis, found doripenem non-inferior to levofloxacin (clinical cure rates, 95.1% and 90.2%, respectively; 95% CI, 0.2 to 9.6). With respect to the treatment of nosocomial pneumonia, one Phase III study found doripenem noninferior to imipenem (clinical cure rates, 68.3% and 64.8%, respectively; difference, 3.5%; 95% CI, -9.1 to 16.1), and another found it noninferior to piperacillin/tazobactam (clinical cure rates, 81.3% and 79.8%, respectively; difference, 1.5%; 95% CI, -9.1 to 12.1). Adverse events with doripenem were similar to those of other antibiotics with which it has been compared. Adverse events in clinical trials of doripenem have included anaphylaxis and rash (l%-5%), gastrointestinal effects (25%-32%, including nausea [1.1%-12.0%], diarrhea [1.9%-11.0%], and vomiting [1.5%-6.6%]), and central nervous system effects (headache [2.1%-16.0%], insomnia [3.7%], anxiety [2.9%], and, rarely, seizures). CONCLUSIONS: In Phase III studies, doripenem was noninferior to meropenem in the treatment of cIAIs; noninferior to levofloxacin in the treatment of cUTIs; and noninferior to imipenem and piperacillin/tazobactam in the treatment of nosocomial pneumonia. As with all new antibiotics, because of the risk of selecting for resistant organisms, use of doripenem should be reserved for infections in which a multidrug-resistant gram-negative organism, polymicrobial infection, or Pseudomonas aeruginosa is suspected.

Nonbloody, red stools from coadministration of cefdinir and iron-supplemented infant formulas.

Cefdinir is an extended-spectrum, third-generation cephalosporin that may be used for treatment of acute otitis media in patients allergic to penicillin. When administered with iron-containing products, including infant formulas, cefdinir or one of its metabolites may bind to ferric ions, forming a nonabsorbable complex that imparts a reddish color to the stool. We describe a 9-month-old infant with failure to thrive and acute otitis media who developed an erythematous maculopapular rash during treatment with amoxicillin-clavulanate. His antibiotic therapy was changed to cefdinir. Five days into a 10-day course of therapy, the infant's mother brought him to the pediatric clinic and reported the appearance of red stools. He had no associated gastrointestinal symptoms (vomiting, abdominal pain, or diarrhea). His hematocrit and hemoglobin level were normal, and Clostridium difficile antigen studies and tests for species of Shigella, Salmonella, and Camphylobacter as well as ova and parasites were all negative. Cefdinir was discontinued, and his stools returned to normal within 48 hours. Three weeks later, he again received cefdinir for recurrent otitis media. Red stools reappeared 48 hours later, were determined to be guaiac negative, and resolved within hours of drug discontinuation. During both occurrences of red stools, the infant had been breastfed and was receiving supplemental feedings with an iron-containing infant formula. In the product labeling of cefdinir, this adverse event is described as a consequence of the drug-drug interaction; however, it is not listed in the adverse drug reaction section of the labeling. As such, one may miss the association between cefdinir and reddish stools when investigating this event as a potential adverse reaction to cefdinir. When using the Naranjo adverse drug reaction probability scale to assess causality in our patient's case, this adverse drug reaction was determined as highly probable. As this infant had been breastfed, the use of a supplemental iron-containing infant formula was not identified as a potential contributing factor until the second occurrence of red stools. Health care professionals should review the entire product labeling, including the drug-drug interaction section, when investigating a potential adverse drug reaction. With the recent approval of generic formulations of cefdinir, clinicians should be aware of this drug-drug interaction with iron-containing products to prevent unnecessary alarm by parents and caregivers, as well as costly medical evaluations for gastrointestinal bleeding.

Impact of an institution-specific hospital-acquired pneumonia protocol on the appropriateness of antibiotic therapy and patient outcomes.

