Publication of pharmacy resident research projects: A systematic review and meta-analysis

DISCLAIMER

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

PURPOSE

Pharmacy residents often aspire to develop research skills through conducting a research project. Project publication rates among pharmacy residents are variable and at times low; however, previous studies have been limited to specific geographic regions and timeframes. This study sought to conduct a systematic review and meta-analysis to determine the proportion of pharmacy resident research projects published in the peer-reviewed literature.

METHODS

A systematic review of PubMed MEDLINE, Embase, and the Web of Science Core Collection was performed from database inception to May 25, 2023. Articles were included if they were full-text, peer-reviewed manuscripts of original research presenting observational data regarding pharmacy resident research project publication rates. Data extraction and assessment of risk of bias were conducted by 2 independent reviewers. A proportional meta-analysis using a random effects model of the included studies was conducted to generate a pooled, overall proportion.

RESULTS

The search yielded 5,225 records and 12 articles that met the inclusion criteria. All studies were retrospective and observational. Risk of selection and cohort identification biases was "high," whereas that of detection and timeframe biases was "low." The included studies represented 6,990 resident research projects, 777 of which were published in the peer-reviewed literature. Publication rates across individual studies ranged from 1.8% to 36.2%. The pooled proportion (scale of 0 to 1) of projects published was 0.13 (0.09-0.19).

CONCLUSION

Pharmacy resident research project publication rates are low at 13%. Furthermore, studies reporting project publication rates over time suggest a neutral or negative trend in publication rates despite an exponential increase in the number of pharmacy residents.

Characterizing redundancy in pharmacy residency research projects

DISCLAIMER

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

PURPOSE

Each year, roughly 5,000 residents conduct research on clinical and practice-based topics to meet the requirements of the ASHP residency standards related to research and project management. Several investigators have evaluated residency research project publication rates, but redundancy among projects has not been evaluated. The primary objective of this study was to determine the rate of redundancy among pharmacy residency research projects.

METHODS

This was a retrospective cohort analysis of abstracts accepted to various regional pharmacy residency conferences from 2017 through 2020. Each abstract was placed in a pharmacy domain by therapeutic area. The categorized data for each year were then further evaluated to identify clinical categories for the year. Topics were labeled as redundant if at least 10 projects fell into the same focus area within a clinical category. Descriptive statistics were used to quantify the incidence of redundancy each year.

RESULTS

A total of 4,027 abstracts were included. The most common pharmacy domains were infectious disease, internal medicine, and benefit of pharmacy services. Overall, 8.2% projects (332 of 4,027) were categorized as redundant. The most common focus areas were rapid diagnostics, opioid reduction protocols, and vancomycin area-under-the-curve vs trough monitoring.

CONCLUSION

Pharmacy residency research projects encompassed topics across a wide range of pharmacotherapy areas. Approximately 1 in 12 projects was redundant. This is likely because the project addressed a "hot topic" in practice and may represent an opportunity for institutions to collaborate to optimize project efficiency and impact.

Multicenter Comparison of the Safety and Efficacy of Clopidogrel Versus Ticagrelor for Neuroendovascular Stents

BACKGROUND

Dual antiplatelet therapy (DAPT) is commonly employed for neuroendovascular stenting due to the significant risk of thromboembolism. Clopidogrel and aspirin are most often selected as initial DAPTs; however, there is limited literature available to support guidance of DAPT in this setting. The objective of this study was to evaluate safety and efficacy in patients whose final regimen included either DAPT with aspirin and clopidogrel (DAPT-C) or DAPT with aspirin and ticagrelor (DAPT-T).

METHODS

This was a multicenter, retrospective cohort of patients who underwent neuroendovascular stenting and received DAPT between July 1, 2017, and October 31, 2020. Study participants were allocated into groups based on discharge DAPT regimen. The primary outcome was incidence of stent thrombosis at 3-6 months on DAPT-C versus DAPT-T, as defined by the presence of thrombus on imaging or new onset stroke. Secondary outcomes included major and minor bleeding and death within 3-6 months after the procedure.

RESULTS

Five hundred and seventy patients were screened across 12 sites. Of those, 486 were included (DAPT-C n = 360, DAPT-T n = 126). There was no difference in the primary outcome of stent thrombosis between the DAPT-C and DAPT-T groups (8% vs. 8%, p = 0.97) and no difference in any of the secondary safety outcomes.

CONCLUSIONS

Using DAPT-C or DAPT-T regimens in a broad population of neuroendovascular stenting procedures appears to have similar safety and efficacy profiles. Further prospective evaluation is warranted to streamline the practice of DAPT selection and monitoring to determine the impact on clinical outcomes.

Enhanced renal clearance impacts levetiracetam concentrations in patients with traumatic brain injury with and without augmented renal clearance

BACKGROUND

The purpose of this study was to examine the impact of ARC on levetiracetam concentrations during the first week following acute TBI. The hypothesis was levetiracetam concentrations are significantly lower in TBI patients with augmented renal clearance (ARC) compared to those with normal renal clearance.

METHODS

This is a prospective cohort pharmacokinetic study of adults with moderate to severe TBI treated with levetiracetam during the first week after injury. Serial blood collections were performed daily for analysis of levetiracetam, cystatin C, and 12-hr creatinine clearance (CrCl) determinations. Patients were divided into two cohorts: with (CrCl ≥130 ml/min/1.73 m2) and without ARC.

RESULTS

Twenty-two patients with moderate to severe TBI were included. The population consisted primarily of young male patients with severe TBI (mean age 40 years old, 68% male, median admission GCS 4). Each received levetiracetam 1000 mg IV every 12 h for the study period. ARC was present in 77.3% of patients, with significantly lower levetiracetam concentrations in ARC patients and below the conservative therapeutic range (< 6mcg/mL) for all study days. In patients without ARC, the serum concentrations were also below the expected range on all but two study days (Days 4 and 5). Four of the 22 (18.2%) patients exhibited seizure activity during the study period (two of these patients exhibited ARC). Cystatin C concentrations were significantly lower in patients with ARC, though the mean for all patients was within the typical normal range.

CONCLUSIONS

ARC has a high prevalence in patients with moderate to severe TBI. Levetiracetam concentrations after standard dosing were low in all TBI patients, but significantly lower in patients with ARC. This study highlights the need to consider personalized drug dosing in TBI patients irrespective of the presence of ARC.

CLINICAL TRIAL REGISTRATION

This study was registered at cliicaltrials.gov (NCT02437838) Registered on 08/05/2015, https://clinicaltrials.gov/ct2/show/NCT02437838 .

