Is now our time? History to provider status for allied health professions and the path for pharmacists.

The designation of health care providers is limited to physicians, physician assistants, nurse practitioners, certified nurse midwives, nurse anesthetists, clinical psychologists, dietitians, and social workers. Pharmacists are not federally recognized health care providers and, therefore, are not eligible for cognitive service reimbursements. This commentary explains the intentions of adding pharmacists as Medicare Part B providers, evaluates current state pharmacist provider status, and calls pharmacists, technicians, and other key stakeholders to advocate on behalf of the profession of pharmacy. If federal provider status is granted to pharmacists, patients will gain better access to care, health spending will decline, and physician lead care teams will have an expert in medications readily available for consultation or other medication-related needs. Reimbursement would provide more resources to administer these needed services to more patients in areas with limited access to health care resources.

A nonthrombotic pulmonary embolus caused by polyalkylimide dermal filler: A case report and literature review of medication management.

BACKGROUND: This report presents the case of a patient who developed a nonthrombotic embolus attributed to a polyalkylimide dermal filler, and it also charts pharmacotherapeutic strategies for polyalkylimide complications reported in the literature. CASE SUMMARY: A 31-year-old female presented to a community teaching hospital with dyspnea, hemoptysis, and fever. A thorough history revealed that the patient received intragluteal injections of a polyalkylimide dermal filler (Bio-Alcamid) 4 days before hospitalization, although it was initially and incorrectly diagnosed as silicone embolism syndrome. High-dose intravenous steroids and antibiotics were ineffective, and the patient was transferred to a higher level of care for surgical management. Therein, the patient developed additional complications, including multiple thromboembolic events and the need for long-term enteral nutrition. After a 63-day stay in the intensive care unit and a 13-day stay in an inpatient postacute facility, the patient's postdischarge care transitions included 3 subsequent emergency department visits related to enteral feeding tube malfunction. PRACTICE IMPLICATIONS: Polyalkylimide is a hydrogel polymer derived from acrylic acid that is used as a dermal filler. Postinjection complications include dermal filler migration and abscess formation. Surgical resection of the filler and prophylactic antibiotics have, anecdotally, been used with success. Comparatively, silicone dermal filler complications may be treated with high-dose intravenous corticosteroids. Although silicone and polyalkylimide are both classified as permanent dermal fillers, the management of their complications differs, especially with regard to medications. This case underscores the necessity for clinicians to accurately identify the type of dermal filler used in order to recommend effective medication management to treat complications. Unlike silicone dermal filler treatment, corticosteroids may actually exacerbate polyalkylimide dermal filler complications. Beta-lactam antibiotics for at least 14 days may be reasonable to treat the cutaneous infectious complications arising from polyalkylimide dermal filler use.

A Low-Dose 4F-PCC Protocol for DOAC-Associated Intracranial Hemorrhage.

PURPOSE: Current guidelines favor 4F-PCC over plasma for reversal of warfarin. Uncertainty remains on the hemostatic effectiveness and thrombotic risk of 4F-PCC for direct-acting oral anticoagulants (DOACs), particularly in patients with intracranial hemorrhage (ICH). This study sought to evaluate the effectiveness and safety of a lower dose protocol of 25 units/kg 4F-PCC for the management of DOAC-associated ICH in a real-world setting. MATERIALS AND METHODS: This was a retrospective study of adult patients who received at least one dose of 4F-PCC from March 2014 to December 2015 for DOAC-associated ICH. The primary outcome was hemostatic effectiveness within 24 hours. The secondary outcome was thromboembolic events within 14 days. RESULTS: Twenty-two patients received 4F-PCC for DOAC-associated ICH and were included in the analysis. Hemostasis was evaluable in 19 patients with post-4F-PCC imaging available and occurred in 18/19 (94.7%) patients. Thromboembolism occurred in 2 out of 22 patients (9.1%). CONCLUSIONS: The use of a lower dose protocol of 25 units/kg of 4F-PCC resulted in high rates of hemostasis in patients with DOAC-associated ICH. Two patients developed thrombotic events within 14 days of 4F-PCC administration.