STUDY OBJECTIVE: To evaluate the impact of a hospital-acquired pneumonia (HAP) protocol on appropriateness of empiric antibiotic therapy, antibiotic deescalation, antibiotic duration, patient mortality, and length of stay. DESIGN: Before- and after-study of protocol implementation. SETTING: A 450-bed, academic medical center. PATIENTS: One hundred consecutive patients with proven or suspected HAP. INTERVENTION: Implementation of an HAP protocol that was based on the 2005 American Thoracic Society-Infectious Diseases Society of America guidelines and included extensive education of clinicians and monitoring by pharmacists. MEASUREMENTS AND MAIN RESULTS: Before protocol implementation, 50 patients with HAP were evaluated against protocol criteria. After protocol implementation, a second cohort of 50 patients with HAP was evaluated. Compared with the preprotocol group, implementation of the protocol led to an increase in both the proportion of patients who received appropriate empiric antibiotic coverage (17 [34%] vs 31 [62%] patients, p=0.005) and appropriate antibiotic deescalation (21 [42%] vs 36 [72%] patients, p=0.002) according to protocol recommendations but did not affect the appropriateness of empiric antibiotic therapy based on final lung culture data (34 [68%] vs 41 [82%] patients, p=0.11). Compared with the preprotocol group, use of the protocol decreased the duration of intravenous antibiotic therapy (median [range] 9 [2-21] vs 7 [1-16] days, p=0.024), was associated with a trend for a shorter duration of stay in the intensive care unit (median [range] 19 [2-57] vs 11 [3-76] days, p=0.065), and did not significantly affect mortality (5 [10%] vs 8 [16%] patients, p=0.37). Pharmacists performed 59 interventions to support the protocol in 29 patients in the postprotocol group, of which 48% were accepted. CONCLUSIONS: Implementation of an HAP protocol improved appropriate empiric antibiotic use and decreased the duration of antibiotic therapy without adversely affecting patient outcomes.

Integration of the Pharmacists' Patient Care Process (PPCP) into a Comprehensive Disease Management Course Series.

Objective. To implement and assess the curricular integration of the Pharmacists' Patient Care Process (PPCP) in a course series for second- and third-year pharmacy students. Methods. The five-step PPCP was integrated within a four-semester pharmacotherapy course starting with the introductory course lectures. Beginning in the spring of 2015, the five steps of the PPCP were delivered to 129 P2 students, along with rollout of curricular integration within corresponding classroom and seminar activities and assessments. Integration focused on the development of course-specific lecture and seminar materials, a faculty guidance strategy and templates, and evaluation approaches for course assessments. Student comprehension and utilization of the PPCP were assessed via 61 unique assessments (12 examinations and 49 quizzes). Faculty incorporation and perception of the PPCP were evaluated via survey. Results. Overall, students demonstrated the most understanding on the lowest levels of the PPCP: 83.6% and 82.2% for the Collect and Implement components, respectively, compared to the higher-level components of Planning (78.0%) and Follow-up (76.0%). Faculty understanding, integration, and utilization of the PPCP in course materials were assessed approximately 6 months after implementation. Twenty-two faculty (96% of course instructors) participated in the survey. Eighteen (82%) have modified instructional materials to incorporate PPCP and among these, 89% agreed/strongly agreed that they possessed a clear understanding of the PPCP. Conclusion. Implementing a successful curricular change such as the integration of the PPCP across multiple courses requires a multi-faceted approach. The development of faculty templates and provision of support through various methods are necessary to ensure consistent and comprehensive integration across the curriculum. Additionally, evaluation of student performance and achievement of intended outcomes should be used to guide curricular assessments and continuous quality improvements throughout the process.

A Transcriptome Survey Spanning Life Stages and Sexes of the Harlequin Bug, Murgantia histrionica.

The harlequin bug, Murgantia histrionica (Hahn), is an agricultural pest in the continental United States, particularly in southern states. Reliable gene sequence data are especially useful to the development of species-specific, environmentally friendly molecular biopesticides and effective biolures for this insect. Here, mRNAs were sampled from whole insects at the 2nd and 4th nymphal instars, as well as sexed adults, and sequenced using Illumina RNA-Seq technology. A global assembly of these data identified 72,540 putative unique transcripts bearing high levels of similarity to transcripts identified in other taxa, with over 99% of conserved single-copy orthologs among insects being detected. Gene ontology and protein family analyses were conducted to explore the functional potential of the harlequin bug's gene repertoire, and phylogenetic analyses were conducted on gene families germane to xenobiotic detoxification, including glutathione S-transferases, carboxylesterases and cytochrome P450s. Genic content in harlequin bug was compared with that of the closely related invasive pest, the brown marmorated stink bug, Halyomorpha halys (Stål). Quantitative analyses of harlequin bug gene expression levels, experimentally validated using quantitative real-time PCR, identified genes differentially expressed between life stages and/or sexes.

Update on Treatment Options for Gonococcal Infections.