Personalized antiseizure medication therapy in critically ill adult patients

Precision medicine has the potential to have a significant impact on both drug development and patient care. It is crucial to not only provide prompt effective antiseizure treatment for critically ill patients after seizures start but also have a proactive mindset and concentrate on epileptogenesis and the underlying cause of the seizures or seizure disorders. Critical illness presents different treatment issues compared with the ambulatory population, which makes it challenging to choose the best antiseizure medications and to administer them at the right time and at the right dose. Since there is a paucity of information available on antiseizure medication dosing in critically ill patients, therapeutic drug monitoring is a useful tool for defining each patient's personal therapeutic range and assisting clinicians in decision-making. Use of pharmacogenomic information relating to pharmacokinetics, hepatic metabolism, and seizure etiology may improve safety and efficacy by individualizing therapy. Studies evaluating the clinical implementation of pharmacogenomic information at the point-of-care and identification of biomarkers are also needed. These studies may make it possible to avoid adverse drug reactions, maximize drug efficacy, reduce drug-drug interactions, and optimize medications for each individual patient. This review will discuss the available literature and provide future insights on precision medicine use with antiseizure therapy in critically ill adult patients.

Multicenter comparison of antiplatelet treatment strategies for urgent/emergent neuroendovascular stenting

BACKGROUND

Emergent neuroendovascular stenting presents challenges for the utilization of antiplatelet agents.

METHODS

This was a multicenter, retrospective cohort of patients who underwent emergent neuroendovascular stenting. The primary endpoints were thrombotic and bleeding events in relation to the timing of antiplatelet administration, route of administration, and choice of intravenous (IV) agent and the study investigated practice variability in antiplatelet utilization.

RESULTS

Five-hundred and seventy patients were screened across 12 sites. Of those, 167 were included for data analysis. For patients who presented with ischemic stroke, artery dissection and emergent internal carotid artery (ICA) stenting who received an antiplatelet agent prior to or during the procedure, 57% were given an IV antiplatelet agent; for patients who were given an antiplatelet agent after the procedure, 96% were given an oral agent. For patients who presented for aneurysm repair and received an antiplatelet agent prior to or during the procedure, 74% were given an IV agent; patients who were given an antiplatelet agent after the completion of the procedure were given an oral antiplatelet agent 90% of the time. In patients who presented with ischemic stroke, artery dissection and emergent ICA stenting who received oral antiplatelet agents post-procedure were more likely to have thrombotic events compared to those who received oral antiplatelet agents prior to or during the procedure (29% vs 9%; p  =  0.04). There were no differences in the primary outcomes observed when comparing other antiplatelet treatment strategies.

CONCLUSION

The optimal timing of antiplatelet administration in relation to stent placement and route of administration of antiplatelet agents is unclear. Timing and route of administration of antiplatelet agents may have an effect on thrombosis in emergent neuroendovascular stenting. Significant practice variation exists in antiplatelet agent utilization in emergent neuroendovascular stenting.

Hypertonic saline use in neurocritical care for treating cerebral edema: A review of optimal formulation, dosing, safety, administration and storage

PURPOSE

Current Neurocritical Care Society guidelines on the management of cerebral edema recommend hypertonic saline (HTS) over mannitol in some scenarios, but practical questions remain regarding the appropriate administration method, concentration/dose, monitoring to ensure safe use, and storage. The aim of this article is to address these practical concerns based on the evidence currently available.

SUMMARY

Many different hypertonic solutions have been studied to define the optimal hyperosmolar substance to relieve acute cerebral edema in patients with conditions such as acute ischemic stroke, intracerebral hemorrhage, subarachnoid hemorrhage, and traumatic brain injury. Mannitol and HTS are the main hyperosmolar therapies in use in contemporary neurocritical care practice. Contemporary use of HTS has followed a circuitous path in regards to the practical aspects of dosing and formulation, with evidence mainly consisting of retrospective or observational data. The effectiveness of bolus doses of HTS to lower acutely elevated intracranial pressure is well accepted. Adverse events with use of HTS are often mild and non-clinically significant if appropriate monitoring of serum sodium and chloride concentrations is performed. Available evidence shows that peripheral administration of HTS is likely safe in certain circumstances. Timely utilization of HTS is complicated by regulatory requirements for safe storage, but with appropriate safeguards HTS can be stored in patient care areas.

CONCLUSION

HTS formulations, methods of administration, infusion rate, and storage vary by institution, and no practice standards exist. Central intravenous administration may be preferred for HTS, but peripheral intravenous administration is safe provided measures are undertaken to detect and prevent phlebitis and extravasation. The safe use of HTS is possible with proper protocols, education, and institutional safeguards in place.

Comparison of nimodipine formulations and administration techniques via enteral feeding tubes in patients with aneurysmal subarachnoid hemorrhage: A multicenter retrospective cohort study

BACKGROUND

Nimodipine improves outcomes following aneurysmal subarachnoid hemorrhage (aSAH) and current guidelines suggest that patients with aSAH receive nimodipine for 21 days. Patients with no difficulty swallowing will swallow the whole capsules or tablets; otherwise, nimodipine liquid must be drawn from capsules, tablets need to be crushed, or the commercially available liquid product be used to facilitate administration through an enteral feeding tube (FT). It is not clear whether these techniques are equivalent. The goal of the study was to determine if different nimodipine formulations and administration techniques were associated with the safety and effectiveness of nimodipine in aSAH.

METHODS

This was a retrospective multicenter observational cohort study conducted in 21 hospitals across North America. Patients admitted with aSAH and received nimodipine by FT for ≥3 days were included. Patient demographics, disease severity, nimodipine administration, and study outcomes were collected. Safety end points included the prevalence of diarrhea and nimodipine dose reduction or discontinuation secondary to blood pressure reduction. Predictors of the study outcomes were analyzed using regression modeling.

RESULTS

A total of 727 patients were included. Administration of nimodipine liquid product was independently associated with higher prevalence of diarrhea compared to other administration techniques/formulations (Odds ratio [OR] 2.28, 95% confidence interval [CI] 1.41-3.67, p-value = 0.001, OR 2.76, 95% CI 1.37-5.55, p-value = 0.005, for old and new commercially available formulations, respectively). Bedside withdrawal of liquid from nimodipine capsules prior to administration was significantly associated with higher prevalence of nimodipine dose reduction or discontinuation secondary to hypotension (OR 2.82, 95% CI 1.57-5.06, p-value = 0.001). Tablet crushing and bedside withdrawal of liquid from capsules prior to administration were associated with increased odds of delayed cerebral ischemia (OR 6.66, 95% CI 3.48-12.74, p-value <0.0001 and OR 3.92, 95% CI 2.05-7.52, p-value <0.0001, respectively).

CONCLUSIONS

Our findings suggest that enteral nimodipine formulations and administration techniques might not be equivalent. This could be attributed to excipient differences, inconsistency and inaccuracy in medication administration, and altered nimodipine bioavailability. Further studies are needed.

Identifying errors and safety considerations in patients undergoing thrombolysis for acute ischemic stroke

BACKGROUND & PURPOSE

Alteplase is the standard of care for early pharmacologic thrombolysis after acute ischemic stroke (AIS). Alteplase is also considered a high-alert medication and is fraught with potential for error. We sought to describe the difference in medication error rates in in patients receiving alteplase for acute ischemic stroke from regional hospitals compared to patients receiving alteplase at the Comprehensive Stroke Center.

