Single center evaluation on the use of conditionally ordered low molecular weight heparins in malignant hematology patients with venous thromboembolism.

BACKGROUND: Cancer and cancer-related treatments are significant independent risk factors for malignant hematology (MH) patients in developing venous thromboembolism (VTE). Treatment of VTE in MH patients at the Princess Margaret Cancer Centre is predominantly initiated with low molecular weight heparin (LMWH) in accordance with guidelines. While guidelines recommend against LMWH use in patients with thrombocytopenia, prescribers may order LMWH conditionally based on platelet values. Currently, there is a lack of consistent practice with variation in both the use of conditional orders as well as the threshold of platelet values for conditional orders. The objectives of the study were to (a) describe the use of conditionally ordered LMWH based on platelet values; (b) determine its safety by measuring administration concordance with conditional orders and bleeding event rates during inpatient admission; and (c) determine its efficacy by measuring the rate of worsening VTE or recurrence during inpatient admission. METHODS: Electronic records of MH inpatients admitted between January 2017 and December 2019 and who were administered at least one dose of an LMWH for the treatment of VTE were screened. RESULTS: One hundred and eight patients were screened to obtain 50 eligible patients with a median age of 59 years (SD = ±18.8 years). The most frequent MH diagnosis was acute lymphoblastic leukemia (30%). Sixty percent (n = 30) of patients received conditional orders. Out of 571 administrations, 543 (95%) were administered concordantly (Χ2(1) = 472, p < 0.0001). In this group of patients, 8 patients had either documented bleeding or experienced a drop in hemoglobin >10 g/L within a 72 h time frame. No patients experienced a recurrent VTE during inpatient treatment (for up to 40 days post-admission). CONCLUSIONS: It appears that conditionally ordered LMWH can be concordantly administered and is safe and effective in the treatment of VTE in MH patients experiencing thrombocytopenia. There were no reports of worsening or new VTE in our small sample.

Medication use during COVID-19: Review of recent evidence.

OBJECTIVE: To keep health care providers, in response to the ongoing coronavirus disease 2019 (COVID-19) pandemic, informed about the medications that have been proposed to treat the disease and the evidence supporting their use. QUALITY OF EVIDENCE: A narrative review of medications most widely used to treat COVID-19 was conducted, outlining the best available evidence for each pharmacologic treatment to date. Searches were performed in PubMed, EMBASE, and MEDLINE using key words COVID-19 and treatment, as well as related terms. Relevant research studies conducted in human populations and cases specific to patients with COVID-19 were included, as were relevant hand-searched papers and reviews. Only articles in English and Chinese were included. MAIN MESSAGE: While current management of patients with COVID-19 largely involves supportive care, without a widely available vaccine, practitioners have also resorted to repurposing medications used for other indications. This has caused considerable controversy, as many of these treatments have limited clinical evidence supporting their use and therefore pose implications for patient safety, drug access, and public health. For instance, medications such as hydroxychloroquine and chloroquine, lopinavir-ritonavir, nonsteroidal anti-inflammatory drugs, angiotensin-converting enzyme inhibitors, and angiotensin receptor blockers gained widespread media attention owing to hype, misinformation, or misinterpretation of research evidence. CONCLUSION: Given the severity of the pandemic and the potential broad effects of implementing safe and effective treatment, this article provides a narrative review of the current evidence behind the most widely used medications to treat COVID-19 in order to enable health care practitioners to make informed decisions in the care of patients with this life-threatening disease.

Non-vitamin K antagonist oral anticoagulant (NOAC) use and dosing in Canadian practice: Insights from the optimising pharmacotherapy in the management approach to lowering risk in atrial fibrillation (OPTIMAL AF) Programme.