The incidence of Neisseria gonorrhoeae infections in the United States has grown over the past decade. The most recent data provided by the Centers for Disease Control and Prevention (CDC) indicate that reported cases have increased by almost 10% over the last 5 years. In conjunction with this rise, the presence of multidrug-resistant strains of N. gonorrhoeae has also emerged. The 2015 CDC guidelines recommend dual therapy with intramuscular ceftriaxone and oral azithromycin as first-line treatment, although components of this regimen are met with a high level of resistance. Although ceftriaxone resistance has not yet been reported in the United States, it is only a matter of time before such isolates are detected, thus ushering in a new era of difficult-to-manage uncomplicated gonococcal infection. The potential public health crisis and patient-associated sequelae (e.g., pelvic inflammatory disease, epididymitis, and human immunodeficiency virus infection) linked with untreatable gonorrhea are cause for great concern. To try to stem this tide, a number of new agents targeted against N. gonorrhoeae are being investigated in clinical trials. In this article, we review the various agents, both currently available and under clinical investigation, and provide recommendations for the management of gonococcal infections.

Impact of students pharmacists on the medication reconciliation process in high-risk hospitalized general medicine patients.

UNLABELLED: OBJECTIVE" To compare the accuracy of medication lists obtained by student pharmacists, nurses, and physicians, and quantify the number of discrepancies identified as part of the medication reconciliation process. METHODS: Between May and July 2012, patients admitted to an internal medicine team at a 350-bed tertiary academic medical center were assessed for inclusion in the study. Physicians and/or nurses conducted medication reviews for these patients at the time of admission, while student pharmacists conducted medication reconciliation. RESULTS: Eighty-six patients were assessed, and 52 met all inclusion criteria. A total of 268 discrepancies were identified as part of the medication reconciliation performed by the student pharmacists, approximating 5 discrepancies per patient (range 0-13). Student pharmacists identified 532 preadmission medications, significantly more than did nurses (355) or physicians (368), p=0.006. CONCLUSION: Student pharmacists, with appropriate oversight, can be used in several tasks that previously may have been designated to pharmacists only, such as medication reconciliation.

Surface microbiology of the iPad tablet computer and the potential to serve as a fomite in both inpatient practice settings as well as outside of the hospital environment.

BACKGROUND: The use of tablet computers and other touch screen technology within the healthcare system has rapidly expanded. It has been reported that these devices can harbor pathogens in hospitals; however, much less is known about what pathogens they can harbor when used outside the hospital environment compared to hospital practice. METHODS: Thirty iPads belonging to faculty with a variety of practice settings were sampled to determine the presence and quantity of clinically-relevant organisms. Flocked nylon swabs and neutralizer solution were used to sample the surface of each iPad. Samples were then plated on a variety of selective agars for presence and quantity of selected pathogens. In addition, faculty members were surveyed to classify the physical location of their practice settings and usage patterns. Continuous variables were compared via an unpaired Student's t test with two-tailed distribution; categorical variables were compared with the Fisher's exact test. RESULTS: Of the iPads sampled, 16 belonged to faculty practicing within a hospital and 14 belonged to a faculty member practicing outside a hospital. More faculty within the hospital group used their iPads at their practice sites (78.6% vs. 31.3%; p = 0.014) and within patient care areas (71.4% vs. 18.8%; p = 0.009) than the non-hospital group. There were no differences in the presence, absence, or quantity of, any of the pathogens selectively isolated between groups. Problematic nosocomial pathogens such as methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and P. aeruginosa were isolated from both hospital and non-hospital faculty iPads. CONCLUSIONS: Gram positive and Gram negative organisms were recovered from the surfaces of iPads regardless of practice setting; these included problematic multidrug-resistant pathogens like MRSA, VRE, and Pseudomonas aeruginosa. Healthcare personnel in all settings should be aware of the potential for tablet computers to serve as a nidus for microorganism transmission.

Faculty development program models to advance teaching and learning within health science programs.

Within health science programs there has been a call for more faculty development, particularly for teaching and learning. The primary objectives of this review were to describe the current landscape for faculty development programs for teaching and learning and make recommendations for the implementation of new faculty development programs. A thorough search of the pertinent health science databases was conducted, including the Education Resource Information Center (ERIC), MEDLINE, and EMBASE, and faculty development books and relevant information found were reviewed in order to provide recommendations for best practices. Faculty development for teaching and learning comes in a variety of forms, from individuals charged to initiate activities to committees and centers. Faculty development has been effective in improving faculty perceptions on the value of teaching, increasing motivation and enthusiasm for teaching, increasing knowledge and behaviors, and disseminating skills. Several models exist that can be implemented to support faculty teaching development. Institutions need to make informed decisions about which plan could be most successfully implemented in their college or school.

A reflective teaching challenge to motivate educational innovation.