METHODS

This was a retrospective cohort comparison of patients who were greater than 18 years old that received intravenous alteplase for the treatment of AIS from June 2015 to June 2018. Several institution specific databases were utilized to obtain pertinent data. A standardized taxonomy was utilized to classify medication errors. Patients were excluded if they received any fibrinolytic other than alteplase or if alteplase was used for a non-stroke indication. Two cohorts (from regional hospitals or the Comprehensive Stroke Center (CSC)) were compared.

RESULTS

A total of 676 patients received alteplase during the study period (34% from the CSC and 66% from regional hospitals). There were 133 (19.8%) errors identified. Ten errors (1.6%) occurred at the CSC and 123 (18.2%) errors occurred at regional hospitals. More patients who had an error with alteplase administration (12.7%) experienced a hemorrhagic conversion compared to those with no error in administration (7.2%, p= 0.04).

CONCLUSION

The error rate of alteplase infusion for ischemic stroke is high, particularly in patients from referring centers. Errors may be associated with adverse events. Further education and administration safeguards should be implemented to decrease the risk of medication errors.

Efficacy and safety of vancomycin loading doses in critically ill patients with methicillin-resistant Staphylococcus aureus infection

Background

While vancomycin loading doses may facilitate earlier pharmacokinetic-pharmacodynamic target attainment, the impact of loading doses on clinical outcomes remains understudied. Critically ill patients are at highest risk of morbidity and mortality from methicillin resistant Staphylococcus aureus (MRSA) infection and hypothesized to most likely benefit from a loading dose. We sought to determine the association between receipt of a vancomycin loading dose and clinical outcomes in a cohort of critically ill adults.

Methods

Four hundred and forty-nine critically ill patients with MRSA cultures isolated from blood or respiratory specimens were eligible for the study. Cohorts were established by receipt of a loading dose (⩾20 mg/kg actual body weight) or not. The primary outcome was clinical failure, a composite outcome of death within 30 days of first MRSA culture, blood cultures positive ⩾7 days, white blood cell count up to 5 days from vancomycin initiation, temperature up to 5 days from vancomycin initiation, or substitution (or addition) of another MRSA agent.

Results

There was no difference in the percentage of patients experiencing clinical failure between the loading dose and no loading dose groups (74.8% versus 72.8%; p = 0.698). Secondary outcomes were also similar between groups, including mortality and acute kidney injury, as was subgroup analysis based on site of infection. Exploratory analyses, including assessment of loading dose based on quartiles and a multivariable logistic regression model showed no differences.

Conclusion

Use of vancomycin loading doses was not associated with improved clinical outcomes in critically ill patients with MRSA infection.

Levetiracetam Compared to Phenobarbital as a First Line Therapy for Neonatal Seizures: An Unexpected Influence of Benzodiazepines on Seizure Response

OBJECTIVES

Neonatal seizures are common complications. Phenobarbital is the agent of choice but leads to adverse neurologic outcomes. There has been increased use of newer agents like levetiracetam. The objective of this study was determining the rate of seizure resolution in neonates treated with phenobarbital or levetiracetam.

METHODS

This was a retrospective, single-center, cohort study from June 1, 2012-June 1, 2018 evaluating seizure resolution in neonates following first-line treatment with phenobarbital versus levetiracetam. Data were collected via review of the patient's charts in the electronic medical record. The primary outcome was seizure resolution without addition of a second antiepileptic agent. Logistic regression was used to assess the impact of pertinent variables.

RESULTS

Each group included 73 patients. The mean gestational age was 36.01 and 37.91 weeks for the phenobarbital and levetiracetam groups, respectively (p = 0.011). The phenobarbital group had higher rates of intraventricular hemorrhage at baseline. The median birth weight was 2750 and 3002 grams in the phenobarbital and levetiracetam groups, respectively (p = 0.10). Forty-five neonates (61.6%) achieved seizure resolution with phenobarbital compared with 30 neonates (41.1%) with levetiracetam (p = 0.01). In neonates who did not receive a benzodiazepine, seizure resolution was similar between groups (51-52%). In neonates who received a benzodiazepine, seizure resolution rate was 94.1% (16/17 neonates) for phenobarbital and 18.2% (4/22 neonates) for levetiracetam.

CONCLUSIONS

These findings suggest seizure resolution with levetiracetam, and phenobarbital may be impacted by benzodiazepine administration. If no benzodiazepine is used, these agents demonstrated similar efficacy. Further research into the pharmacodynamic interaction with benzodiazepines is necessary.

First-Dose Vancomycin Pharmacokinetics Versus Empiric Dosing on Area-Under-the-Curve Target Attainment in Critically Ill Patients

BACKGROUND

Early attainment of target area under the curve (AUC) to minimum inhibitory concentration (MIC) ratios have been associated with clinical success, as well as lower incidence of acute kidney injury (AKI), in patients receiving vancomycin for methicillin-resistant Staphylococcus aureus (MRSA). Critically ill patients are particularly vulnerable to poor outcomes from infection and face multiple risk factors for AKI, thus early precision dosing of vancomycin is vital in this population. We hypothesized that a personalized dosing approach, using vancomycin levels obtained after the first dose to guide further dosing, would be superior to empiric dosing in terms of AUC target attainment assessed at steady state (SS).

METHODS

A retrospective cohort study of 66 critically ill adult patients admitted to the medical intensive care unit without AKI and receiving vancomycin with at least two SS concentrations obtained for AUC calculation was performed. Patients were separated into cohorts based on whether they had two concentrations assessed after the first dose of vancomycin and were subsequently dosed based on personalized pharmacokinetic calculations (first-dose kinetics) or whether they were empirically dosed using population estimates. The primary outcome was AUC target attainment (400-600 mg hour/L) at SS.

RESULTS

Compared with patients receiving empiric dosing by population estimates, using first-dose kinetics to guide subsequent dosing resulted in significantly greater AUC target attainment at SS (58.6% first-dose vs 32.4% empiric; p=0.033). Patients dosed empirically yielded more variable AUC values across a wide range compared with the first-dose kinetics group (coefficient of variation 40.7% empiric vs 26.1% first-dose). There was no difference in AKI up to 48 hours after SS concentrations between the two dosing schemes.

CONCLUSIONS

A dosing strategy using two vancomycin serum concentrations after the first dose and calculating personalized pharmacokinetic parameters to guide subsequent dosing is associated with greater AUC target attainment at SS compared with empiric dosing of vancomycin in critically ill adults with relatively stable renal function.

Stress-Related Gastrointestinal Bleeding in Patients with Aneurysmal Subarachnoid Hemorrhage: A Multicenter Retrospective Observational Study

BACKGROUND/OBJECTIVE

Stress-related mucosal bleeding (SRMB) occurs in approximately 2-4% of critically ill patients. Patients with aneurysmal subarachnoid hemorrhage (aSAH) have a (diffuse) space-occupying lesion, are critically ill, often require mechanical ventilation, and frequently receive anticoagulation or antiplatelet therapy after aneurysm embolization, all of which may be risk factors for SRMB. However, no studies have evaluated SRMB in patients with aSAH. Aims of the study were to determine the incidence of SRMB in aSAH patients, evaluate the effect of acid suppression on SRMB, and identify specific risk factors for SRMB.