AIMS: To estimate the rate of non-vitamin K oral anticoagulant (NOAC) dosing that is lower- and higher-than-recommended and to describe the reasons for NOAC dose discordance with Health Canada prescribing information. METHODS: The OPTIMAL AF Programme was an observational cohort quality assessment initiative in which primary and specialty care physicians in eight provinces provided a snapshot of their anticoagulated non-valvular atrial fibrillation (NVAF) patients through either an electronic medical record (EMR) system or standardised, paper-based data collection methods. RESULTS: Data on 1681 NVAF patients receiving oral anticoagulation (OAC) for stroke prevention was provided by 102 physicians. A NOAC was prescribed in 1379 patients (8%). The standard recommended dose was prescribed in 849 (76%) and reduced dose in 264 (24%). Concordance of the reduced dose with Health Canada prescribing information occurred in 154 patients (58%). The standard dose was concordant in 805 (95%). The main reasons for the use of discordant reduced doses were age of 80 years or more, elevated creatinine, prior bleeding or dose recommended by specialist. DISCUSSION AND CONCLUSION: The vast majority of Canadian patients meeting the Canadian Cardiovascular Society (CCS) guideline recommendations for OAC to decrease AF-related stroke risk were receiving product monograph-concordant NOAC dosing (85%). Nonetheless, this highlights the fact that an important proportion of patients were prescribed doses that are discordant and opportunities remain to improve NOAC dosing to optimise stroke prevention.

Cardiologists' and nephrologists' management of atrial fibrillation in hemodialysis patients
.

BACKGROUND: Antithrombotic therapy for stroke prevention in atrial fibrillation (AF) is considered a standard of care, but for hemodialysis (HD) patients the benefits are unclear, and bleeding risks are high. Our study objective was to compare cardiologists' and nephrologists' stroke prevention practices in different patient risk scenarios. MATERIALS AND METHODS: A cross-sectional, online survey was distributed to members of three Canadian physician societies (Nephrology, Cardiovascular, Heart Rhythm), and to cardiologists affiliated with three Canadian Universities. The questionnaire included four AF scenarios in HD patients with varying stroke and bleeding risks. Physicians selected one of six antithrombotic therapy options for each scenario. RESULTS: Cardiologists were 3 times more likely than nephro-logists to choose anticoagulant therapy over both antiplatelet and no drug therapy, regardless of stroke or bleeding risk (p < 0.001). Physicians' drug therapy choices in regards to level of stroke and bleeding risk reflected the expected pattern based on current evidence. CONCLUSION: Cardiologists were more likely to prescribe anticoagulant therapy for AF in the HD population compared to nephrologists, regardless of patient stroke or bleeding risk.

Médicaments utilisés durant la COVID-19: Examen des données probantes récentes.

OBJECTIF: En réponse à la pandémie actuelle de maladie à coronavirus 2019 (COVID-19), garder les médecins au fait des médicaments qui ont été proposés pour combattre la maladie, et des données probantes à l'appui de leur utilisation. SOURCES D'INFORMATION: Une revue narrative des médicaments les plus fréquemment utilisés pour combattre la COVID-19 a été réalisée, afin de souligner les meilleures données probantes disponibles concernant chaque traitement pharmacologique jusqu'ici. Des recherches ont été effectuées sur PubMed, EMBASE et MEDLINE à l'aide des mots-clés anglais COVID-19 et treatment, ainsi que d'autres mots-clés connexes. Ont été inclus les études pertinentes menées auprès de populations humaines et des cas de patients atteints de la COVID-19, ainsi que les articles et revues relevés à la main. Seuls les articles rédigés en anglais et en chinois ont été retenus. MESSAGE PRINCIPAL: Alors que la prise en charge actuelle des patients atteints de la COVID-19 consiste principalement en soins de soutien, sans accès aux vaccins, les praticiens se sont tournés vers des médicaments utilisés dans d'autres indications. Cela a causé une grande controverse, puisque des données cliniques limitées étayaient l'utilisation de beaucoup de ces traitements, et cela pouvait se répercuter sur la sécurité du patient, l'accès aux médicaments et la santé publique. Par exemple, les médicaments tels que l'hydroxychloroquine et la chloroquine, le lopinavir-ritonavir, les anti-inflammatoires non stéroïdiens, les inhibiteurs de l'enzyme de conversion de l'angiotensine et les antagonistes des récepteurs de l'angiotensine ont capté l'attention des médias en raison de la médiatisation, de la mésinformation ou de la mauvaise interprétation des données de recherche. CONCLUSION: Vu la gravité de la pandémie et les vastes effets éventuels de l'adoption de traitements sûrs et efficaces, cet article se veut être une revue narrative des données probantes actuelles étayant les médicaments les plus utilisés pour le traitement de la COVID-19 afin de permettre aux professionnels de la santé de prendre des décisions éclairées en matière de soins pour les patients qui sont atteints de cette maladie potentiellement mortelle.