Development and Implementation of Interprofessional Relations Between a College of Pharmacy and Osteopathic Residency Programs in a Community Teaching Hospital.

Background: Team-based health care optimizes patient outcomes, and therefore, both interprofessional education (IPE) and interprofessional relations (IPR) are required in health professions education, postgraduate training, and real-world clinical practice. Existing literature describes progressive developments and assessments of IPE in colleges of pharmacy and medicine; however, there are fewer reports describing processes or projects that foster physician-pharmacist IPR in clinical practices without established interprofessional collaborations. Objectives: The primary objective was to establish IPR between pharmacists and osteopathic residents in a community teaching hospital. The secondary objective was to innovate the delivery of pharmacotherapeutic content delivered to the residents during their didactic lecture series by providing active learning strategies. Methods: This report describes a project wherein college of pharmacy faculty developed IPR with osteopathic residents in a community teaching hospital that previously did not have any established physician-pharmacist IPR. Osteopathic medical residents completed a post-implementation survey after they attended a 12-month series of didactic lectures that incorporated active learning delivered by pharmacist faculty. Results: Sixty-six residents were eligible to complete the survey; 20 residents completed the survey. Eighteen residents believed that both physicians and pharmacists should be educated to establish IPR and that it should be included in professional, graduate, and continuing education settings for both professions. Sixteen residents believed that the active learning techniques employed by college of pharmacy faculty were useful for IPR. Conclusions: Physician-pharmacist IPR may be achievable in settings where IPR was previously sparse. Shared interests, adherence, and innovations in IPR frameworks are essential for developing physician-pharmacist IPR.

Theophylline for the management of respiratory disorders in adults in the 21st century: A scoping review from the American College of Clinical Pharmacy Pulmonary Practice and Research Network.

Theophylline is an oral methylxanthine bronchodilator recommended as alternate therapy for the treatment of asthma and chronic obstructive pulmonary disease (COPD). However, it is not generally recommended for the treatment of other respiratory disorders such as obstructive sleep apnea (OSA) or hypoxia. Most clinical practice guidelines rely on evidence published prior to the year 2000 to make these recommendations. This scoping review aimed to gather and characterize evidence describing theophylline for the management of respiratory disorders in adults between January 1, 2000 and December 31, 2020. Databases searched included Ovid MEDLINE, Embase, CINAHL Complete, Scopus, and International Pharmaceutical Abstracts. This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for scoping reviews. Studies were included if they were published in English, theophylline was used for any respiratory disorder, and the study outcomes were disease- or patient-oriented. After removal of duplicates, 841 studies were screened and 55 studies were included. Results aligned with current clinical guideline recommendations relegating theophylline as an alternative therapy for the treatment of respiratory disorders, in favor of inhaled corticosteroids and inhaled bronchodilators. This scoping review identified the need for future research including: theophylline versus other medications deemed alternative therapies for asthma and COPD, meta-analyses of low-dose theophylline, and studies evaluating evidence-based patient-oriented outcomes for OSA, hypoxia, ventilator-induced diaphragmatic dysfunction, and spinal cord injury-related pulmonary function.

Major publications in the critical care pharmacotherapy literature: 2019.

PURPOSE: To summarize selected meta-analyses and trials related to critical care pharmacotherapy published in 2019. MATERIALS AND METHODS: The Critical Care Pharmacotherapy Literature Update (CCPLU) Group screened 36 journals monthly for impactful articles and reviewed 113 articles during 2019 according to Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) criteria. RESULTS: Articles with a 1A grade, including three clinical practice guidelines, six meta-analyses, and five original research trials are reviewed here from those included in the monthly CCPLU. Clinical practice guidelines on the use of polymyxins and antiarrhythmic drugs in cardiac arrest as well as meta-analyses on antipsychotic use in delirium, stress ulcer prophylaxis (SUP), and vasoactive medications in septic shock and cardiac arrest were summarized. Original research trials evaluated delirium, sedation, neuromuscular blockade, SUP, anticoagulation reversal, and hemostasis. CONCLUSION: This clinical review and expert opinion provides summary and perspectives of clinical practice impact on influential critical care pharmacotherapy publications in 2019.