METHODS

This was a multicenter, retrospective, observational study conducted across 17 centers. Each center reviewed up to 50 of the most recent cases of aSAH. Patients with length of stay (LOS) < 48 h or active GI bleeding on admission were excluded. Variables related to demographics, aSAH severity, gastrointestinal (GI) bleeding, provision of SRMB prophylaxis, adverse events, intensive care unit (ICU), and hospital LOS were collected for the first 21 days of admission or until hospital discharge, whichever came first. Descriptive statistics were used to analyze the data. A multivariate logistic regression modeling was utilized to examine the relationship between specific risk factors and the incidence of clinically important GI bleeding in patients with aSAH.

RESULTS

A total of 627 patients were included. The overall incidence of clinically important GI bleeding was 4.9%. Of the patients with clinically important GI bleeding, 19 (61%) received pharmacologic prophylaxis prior to evidence of GI bleeding, while 12 (39%) were not on pharmacologic prophylaxis at the onset of GI bleeding. Patients who received an acid suppressant agent were less likely to experience GI bleeding than patients who did not receive pharmacologic prophylaxis prior to evidence of bleeding (OR 0.39, 95% CI 0.18-0.83). The multivariate regression analysis identified any instance of elevated intracranial pressure, creatinine clearance < 60 ml/min and the incidence of cerebral vasospasm as specific risk factors associated with GI bleeding. Cerebral vasospasm has not previously been described as a risk for GI bleeding (OR 2.5 95% CI 1.09-5.79).

CONCLUSIONS

Clinically important GI bleeding occurred in 4.9% of patients with aSAH, similar to the general critical care population. Risk factors associated with GI bleeding were prolonged mechanical ventilation (> 48 h), creatinine clearance < 60 ml/min, presence of coagulopathy, elevation of intracranial pressure, and cerebral vasospasm. Further prospective research is needed to confirm this observation within this patient population.

Evaluation of Two Fosphenytoin Loading Dose Regimens and Monitoring in Infants and Neonates Less Than Six Months of Age

OBJECTIVES

The objectives of the study were to compare the free serum concentrations after different fosphenytoin loading dose strategies in patients younger than 6 months old and to investigate the frequency of seizure cessation following a loading dose of fosphenytoin.

METHODS

This retrospective cohort study included neonates and infants admitted to a 150-bed children's hospital between August 1, 2014, and February 1, 2018. Patients were included if they were younger than 6 months old and had a postload free phenytoin serum concentration collected during the specified time frame. Patients were identified through a database query screening for the inclusion criteria. Patients were separated into 2 groups with the 15 mg/kg group as per protocol and the 20 mg/kg group as noted in common practice. Data collection included demographic information, fosphenytoin dose, time of administration of the fosphenytoin loading dose, time of sampling, free phenytoin serum concentration results, concomitant antiepileptic agents, albumin serum concentration, and total bilirubin serum concentration.

RESULTS

Forty-one patients were included for analysis, 12 in the 15 mg/kg group and 29 in the 20 mg/kg group. The average free phenytoin concentration after the loading dose was 2.45 ± 0.54 mg/L in the 15 mg/kg group and 2.52 ± 0.66 mg/L in the 20 mg/kg group. Seizure cessation after the fosphenytoin loading dose was achieved in 3 of 12 (25%) patients in the 15 mg/kg group and in 13 of 29 (45%) patients in the 20 mg/kg group (p = 0.305).

CONCLUSIONS

The study demonstrates that a traditional range of fosphenytoin loading dose (15-20 mg/kg) led to elevated postloading dose free phenytoin serum concentrations in the majority of patients with a seizure cessation rate of approximately 39%. The question remains as to what the optimal dose and target concentration should be in this patient population to achieve the best efficacy without risking associated toxicities.

Impact of PhORCAS references on overall application score for postgraduate year 1 pharmacy residency candidates

Purpose

The disparity between the number of applicants for postgraduate year 1 (PGY1) pharmacy residency positions and the number of available residency positions increases the need to optimize how applicants are evaluated. The purpose of the study described here was to evaluate the correlation of ratings of residency candidate characteristics by academic and professional references listed on residency applications with overall application score, applicant ranking, and the likelihood of candidates receiving an invitation to interview.

Methods

A multicenter, retrospective study was conducted to evaluate the correlation of reference writers’ ratings of 13 candidate characteristics and their overall recommendations with program-determined outcomes (eg, final application score, applicant ranking, and invitation to interview) through analysis of PGY1 applications submitted through the Pharmacy Online Residency Centralized Application System (PhORCAS) from 2015 through 2018. Keywords and themes within the open-ended section of letters of reference were also analyzed for correlation with overall application score.

Results

A total of 5,923 references listed on 1,867 applications to 4 PGY1 pharmacy residency programs processed by PhORCAS were included in the analysis. For the majority of applicant characteristic ratings (ie, 74% of 56,872 ratings overall), reference writers rated candidates as exceeding expectations, and applicants were “highly recommended” by these evaluators in 91% of cases. References’ average characteristic ratings and overall recommendations were poorly correlated with final application score (R2 = 0.12 [P &lt; 0.0001] and R2 = 0.08 [P &lt; 0.0001], respectively), final ranking (R2 = 0.02 [P &lt; 0.0001] and R2 = 0.03 [P &lt; 0.0001], respectively), and invitation to interview (R2 = 0.07 [P &lt; 0.0001] and R2 = 0.04 [P &lt; 0.0001], respectively). For the themes evaluated, references’ use of teaching words best correlated with normalized final application score, although the correlation was poor (R2 = 0.007, P = 0.0001).

Conclusion

Reference writers’ ratings of PGY1 residency candidate characteristics in PhORCAS are poorly correlated with application score, applicant ranking, and invitation to interview. The results of this study suggest that the existing PhORCAS standardized form for submitting references is of limited utility in its current state.

Guidelines for the Acute Treatment of Cerebral Edema in Neurocritical Care Patients

BACKGROUND

Acute treatment of cerebral edema and elevated intracranial pressure is a common issue in patients with neurological injury. Practical recommendations regarding selection and monitoring of therapies for initial management of cerebral edema for optimal efficacy and safety are generally lacking. This guideline evaluates the role of hyperosmolar agents (mannitol, HTS), corticosteroids, and selected non-pharmacologic therapies in the acute treatment of cerebral edema. Clinicians must be able to select appropriate therapies for initial cerebral edema management based on available evidence while balancing efficacy and safety.

METHODS

The Neurocritical Care Society recruited experts in neurocritical care, nursing, and pharmacy to create a panel in 2017. The group generated 16 clinical questions related to initial management of cerebral edema in various neurological insults using the PICO format. A research librarian executed a comprehensive literature search through July 2018. The panel screened the identified articles for inclusion related to each specific PICO question and abstracted necessary information for pertinent publications. The panel used GRADE methodology to categorize the quality of evidence as high, moderate, low, or very low based on their confidence that the findings of each publication approximate the true effect of the therapy.