Atrial fibrillation anticoagulation care in a large urban family medicine practice.

OBJECTIVE: To determine the proportion of patients with atrial fibrillation (AF) in primary care achieving guideline-concordant stroke prevention treatment based on both the previous (2010) and the updated (2012) Canadian guideline recommendations. DESIGN: Retrospective chart review. PARTICIPANTS: Primary care patients (N = 204) with AF. The mean age was 71.3 years and 53.4% were women. SETTING: Large urban community family practice in Toronto, Ont. MAIN OUTCOME MEASURES: Patient demographic characteristics such as sex and age; a list of current cardiac medications including anticoagulants and antiplatelets; the total number of medications; relevant current and past medical history including presence of diabetes, stroke or transient ischemic attack, hypertension, and vascular disease; number of visits to the family physician and cardiologist in the past year and past 5 years, and how many of these were for AF; the number of visits to the emergency department or hospitalizations for AF, congestive heart failure, or stroke; if patients were taking warfarin, how often their international normalized ratios were recorded, and how many times they were in the reference range; CHADS2 (congestive heart failure, hypertension, age ≥ 75, diabetes mellitus, and stroke or transient ischemic attack) score, if recorded; and reason for not taking oral anticoagulants when they should have been, if recorded. RESULTS: Among those who had CHADS2 scores of 0, 64 patients (97.0%) were receiving appropriate stroke prevention in AF (SPAF) treatment according to the 2010 guidelines. When the 2012 guidelines were applied, 39 patients (59.1%) were receiving appropriate SPAF treatment (P < .001). For those with CHADS2 scores of 1, 88.4% of patients had appropriate SPAF treatment according to the 2010 guidelines, but only 55.1% were adequately treated according to the 2012 guidelines (P < .001). Of the patients at the highest risk (CHADS2 score > 1), 68.1% were adequately treated with anticoagulation and an additional 8.7% (6 of 69) had documented reasons why they were not taking anticoagulants. CONCLUSION: When assessed using the 2012 Canadian Cardiovascular Society AF guidelines, the proportion of patients receiving appropriate SPAF therapy in this primary care setting decreased substantially. All patients with CHADS2 scores of 0 or 1 should be reassessed to ensure that they are receiving optimal stroke prevention treatment.

Current Gaps in the Provision of Safe and Effective Anticoagulation in Atrial Fibrillation and the Potential for Factor XI-Directed Therapeutics.

The global prevalence of atrial fibrillation is rapidly increasing, in large part due to the aging of the population. Atrial fibrillation is known to increase the risk of thromboembolic stroke by 5 times, but it has been evident for decades that well-managed anticoagulation therapy can greatly attenuate this risk. Despite advances in pharmacology (such as the shift from vitamin K antagonists to direct oral anticoagulants) that have increased the safety and convenience of chronic oral anticoagulation in atrial fibrillation, a preponderance of recent observational data indicates that protection from stroke is poorly achieved on a population basis. This outcomes deficit is multifactorial in origin, stemming from a combination of underprescribing of anticoagulants (often as a result of bleeding concerns by prescribers), limitations of the drugs themselves (drug-drug interactions, bioaccumulation in renal insufficiency, short half-lives that result in lapses in therapeutic effect, etc), and suboptimal patient adherence that results from lack of understanding/education, polypharmacy, fear of bleeding, forgetfulness, and socioeconomic barriers, among other obstacles. Often this adherence is not reported to treating clinicians, further subverting efforts to optimize care. A multidisciplinary, interprofessional panel of clinicians met during the 2023 International Society of Thrombosis and Haemostasis Congress to discuss these gaps in therapy, how they can be more readily recognized, and the potential for factor XI-directed anticoagulants to improve the safety and efficacy of stroke prevention. A full appreciation of this potential requires a reevaluation of traditional teaching about the "coagulation cascade" and decoupling the processes that result in (physiologic) hemostasis and (pathologic) thrombosis. The panel discussion is summarized and presented here.