Upper Gastrointestinal Bleeding in a Male Patient Taking Megestrol Acetate and Rivaroxaban: A Case Report.

OBJECTIVE: This report describes the case of a 76-year-old male who developed an upper gastrointestinal bleed shortly after beginning megestrol acetate (MGA) to treat geriatric failure to thrive (GFTT). He was also taking rivaroxaban for stroke prevention because of atrial fibrillation but had a low risk of bleeding. This article aims to provide the reader with an overview of MGA's impact on hemostasis, as well as a review of therapeutics on appetite stimulants and important transitions of care considerations for GFTT.
SETTING: The primary setting was a community teaching hospital in Florida. The patient had many transitions of care, including hospital-to-skilled nursing facility and then a hospital readmission for the primary problem reported here. A skilled nursing facility medication administration record and outpatient community pharmacy were the primary sources of the patient's admission and discharge medication histories.
PRACTICE CONSIDERATIONS: MGA's published labeling supports a prothrombotic mechanism; however, its pharmacology may also confer anticoagulant properties. This may lead to potential drug-drug interactions in patients on concomitant anticoagulant therapy. There is weak evidence supporting appetite stimulants in GFTT, and transitions of care in this population is especially important because of these patients' frequent care continuum contact.
CONCLUSIONS: MGA, a synthetic derivative of endogenous progesterone used to treat GFTT, may exert either prothrombotic or anticoagulant effects, and as such potential for drug interactions with anticoagulants must be considered. Patients taking MGA should be closely monitored for coagulation changes throughout transitions of care.

Association Between Estimated Pharmacokinetic/Pharmacodynamic Predictions of Efficacy and Observed Clinical Outcomes in Obese and Nonobese Patients With Enterobacteriaceae Bloodstream Infections.

BACKGROUND: Evidence on pharmacokinetic/pharmacodynamic (PK/PD) alterations and clinical outcomes in obese patients with serious infections remains limited. This study aimed to evaluate predicted PK/PD indices of efficacy and observed clinical outcomes between obese and nonobese patients receiving cefepime or piperacillin-tazobactam for Enterobacteriaceae bacteremia. METHODS: This was a retrospective study of adult inpatients from 1/2012 to 9/2015 with Enterobacteriaceae bacteremia who received empiric cefepime or piperacillin-tazobactam. The primary outcome was clinical cure. First-dose free-drug exposure was estimated via predicted concentrations generated from population PK analyses and used to assess PD target attainment (>50% fT > minimum inhibitory concentration [MIC]) for the specific Enterobacteriaceae isolate. Multivariable logistic regression was utilized to identify independent predictors of clinical cure. RESULTS: One hundred forty-two patients were included, 57 obese and 85 nonobese. Clinical cure was achieved in 68.4% of obese and 62.4% of nonobese patients (P = .458). No significant difference in outcomes was observed when evaluated by World Health Organization (WHO) obesity classes. The PK/PD target was achieved in 98.2% of obese and 91.8% of nonobese patients (P = .144). Independent predictors of clinical cure were immunosuppression and a shorter duration of bacteremia. Obesity was not identified as a significant predictor of clinical outcomes. CONCLUSIONS: Neither predicted PK/PD parameters nor clinical outcomes differed significantly between obese and nonobese patients treated with piperacillin-tazobactam or cefepime. As the majority of patients received extended-infusion piperacillin-tazobactam for bacteremia due to pathogens with low MICs, the potentially detrimental pathophysiologic derangements caused by obesity may not have been realized. Further studies are warranted to establish the optimal treatment of serious infections in obese patients.