RESULTS

The panel generated recommendations regarding initial management of cerebral edema in neurocritical care patients with subarachnoid hemorrhage, traumatic brain injury, acute ischemic stroke, intracerebral hemorrhage, bacterial meningitis, and hepatic encephalopathy.

CONCLUSION

The available evidence suggests hyperosmolar therapy may be helpful in reducing ICP elevations or cerebral edema in patients with SAH, TBI, AIS, ICH, and HE, although neurological outcomes do not appear to be affected. Corticosteroids appear to be helpful in reducing cerebral edema in patients with bacterial meningitis, but not ICH. Differences in therapeutic response and safety may exist between HTS and mannitol. The use of these agents in these critical clinical situations merits close monitoring for adverse effects. There is a dire need for high-quality research to better inform clinicians of the best options for individualized care of patients with cerebral edema.

Factor Xa Inhibitor-Related Intracranial Hemorrhage

Background:

Since the approval of the oral factor Xa inhibitors, there have been concerns regarding the ability to neutralize their anticoagulant effects after intracranial hemorrhage (ICH). Multiple guidelines suggest using prothrombin complex concentrates (PCCs) in these patients on the basis of research that includes a limited number of patients with ICH. Given this, we aimed to evaluate the safety and efficacy of PCCs for factor Xa inhibitor–related ICH in a large, multicenter cohort of patients.

Methods:

This was a multicenter, retrospective, observational cohort study of patients with apixaban- or rivaroxaban-related ICH who received PCCs between January 1, 2015, and March 1, 2019. The study had 2 primary analysis groups: safety and hemostatic efficacy. The safety analysis evaluated all patients meeting inclusion criteria for the occurrence of a thrombotic event, which were censored at hospital discharge or 30 days after PCC administration. Patients with intracerebral, subarachnoid, or subdural hemorrhages who had at least 1 follow-up image within 24 hours of PCC administration were assessed for hemostatic efficacy. The primary efficacy outcome was the percentage of patients with excellent or good hemostasis on the basis of the modified Sarode criteria. Secondary outcomes included an evaluation of in-hospital mortality, length of stay, infusion-related reactions, and thrombotic event occurrence during multiple predefined periods.

Results:

A total of 663 patients were included and assessed for safety outcomes. Of these, 433 patients met criteria for hemostatic efficacy evaluation. We observed excellent or good hemostasis in 354 patients (81.8% [95% CI, 77.9–85.2]). Twenty-five (3.8%) patients had a total of 26 thrombotic events, of which 22 occurred in the first 14 days after PCC administration. One patient had documentation of an infusion-related reaction. For the full cohort of patients, in-hospital mortality was 19.0%, and the median intensive care unit and hospital lengths of stay were 2.0 and 6.0 days, respectively.

Conclusions:

Administration of PCCs after apixaban- and rivaroxaban-related ICH provided a high rate of excellent or good hemostasis (81.8%) coupled with a 3.8% thrombosis rate. Randomized, controlled trials evaluating the clinical efficacy of PCCs in patients with factor Xa inhibitor–related ICH are needed.

Sleep quality during an overnight on-call program

PURPOSE

Many institutions deploy pharmacy residents to expand clinical pharmacy services, often in the form of overnight, in-house on-call programs. There is little published evidence regarding pharmacy resident sleep and sleepiness after a night of overnight, in-house on-call activity. A prospective observational cohort study was conducted to determine the relationship between overnight, in-house on-call programs and pharmacy resident sleep and sleep quality.

METHODS

The cohort study included both postgraduate year 1 and postgraduate year 2 pharmacy residents. Each resident participated in 10 to 15 overnight on-call shifts. Sleep and sleep quality were assessed using devices worn on residents' wrists on the nights prior to, during, and after on-call shifts. Resident sleepiness was assessed via the Epworth Sleepiness Scale (ESS) during specified baseline and postcall periods. Univariate and multivariate analysis were used to assess the relationship between measurements of sleep, sleep quality, and sleepiness.

RESULTS

We enrolled a total of 23 residents in the study and recorded data on 269 on-call shifts. Frequently (42.6% of shifts) residents had no time to sleep during overnight on-call shifts. Among those who did have sleep time, the mean sleep time during an overnight, in-house on-call shift was 1.22 (SD, 1.56) hours. Additionally, ESS scores indicated a 2.4-fold increase in sleepiness on the morning after vs the morning before on-call shifts.

CONCLUSION

Residents often did not sleep while on call. Sleep periods overnight were short and of poor quality. Predictably, residents reported increased sleepiness after an overnight on-call shift. Residents received an average of approximately 10 clinical consultation calls per overnight shift.

Prealbumin Is Associated With In-Hospital Mortality in Critically Ill Patients

BACKGROUND

Prealbumin (PAB) has been shown to be a useful index of nutrition status in clinically stable patients. In the setting of critical illness, however, PAB is a negative acute phase reactant and may also reflect severity of illness. The purpose of this study was to evaluate the relationship between PAB and clinical outcomes in critically ill patients.

METHODS

This was a single-center, retrospective, nonrandomized cohort study of adult intensive care unit (ICU) patients. Baseline PAB and change in PAB were analyzed. The primary outcome was in-hospital mortality, and the secondary outcome was hospital length of stay (LOS). Data collected included PAB levels, Charlson Comorbidity Index, LOS, in-hospital mortality, and nutrition intake. Linear and logistic regressions were used to characterize the association between PAB levels and clinical outcomes.

RESULTS

Our study included 926 patients. Patients expiring in hospital experienced a greater decrease in PAB over time, -1.3 vs -0.7 mg/dL (odds ratio 0.94 [0.9-0.98] in multivariable regression, P = .002). Baseline PAB was not associated with in-hospital mortality or LOS. Exploratory analyses demonstrated a weak correlation between nutrition and change in PAB.

CONCLUSION

Our data demonstrate that change in PAB is associated with hospital mortality. Nutrition intake weakly correlated with change in PAB. PAB does not appear to be a robust marker of nutrition therapy but may have value as a prognostic indicator in the ICU setting.

Fever Burden in Patients With Subarachnoid Hemorrhage and the Increased Use of Antibiotics

BACKGROUND

Fever occurs in the majority of subarachnoid hemorrhage (SAH) patients. Nearly 50% of SAH patients have noninfectious fevers. Data are lacking describing the effects of fever burden in the SAH patient population.

METHODS

This was a single-center, retrospective observational cohort study in patients more or equal to 18 years of age with a diagnosis of nontraumatic SAH admitted to an ICU between January 1, 2010 and September 1, 2015. Exclusion criteria were SAH secondary to trauma or admission for more than 48 hours. Temperature measurements, demographic data, and other pertinent information were collected from Day 0 to Day 13. Daily fever burden was calculated for each patient by calculating an area under the curve.

RESULTS

A total of 194 subjects were included. The mean study period maximum temperature (Tmax) for all 194 patients was 40.8 ± 0.83°C. The mean overall fever burden for all 194 patients was 89.2 ± 99.59°C h more than 37°C. The overall fever burden peaked on day 5 and declined thereafter. Fever burden, Tmax, and length of stay in the hospital were all significantly associated with receipt of antibiotics. Only Tmax was associated with poor outcome. The 31 patients who had fever but no identified cause of infection received 1000 doses of antibiotics or 32.25 doses per patient.