Physician and nurse practitioner perspectives of a modified Routine Opioid Outcome Monitoring (ROOM) Tool.

Introduction The Routine Opioid Outcome Monitoring (ROOM) Tool was developed for use in community pharmacies in Australia. It facilitates pharmacists' screening and brief interventions regarding an individual's opioid use for chronic pain. At our academic teaching hospital, the ROOM Tool was adapted to incorporate a communication tool that includes a pharmacist's assessment and recommendations for primary care providers. This modified ROOM Tool was implemented as part of usual care in our outpatient pharmacies; however, the value to primary care providers is unknown. Aim The aim of this study was to determine primary care provider perspectives on the modified ROOM Tool. Methods Focus groups were conducted with primary care providers from an Academic Family Health Team. The focus group encompassed topics related to the positive and negative aspects of the modified ROOM Tool in supporting the care of patients using opioids for chronic pain. Qualitative content analysis of transcripts was performed to identify themes. Results Three focus groups were conducted with a total of six participants. Four themes emerged: (i) Facilitators to using the tool, (ii) Barriers to using the tool, (iii) Recommendations for improvement, (iv) Impact of the tool on patient care and safety. Discussion The ROOM Tool paired with the communication tool supports collaboration between pharmacists and primary care providers. The communication tool standardises the approach for communicating the pharmacist's assessment and recommendations. Recommendations to refine this modified ROOM Tool may increase its utility to primary care providers and enhance the impact on patient care and safety.

Experiences of Patients With Atrial Fibrillation With Combination Antithrombotic Therapy Post-Percutaneous Coronary Intervention.

Background: Up to 30% of patients with atrial fibrillation (AF) have coronary artery disease, and many undergo percutaneous coronary intervention (PCI). In the setting of acute coronary syndrome with PCI, or high-risk elective PCI, Canadian AF guidelines recommend 1-30 days of acetylsalicylic acid, 1-12 months of clopidogrel, and oral anticoagulation (OAC) with doses that may change throughout the 12 months post-PCI. The complexity of these regimens may contribute to unplanned modifications (UPMs), increasing the risk of thrombosis and/or bleeding. We describe what happens to these patients and their antithrombotic therapy (ATT) after discharge. Methods: Prospective follow-up was conducted of patients with AF requiring OAC who underwent PCI and were discharged on combination ATT. Patients were contacted at 1, 3, 6, and 12 months post-PCI. Results: Sixty-five patients were enrolled, with data at any time point available for 61 of them (94%). Of these, 44 (68%) experienced at least one UPM to ATT. In total, 105 UPMs occurred. The most common UPM was an extended duration of P2Y12 inhibitor (23 instances; 22%). The most common UPM with acetylsalicylic acid was extended (11 instances; 11%) or shortened (11 instances; 11%) duration. Thirty-nine UPMs (37%) were related to OACs; 9 (23%) were related to warfarin, and 30 (77%) were related to direct OACs. Of all patients with at least one UPM, 33 (75%) experienced bleeding. Conclusions: More than 2 in 3 patients with AF undergoing PCI experienced a UPM to their ATT. This study underscores the challenges of combination ATT for patients and clinicians alike, emphasizing the need for patient support after discharge.