OBJECTIVE: To describe a teaching challenge intended to increase faculty use of evidence-based and student-centered instructional strategies in the demanding school of pharmacy context with technology-savvy students. DESIGN: A teaching challenge was created that required faculty members to incorporate a "new-to-you" innovative teaching method in a class, course, or experiential activity. The method was linked to at least 1 of 7 evidence-based principles for effective teaching. Faculty members were exposed to colleagues' teaching strategies via brief voluntary presentations at department meetings. ASSESSMENT: A post-challenge survey provided assessment data about the challenge. Responses to a baseline survey provided additional information about what faculty members were already doing (52% response rate). Eighty-one percent of faculty respondents completed the challenge. A wide array of new strategies (13 categories such as flipped classrooms and social media) was implemented and 75% included the use of technology. Nearly all respondents (96%) thought that participation in the challenge was worth the effort and planned to participate again the following year. All faculty members intended to continue using their new strategy and 56% planned additional modifications with future implementations. The challenge demonstrated how multiple goals of curricular improvement, faculty development, and student-centered instruction could be achieved together. CONCLUSION: The teaching challenge motivated most of the faculty members to try something new to them. Links between evidence-based principles and day-to-day activities were strengthened. The new-to-you design placed the challenge within reach of faculty members regardless of their background, subject, or experience.

Providers' perceptions of student pharmacists on inpatient general medicine practice experiences.

OBJECTIVE: To assess health care providers' perceptions of student pharmacists involved as members of a general medicine team. METHODS: A brief, anonymous, online survey instrument was distributed to 134 health care providers at 4 major medical centers in Massachusetts who interacted with Northeastern University student pharmacists during inpatient general medicine advanced pharmacy practice experiences beginning in March 2011. The survey instrument assessed health care provider perception of student pharmacists' involvement, preparedness, clinical skills, and therapeutic recommendations. RESULTS: Of the 79 providers who responded, 96.2% reported that student pharmacists were prepared for medical rounds and 87.3% reported that student pharmacists were active participants in patient care. Also, 94.9% and 98.7% of providers indicated that student pharmacist recommendations were appropriate and accurate, respectively. The majority (61.8%) of providers believed that student pharmacist involvement on internal medicine teams was beneficial. CONCLUSIONS: Provider perceptions regarding student pharmacist participation on general medicine practice experiences were mostly positive.

Fidaxomicin: the newest addition to the armamentarium against Clostridium difficile infections.

BACKGROUND: Fidaxomicin, a macrolide antibiotic, was the first medication for the management of Clostridium difficile infections (CDI) to be approved by the US Food and Drug Administration in more than 20 years. OBJECTIVE: This article reviews published literature on fidaxomicin for management of CDI, including its chemistry, spectrum of activity, pharmacokinetic properties, pharmacodynamics, therapeutic efficacy, adverse events, dosing, administration, and pharmacoeconomic considerations. METHODS: Pertinent English-language literature was reviewed through searches of MEDLINE, EMBASE, and BIOSIS from 1975 through September 2011. Reference lists of identified publications and published abstracts from the Interscience Conference on Antimicrobial Agents and Chemotherapy meetings were also reviewed. Search terms included, but were not limited to, fidaxomicin, difimicin, lipiarmycin, tiacumicin B, OPT-80, Clostridium spp, and diarrhea. RESULTS: A total of 79 publications were identified and 10 were excluded; 6 review articles and 4 abstracts that were later published as articles. Fidaxomicin's in vitro profile is favorable compared with oral metronidazole and vancomycin, with minimum inhibitory concentrations against C difficile that are 2 dilutions lower. From the 2 published Phase III trials, fidaxomicin was deemed to be noninferior in the treatment of mild to moderate CDI compared with oral vancomycin. Recurrence rates for all strains of CDI were lower with fidaxomicin than vancomycin. Adverse events associated with fidaxomicin were similar to placebo, with nausea and vomiting being the most common. Although no pharmacoeconomic studies have compared fidaxomicin with metronidazole or vancomycin, the current price exceeds $2500 (US) per treatment course. CONCLUSIONS: Reports suggest that fidaxomicin is noninferior to oral vancomycin in the treatment of mild or moderate CDI, although no published comparisons with metronidazole exist to date. Additionally, fidaxomicin improved outcomes compared with oral vancomycin in terms of rates of relapse and recurrent CDI, and in patients who might require concomitant antibiotics. Prospective, randomized studies comparing fidaxomicin with metronidazole in the treatment of mild or moderate CDI, as well as against vancomycin for severe CDI, should be undertaken to clarify the exact role of fidaxomicin in clinical practice.