CONCLUSION

Fever is common in SAH patients and is associated with antibiotic use, infection, vasospasm, and poor outcome. Some SAH patients may receive antibiotics unnecessarily for noninfectious fever. Clinicians should consider using site-specific parameters related to infection rather than systemic symptoms such as fever to evaluate infection in SAH patients.

Development of a Coprecepting Model for a Preceptor-in-Training Program for New Practitioners

Background: Preceptor development is a focus of pharmacy residency programs across the country. Graduation from residency into the role of preceptor can be a challenge, as it is one of many transitions junior practitioners make in their early careers. Literature in recent years has brought attention to the need to establish preceptor development programs that adequately allow newer preceptors to develop their skills in experiential education, for both pharmacy residents and students. Furthermore, many preceptor development programs as implemented are often didactic in nature, and include readings, webinars, and other passive learning regarding the art of precepting. Objective: Given the need to develop a preceptor development program in our service line that met the needs of preceptors-in-training and full preceptors, we offer a description of our preceptor development program in the intensive care unit. Methods: We focused on active development of preceptor skills for multiple layers of resident and student learners. In addition, this model incorporated instructing, modeling, coaching, and facilitating, as the relationship between full preceptor and preceptor-in-training evolved. It also offered the opportunity for real-time feedback and discussion on precepting performance. Conclusions: We describe our coprecepting model as an opportunity that succeeded for us in helping to transition our preceptors-in-training to full preceptors. It met the needs of our department, staff, and patients, and we believe it has the potential to be valuable as a tool extrapolated to the preceptor development programs of other institutions.

Patients' and Care Providers' Perceptions of Television-Based Education in the Intensive Care Unit

BACKGROUND

Delivery of patient education materials to promote health literacy is a vital component of patient-centered care, which improves patients' decision-making, reduces patients' anxiety, and improves clinical outcomes.

OBJECTIVES

To evaluate perceptions of television-based patient education among patients, caregivers, nurses, and other care providers (attending physicians, advanced practice nurses, physician assistants, and resident fellows) in the intensive care unit.

METHODS

A Likert-scale survey of the perceptions of patients, caregivers, nurses, and other care providers in the medical and cardiovascular intensive care units of a large academic medical center. Perceptions of the effects of television-based education on anxiety, knowledge, and health-related decision-making were assessed.

RESULTS

A total of 188 participants completed the survey. Among them, 75% of nurses and 76% of other providers agreed or strongly agreed that television-based education improved patients' and caregivers' knowledge (P = .95). More nurses (47%) than other providers (29%) agreed that television-based education would lead to more informed health decisions by patients (P = .04). Patients and caregivers are 23 times more likely than providers to strongly agree that television-based education reduces anxiety, and they are more optimistic regarding the benefits of television-based education (relative risk ratio 23.47; 95% CI 9.75-56.45; P < .001).

CONCLUSION

Patients and caregivers strongly suggested that television is a useful tool for providing health literacy education in an intensive care unit.

Augmented Renal Clearance

Augmented renal clearance (ARC) is a phenomenon in critically ill patients characterized by increased creatinine clearance and elimination of renally eliminated medications. Patients with severe neurologic injury, sepsis, trauma, and burns have been consistently identified as at risk of ARC, with mean creatinine clearances ranging from 170 ml/minute to more than 300 ml/minute. Several potential mechanisms may contribute to the occurrence of ARC including endogenous responses to increased metabolism and solute production, alterations in neurohormonal balance, and therapeutic maneuvers such as fluid resuscitation. Augmented renal clearance is associated with suboptimal exposure to critical medications, including β-lactams and vancomycin, increasing the risk of treatment failure. Although definitive screening tools are not yet known, critical care pharmacists must be vigilant in recognizing when ARC may be a contributing factor affecting expected treatment outcomes in individual patients. Optimizing dosing strategies in critically ill patients with ARC remains a goal of continued research. The current review discusses the clinical characteristics and methods of identifying patients at risk of ARC, potential mechanisms for ARC, and describes pharmacotherapy dosing considerations in patients with ARC.

Use of simulation training to prepare pharmacy residents for medical emergencies

PURPOSE

The use of high-fidelity simulation training for preparing pharmacy residents for various high-stress and high-impact medical emergencies and the impact of this training on pharmacy residents' perception of preparedness are described.

SUMMARY

During the 2015-16 residency year at the University of Kentucky Medical Center, simulation training, in addition to lecture-based orientation training, was chosen as a method to reinforce skills and knowledge learned throughout the orientation, before residents began working on-call shifts. Three different simulation exercises were developed to cover five selected topics over the course of 3 different days: sepsis as its own session, a surgical-themed session combining bleeding reversal and malignant hyperthermia, and a neurologic-themed session combining stroke and status epilepticus. Postgraduate year 2 (PGY2) specialty residents in critical care and emergency medicine helped facilitate the cases. The specialty residents played the role of the physician or nurse for the case and were allowed to answer questions asked of the pharmacy residents, appropriate to their respective roles. Following completion of the simulation exercise, a survey tool was sent to pharmacy residents to rate their perception of preparedness before and after the training for each scenario and again at 6 months after the simulation training to assess sustainability of the training. Participants generally responded that the simulations met their expectations and that the PGY2 residents facilitated the simulations fairly well (scores of 68.5-80 on a scale of 0-100). The resident-reported that beneficial effects of simulation training persisted at 6 months following the simulation exercises.

CONCLUSION

Simulation training increased pharmacy residents' self-reported preparedness for high-stress, high-impact clinical scenarios and medical emergencies.

Status epilepticus alert reduces time to administration of second-line antiseizure medications

Background

Status epilepticus (SE) is a neurologic emergency with high morbidity and mortality. Delays in SE treatment are common in clinical practice and can be associated with poorer outcomes. Our goal was to determine whether the implementation of an SE alert protocol improves time to administration of a second-line antiseizure medication (ASM) in hospitalized adults.

Methods

We developed and implemented an inpatient SE alert system. A quasiexperimental cohort study was performed. We analyzed all patients aged 18-85 years who were managed at the University of Kentucky Medical Center using the SE alert protocol between March 2015 and June 2017 (n = 19). Controls were the first 20 consecutive patients treated for SE over the same time period, but who were managed with usual care (i.e., without SE alert protocol).

Results

Time to administration of a second-line ASM was shorter with the use of the SE alert system (22.21 ± 3.44 minutes) compared to usual care (58.30 ± 6.72 minutes; p < 0.0001).

Conclusion

Implementation of an SE alert system led to a marked improvement in time to administration of a second-line ASM.

Classification of evidence

This study provides Class III evidence that for adult inpatients treated for SE, implementation of an SE alert protocol reduces time to administration of second-line ASM.