Contexte: Jusqu'à 30 % des patients atteints de fibrillation auriculaire (FA) ont une coronaropathie, et nombre d'entre eux doivent subir une intervention coronarienne percutanée (ICP). En présence d'un syndrome coronarien aigu nécessitant une ICP ou dans le cas d'une ICP non urgente associée à un risque élevé, on recommande, dans les lignes directrices canadiennes sur la FA, un traitement de 1 à 30 jours par l'acide acétylsalicylique, de 1 à 12 mois par le clopidogrel, et une anticoagulothérapie orale (ACO) à des doses pouvant varier durant les 12 mois suivant l'ICP. La complexité de ces schémas posologiques peut contribuer à des modifications non planifiées (MNP) du traitement, ce qui accroît le risque de thrombose et/ou de saignement. Nous décrivons ce qui advient de ces patients et de leur traitement antithrombotique (TAT) après le congé de l'hôpital. Méthodologie: Un suivi prospectif a été réalisé chez des patients atteints de FA nécessitant une ACO, ayant subi une ICP et recevant un TAT lors de leur congé de l'hôpital. Les patients ont été contactés 1, 3, 6 et 12 mois après leur ICP. Résultats: Parmi les soixante-cinq patients inscrits, des données ont été obtenues pour 61 d'entre eux (94 %) à un moment ou à un autre. Au moins une MNP du TAT a eu lieu chez 44 (68 %) de ces 61 patients, pour un total de 105 MNP. La MNP la plus fréquente était la prolongation de la durée du traitement par un inhibiteur du P2Y12 (23 cas, soit 22 %). La MNP la plus fréquente du traitement par l'acide acétylsalicylique était la prolongation (11 cas, soit 11 %) ou le raccourcissement (11 cas, soit 11 %) de la durée du traitement. Au total, 39 MNP (37 %) étaient liées à des anticoagulants oraux, 9 (23 %) à la warfarine et 30 (77 %) à des anticoagulants oraux directs. Sur l'ensemble des patients ayant fait l'objet d'au moins une MNP, 33 (75 %) ont subi un saignement. Conclusions: Une MNP du TAT a eu lieu chez plus des deux tiers des patients atteints de FA ayant subi une ICP. Cette étude souligne les difficultés que pose un TAT d'association, tant pour les patients que pour les médecins, ce qui met en évidence la nécessité d'accompagner les patients après leur congé de l'hôpital.

A review of the cost of atrial fibrillation.

OBJECTIVES: To systematically review and synthesize the literature on the costs of atrial fibrillation (AF) with attention to study design and costing methods, geography, and intervention approaches. METHODS: A systematic search for previously published studies reporting the costs for AF patients was conducted. Data were analyzed in three steps: first by evaluating overall system costs; second by evaluating the relative contribution of specific cost components; and third by examining variations across study designs, across primary treatment approach, and by geography. Finally, a specific review of the treatment costs associated with anticoagulation treatment was examined given the clinical importance and attention given to these costs in the literature. RESULTS: The literature search resulted in 115 articles. On review of the abstracts or full text of these articles, 21 articles met all study criteria and reported on health system AF-related direct costs. A further six articles focused exclusively on anticoagulation costs for patients with AF. The overall average annual system cost across 27 estimates obtained from the literature was $5450 (SD = $3624) in 2010 Canadian dollars and ranged from a low of $1,632 to a high of $21,099. About one-third of these costs could be attributed to anticoagulation management. The largest cost component was acute care, followed by outpatient and physician and then medication-related costs. CONCLUSION: AF-related medical costs are high, reflecting resource-intensive and long-term treatments including anticoagulation treatment. These costs, accompanied with increasing prevalence, justify increased attention to the management of patients with AF. Future studies of AF cost should ensure a broad assessment of the incremental direct medical and societal cost associated with this diagnosis.

Opioid Utilization and Management in the Setting of Stewardship During Inpatient Rehab Care.

Background: Opioid utilization and management in an inpatient rehabilitation setting have not been widely described, despite the unique opportunities that exist in this setting to support opioid stewardship across transitions in care. We aimed to characterize opioid utilization and management by interprofessional teams across a large, inpatient rehabilitation setting after incorporation of opioid stewardship principles by pharmacists as part of their daily practice. Patients and methods: This was a retrospective chart review at Toronto Rehab, University Health Network, Toronto, Canada. Patients with admission orders for any opioid from November 2017 to February 2018 were included. Complex continuing care and palliative care patients were excluded. Descriptive statistics were primarily used to describe the data as well as univariate linear regression to compare associations with milligram morphine equivalent (MME) reduction. Results: A total of 448 patients were included. A reduction in total daily MME was seen in 49% (n=219) of the patients during their inpatient stay, with 73% (n=159) of these patients having a reduction of ≥50%. Sixty-nine percent (n=311) of the patients received an opioid prescription at discharge, with most scheduled (90%, n=98) with a supply of less than 30 days. Rehabilitation length of stay was correlated with a MME decrease during rehab (p<0.01), suggesting that longer lengths of stay contributed to a greater reduction in MME. Patients with chronic opioid use prior to acute care admission (p=0.01), and those who started extended-release opioids during acute care (p=0.02) were significantly less likely to discontinue opioids during rehab stay. Conclusion: Opioid utilization and management in the setting of opioid stewardship across inpatient rehab and transitions of care were characterized. Opportunities exist for further quality improvement initiatives within inpatient rehabilitation and acute care settings to identify and support patients with complex pain management needs.

An analysis of Canadian doctor of pharmacy hospital preceptor experiences in alternative preceptor models.

OBJECTIVE: To describe pharmacy preceptors' experiences in alternative preceptor models and their perceptions of these models' impact on the knowledge, skills, attitudes, behaviors, and professional practices of both themselves and their students. METHODS: Pharmacy preceptors with experience using alternative preceptor models participated in semi-structured interviews. Models included peer-assisted learning (PAL) (≥ two students of the same educational level), near-peer teaching (NPT) (≥ one junior student with ≥ one senior student), and co-preceptorship (CoP) (≥ two preceptors). Interviews were transcribed, coded, and analyzed for themes using the Kirkpatrick framework for evaluating educational interventions. RESULTS: Twenty hospital pharmacy preceptors from 13 institutions were interviewed, and 13 themes were identified. Fourteen preceptors had experience with PAL, 9 with NPT, and 9 with CoP. Preceptors perceived that NPT and PAL fostered comfortable learning environments that supported student success; challenges included increased time teaching multiple students and completing evaluations. CoP allowed preceptors to balance teaching with clinical duties while broadening students' exposure to different practice settings. Preceptors improved skills in time management, communicating feedback, and adapting to individual students' learning needs and styles. Alternative models enabled preceptors to provide care to more patients and complete projects, thus extending their professional practice. They also described that students participating in these models developed a sense of responsibility for patient care and will be primed to work collaboratively with pharmacy colleagues in the future. CONCLUSIONS: Preceptors expressed satisfaction with alternative preceptor models. The models enhanced the learning, skill development, and professional practice of both preceptors and students.

Medication reconciliation during internal hospital transfer and impact of computerized prescriber order entry.

BACKGROUND: Internal hospital transfer is a vulnerable time during which patients are at high risk of medication discrepancies that can result in clinically significant harm, medication errors, and adverse drug events. OBJECTIVE: To identify, characterize, and assess the clinical impact of unintentional medication discrepancies during internal hospital transfer and to investigate the influence of computerized prescriber order entry (CPOE) on medication discrepancies. METHODS: All patients transferred between 10 inpatient units at 2 tertiary care hospitals were prospectively assessed to identify discrepancies. Interfaces included transfers between (1) units that both used paper-based medication ordering systems; (2) units that both used CPOE-based systems; and (3) units that used both paper-based and CPOE-based systems (hybrid transfer). The primary endpoint was the number of patients with at least 1 unintentional medication discrepancy during internal hospital transfer. Discrepancies were identified through assessment and comparison of a best possible medication transfer list with the actual transfer orders. A multidisciplinary team of clinicians assessed the potential clinical impact and severity of unintentional discrepancies. RESULTS: Overall, 190 patients were screened and 129 patients were included. Eighty patients (62.0%) had at least 1 unintentional medication discrepancy at the time of transfer, and the most common discrepancy was medication omission (55.6%). Factors that independently increased the risk of a patient experiencing at least 1 unintentional discrepancy included lack of best possible medication history, increasing number of home medications, and increasing number of transfer medications. Forty-seven patients (36.4%) had at least 1 unintentional discrepancy with the potential to cause discomfort and/or clinical deterioration. The risk of discrepancies was present regardless of the medication-ordering system (paper, CPOE, or hybrid). CONCLUSIONS: Clinically significant medication discrepancies occur commonly during internal hospital transfer. A structured, collaborative, and clearly defined medication reconciliation process is needed to prevent internal transfer discrepancies and patient harm.