Management of antiplatelet therapy in patients undergoing neuroendovascular procedures

Neuroendovascular techniques for treating cerebral aneurysms and other cerebrovascular pathology are increasingly becoming the standard of care. Intraluminal stents, aneurysm coils, and other flow diversion devices typically require concomitant antiplatelet therapy to reduce thromboembolic complications. The variability inherent with the pharmacodynamic response to common antiplatelet agents such as aspirin and clopidogrel complicates optimal selection of antiplatelet agents by clinicians. This review serves to discuss the literature related to antiplatelet use in neuroendovascular procedures and provides recommendations for clinicians on how to approach patients with variable response to antiplatelet agents, particularly clopidogrel.

Treatment of Hyponatremia in Patients with Acute Neurological Injury

BACKGROUND

Little data exist regarding the practice of sodium management in acute neurologically injured patients. This study describes the practice variations, thresholds for treatment, and effectiveness of treatment in this population.

METHODS

This retrospective, multicenter, observational study identified 400 ICU patients, from 17 centers, admitted for ≥48 h with subarachnoid hemorrhage (SAH), traumatic brain injury (TBI), intraparenchymal hemorrhage, or intracranial tumors between January 1, 2011 and July 31, 2012. Data collection included demographics, APACHE II, Glascow Coma Score (GCS), serum sodium (Na+), fluid rate and tonicity, use of sodium-altering therapies, intensive care unit (ICU) and hospital length of stay, and modified Rankin score upon discharge. Data were collected for the first 21 days of ICU admission or ICU discharge, whichever came first. Sodium trigger for treatment defined as the Na+ value prior to treatment with response defined as an increase of ≥4 mEq/L at 24 h.

RESULTS

Sodium-altering therapy was initiated in 34 % (137/400) of patients with 23 % (32/137) having Na⁺ >135 mEq/L at time of treatment initiation. The most common indications for treatment were declining serum Na⁺ (68/116, 59 %) and cerebral edema with mental status changes (21/116, 18 %). Median Na⁺ treatment trigger was 133 mEq/L (IQR 129-139) with no difference between diagnoses. Incidence and treatment of hyponatremia was more common in SAH and TBI [SAH (49/106, 46 %), TBI (39/97, 40 %), ICH (27/102, 26 %), tumor (22/95, 23 %); p = 0.001]. The most common initial treatment was hypertonic saline (85/137, 62 %), followed by oral sodium chloride tablets (42/137, 31 %) and fluid restriction (15/137, 11 %). Among treated patients, 60 % had a response at 24 h. Treated patients had lower admission GCS (12 vs. 14, p = 0.02) and higher APACHE II scores (12 vs. 10, p = 0.001). There was no statistically significant difference in outcome when comparing treated and untreated patients.

CONCLUSION

Sodium-altering therapy is commonly employed among neurologically injured patients. Hypertonic saline infusions were used first line in more than half of treated patients with the majority having a positive response at 24 h. Further studies are needed to evaluate the impact of various treatments on patient outcomes.

Different Therapeutic Approaches and Outcome in the Treatment of Pterygium

Purpose

This study was initiated to investigate the role of different therapeutic modalities in the outcome of the surgical treatment of pterygium.

Methods

The results of treatment of pterygia with a variety of surgical techniques were studied in 56 eyes (49 patients) operated on at Bristol Eye Hospital during a period of five years. The surgical techniques included simple excision; bare sclera; conjunctival autograft; sliding conjunctival flap; lamellar keratoplasty and penetrating keratoplasty. Twelve eyes received additional beta irradiation in a fractionated total dose of 40 Gys.

Results

The incidence of recurrence was 23.2% for the 43 treated primary pterygia, and 23% for the 13 recurrent pterygia. All recurrences occurred between 2.5 and 11 months postoperatively. None of the 11 cases where additional beta irradiation was used showed any recurrence or other complication within the study period. In the recurrent pterygia group, the cases treated with a combination of surgical excision and beta irradiation, showed significantly lower recurrence rate (p<0.001) compared to those cases treated with surgical excision alone.

Conclusions

Beta irradiation as a complement to surgical treatment of pterygium, is successful in treating high risk cases such as reoperations, whereas for the majority of primary pterygia surgical excision alone is adequate. Additionally, follow up of one year will reveal any recurrences.

Direct observation of orbital hybridisation in a cuprate superconductor

The minimal ingredients to explain the essential physics of layered copper-oxide (cuprates) materials remains heavily debated. Effective low-energy single-band models of the copper–oxygen orbitals are widely used because there exists no strong experimental evidence supporting multi-band structures. Here, we report angle-resolved photoelectron spectroscopy experiments on La-based cuprates that provide direct observation of a two-band structure. This electronic structure, qualitatively consistent with density functional theory, is parametrised by a two-orbital (\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$d_{x^2 - y^2}$$\end{document}dx2-y2 and \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$d_{z^2}$$\end{document}dz2) tight-binding model. We quantify the orbital hybridisation which provides an explanation for the Fermi surface topology and the proximity of the van-Hove singularity to the Fermi level. Our analysis leads to a unification of electronic hopping parameters for single-layer cuprates and we conclude that hybridisation, restraining d-wave pairing, is an important optimisation element for superconductivity.

The essential physics of cuprate superconductors is often described by single-band models. Here, Matt et al. report direct observation of a two-band electronic structure in La-based cuprates.

Neuroleptic Malignant Syndrome

Objective: To review evidence for the treatment of neuroleptic malignant syndrome (NMS) and to discuss how to rechallenge patients with neuroleptics when continued pharmacotherapy for chronic psychological illness is required. Data Sources: A PubMed search was conducted through March 2016 using available medical subject heading (MeSH) terms and keywords that included neuroleptic malignant syndrome, treatment, dantrolene, and bromocriptine. A manual search of article reference sections followed. Study Selection and Data Extraction: Case reports and case series in English that discussed NMS and atypical NMS treatment as well as neuroleptic rechallenge were included for review. Data Synthesis: The reported incidence of NMS was 0.02% to 0.03%, with a mortality rate of 5.6%. Current literature on NMS is primarily retrospective and emphasizes diagnostic criteria, causative agents, and potential pharmacotherapy. Details regarding timing of administration, dose, and duration of pharmacotherapy are inconsistently reported. Reported dosing strategies and outcomes have been summarized. Instances of rechallenge were infrequently reported but demonstrate that recurrence may happen at any time after NMS resolution. Recommendations regarding safe rechallenge are provided. Conclusion: NMS is a rare adverse drug reaction, with a complex pathophysiology and presentation. Timely diagnosis and discontinuation of antipsychotic therapy is the first-line treatment, followed by supportive care and pharmacotherapy. Antipsychotic rechallenge is often required and should be attempted only after a drug-free period and with a different agent, slowly titrated with close monitoring.

Steady-state pharmacokinetic simulation of intermittent vs. continuous infusion valproic acid therapy in non-critically ill and critically ill patients

OBJECTIVES

Valproic acid (VPA) is a broad-spectrum antiepileptic drug used for a variety of neurologic disorders. The relatively short half-life seen with intermittent intravenous bolus doing may lead to serum concentration variability. Continuous infusion VPA therapy is an approach to mitigate these effects. The objective of this study is to characterize the pharmacokinetics of continuous infusion of VPA in acutely ill patients and to determine dosing regimens that most frequently obtain goal steady-state serum concentrations.