The 2020 Canadian Cardiovascular Society/Canadian Heart Rhythm Society Comprehensive Guidelines for the Management of Atrial Fibrillation.

The Canadian Cardiovascular Society (CCS) atrial fibrillation (AF) guidelines program was developed to aid clinicians in the management of these complex patients, as well as to provide direction to policy makers and health care systems regarding related issues. The most recent comprehensive CCS AF guidelines update was published in 2010. Since then, periodic updates were published dealing with rapidly changing areas. However, since 2010 a large number of developments had accumulated in a wide range of areas, motivating the committee to complete a thorough guideline review. The 2020 iteration of the CCS AF guidelines represents a comprehensive renewal that integrates, updates, and replaces the past decade of guidelines, recommendations, and practical tips. It is intended to be used by practicing clinicians across all disciplines who care for patients with AF. The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) system was used to evaluate recommendation strength and the quality of evidence. Areas of focus include: AF classification and definitions, epidemiology, pathophysiology, clinical evaluation, screening and opportunistic AF detection, detection and management of modifiable risk factors, integrated approach to AF management, stroke prevention, arrhythmia management, sex differences, and AF in special populations. Extensive use is made of tables and figures to synthesize important material and present key concepts. This document should be an important aid for knowledge translation and a tool to help improve clinical management of this important and challenging arrhythmia.

An Analysis of Canadian Doctor of Pharmacy Student Experiences in Non-Traditional Student-Preceptor Models.

Objective. To describe students' experiences and perceptions of non-traditional student-preceptor learning models and evaluate the effectiveness of these models on students' learning experience. Methods. Pharmacy students who had completed at least one experiential rotation with a non-traditional learning model participated in semi-structured interviews. Models included peer-assisted learning (PAL; two or more students of same educational level), near-peer teaching (NPT; one or more junior students with one or more senior students), and co-preceptorship (CoP; two or more preceptors). Interviews were transcribed, coded, and analyzed for themes. Themes were mapped according to the Kirkpatrick model for evaluating educational training. Results. Twenty semi-structured interviews were conducted. Forty-three experiences (19 CoP, 14 PAL, 10 NPT) from 14 institutions were described. Many themes overlapped between the three models. In CoP, learners described increased preceptor availability and exposure to different patient care approaches. Challenges arose when preceptors had different expectations. Students overwhelmingly endorsed a multi-learner environment. Both PAL and NPT learners felt supported as collaboration with other learners was readily fostered. Potential challenges in PAL and NPT were difficulties when personalities conflicted and when there was a significant knowledge gap between the learners. All three models allowed for the development of skills, including communication and collaboration. Learners reported an enhanced approach to patient care and professional practice, including approaches to teaching as new preceptors. Conclusion. Pharmacy students and graduates valued their experiences in non-traditional student-preceptor models. Institutions may find support for using these precepting models to increase placement capacity.

Establishing Therapeutic Equivalence of Complex Pharmaceuticals: The Case of Dabigatran.

Dabigatran is widely used for stroke prevention in atrial fibrillation. Dabigatran is no longer patent-protected in Canada and 2 generic formulations were recently approved by Health Canada. Branded dabigatran uses a complex formulation to maintain the acidic microenvironment required for maximal absorption. Consequently, food does not influence its bioavailability and the efficacy and safety of dabigatran are similar with or without concomitant intake of proton pump inhibitors (PPIs). Unfortunately, current bioequivalence criteria do not mandate testing of the generic formulations with food or with concomitant intake of PPIs; thus, the only data available for the approved generic products are in fasted, healthy volunteers. Without confirmation that the bioavailability of the generic dabigatran products is maintained in the presence of food or with coadministration of PPIs, it is uncertain whether they will afford patients the same protection from stroke as the branded product. Clinicians and patients must be made aware of this limitation to make informed prescribing decisions. The rules for establishing bioequivalence have not kept pace with the increasing complexity of pharmaceutical products; we urge regulators to update the regulatory process to ensure the therapeutic equivalence of generic products.