METHODS

This is a retrospective pharmacokinetics study in adult patients receiving continuous infusion VPA per institutional protocol for seizure or status migrainosus. Pharmacokinetic parameters were reviewed for 234 patients (25 critically ill) and compared between the two groups (non-critically ill vs. critically ill). Intermittent and continuous infusion dosing strategies were modeled utilizing Monte Carlo simulations for both cohorts. Frequencies of serum concentration attainment were reported.

RESULTS

The percent target attainment for the non-critically ill group and critically ill group were 69.4 and 58.3% (p = 0.282) post-loading dose and 69.7 and 37.5% (p = 0.004) steady state, respectively. The volume of distribution was significantly different between the two groups (0.35 vs. 0.68 L/kg, p = < 0.0001). Highest frequency of target attainment (50-100 mcg/ml) occurred in the continuous infusion 2 mg/kg/h simulation for both critically ill (45.19%) and acutely ill (48.16%) groups.

DISCUSSION

Critically ill patients have an increased volume of distribution. Increasing the volume of distribution requires higher loading doses of VPA to obtain desired therapeutic concentrations. Continuous infusion VPA provides more consistent serum steady-state concentrations while mitigating pharmacokinetic variability.

Antiepileptic dosing for critically ill adult patients receiving renal replacement therapy

OBJECTIVES

The aim of this review was to evaluate current literature for dosing recommendations for the use of antiepileptic medications in patients receiving renal replacement therapy (RRT).

DATA SOURCES

With the assistance of an experienced medical librarian specialized in pharmacy and toxicology, we searched MEDLINE, EMBASE, CINAHL, Web of Science, WorldCat, and Scopus through May 2016.

STUDY SELECTION AND DATA EXTRACTION

Four hundred three articles were screened for inclusion, of which 130 were identified as potentially relevant. Micromedex® DRUGDEX as well as package inserts were used to obtain known pharmacokinetic properties and dosage adjustment recommendations in RRT if known.

DATA SYNTHESIS

Data regarding antiepileptic drug use in RRT are limited and mostly consist of case reports limiting our proposed dosing recommendations. Known pharmacokinetic parameters should guide dosing, and recommendations are provided where possible.

CONCLUSION

Additional studies are necessary before specific dosing recommendations can be made for most antiepileptic drugs in critically ill patients receiving RRT, specifically with newer agents.

Pharmacokinetic Alterations of Antimicrobials in the Critically Ill

Critical illness is accompanied by multiple physiologic alterations that affect the pharmacokinetics of antimicrobials. Although the pharmacokinetics of a number of antimicrobials have been studied in critically ill individuals, an understanding of the physiological alterations in critical illness and general pharmacokinetic principles of antimicrobials is imperative for appropriate selection, dosing, and prediction of toxicity.

A trans-Atlantic examination of haddock Melanogrammus aeglefinus food habits

The food habits of Melanogrammus aeglefinus were explored and contrasted across multiple north-eastern and north-western Atlantic Ocean ecosystems, using databases that span multiple decades. The results show that among all ecosystems, echinoderms are a consistent part of M. aeglefinus diet, but patterns emerge regarding where and when M. aeglefinus primarily eat fishes v. echinoderms. Melanogrammus aeglefinus does not regularly exhibit the increase in piscivory with ontogeny that other gadoids often show, and in several ecosystems there is a lower occurrence of piscivory. There is an apparent inverse relationship between the consumption of fishes and echinoderms in M. aeglefinus over time, where certain years show high levels of one prey item and low levels of the other. This apparent binary choice can be viewed as part of a gradient of prey options, contingent upon a suite of factors external to M. aeglefinus dynamics. The energetic consequences of this prey choice are discussed, noting that in some instances it may not be a choice at all.

Pharmacy residents' preparedness for the emotional challenges of patient care

PURPOSE

Results of a survey to determine levels of pharmacy resident exposure to and preparedness for emotionally unsettling clinical scenarios are presented.

METHODS

A pretested electronic survey was distributed to 1501 U.S. pharmacy residency program directors (RPDs), who were asked to complete the survey and forward it to residents in their programs. Both respondent groups provided perspectives on pharmacy residents' frequency of exposure to and preparedness for nine scenarios that could potentially be emotionally unsettling to pharmacy residents (e.g., a patient's death, participation in a response to a cardiorespiratory arrest). RPDs and residents were queried regarding training methods used by their programs to prepare trainees to cope with emotionally unsettling events.

RESULTS

A total of 940 responses were received. Overall, resident-reported ex posure to the nine scenarios listed in the survey was infrequent. Majorities of both RPDs and residents (85.2% and 67.1%, respectively) indicated that residents could be better prepared for the emotional challenges of patient care. The most common method of training was a one-on-one discussion between a preceptor and a resident on an as-needed basis. No training was reported by 30% and 40% of RPDs and residents, respectively.

CONCLUSION

The majority of RPD and resident respondents indicated that residents could be better prepared for the emotional challenges of patient care. The most commonly reported method of training for coping with emotional challenges was a one-on-one discussion between a preceptor and a resident on an as-needed basis.

Lunar atmosphere. How surface composition and meteoroid impacts mediate sodium and potassium in the lunar exosphere

Despite being trace constituents of the lunar exosphere, sodium and potassium are the most readily observed species due to their bright line emission. Measurements of these species by the Ultraviolet and Visible Spectrometer (UVS) on the Lunar Atmosphere and Dust Environment Explorer (LADEE) have revealed unambiguous temporal and spatial variations indicative of a strong role for meteoroid bombardment and surface composition in determining the composition and local time dependence of the Moon's exosphere. Observations show distinct lunar day (monthly) cycles for both species as well as an annual cycle for sodium. The first continuous measurements for potassium show a more repeatable variation across lunations and an enhancement over KREEP (Potassium Rare Earth Elements and Phosphorus) surface regions, revealing a strong dependence on surface composition.

A phase 1b clinical trial of the CD40-activating antibody CP-870,893 in combination with cisplatin and pemetrexed in malignant pleural mesothelioma

BACKGROUND

Data from murine models suggest that CD40 activation may synergize with cytotoxic chemotherapy. We aimed to determine the maximum tolerated dose (MTD) and toxicity profile and to explore immunological biomarkers of the CD40-activating antibody CP-870,893 with cisplatin and pemetrexed in patients with malignant pleural mesothelioma (MPM).

PATIENTS AND METHODS

Eligible patients had confirmed MPM, ECOG performance status 0-1, and measurable disease. Patients received cisplatin 75 mg/m(2) and pemetrexed 500 mg/m(2) on day 1 and CP-870,893 on day 8 of a 21-day cycle for maximum 6 cycles with up to 6 subsequent cycles single-agent CP-870,893. Immune cell subset changes were examined weekly by flow cytometry.

RESULTS

Fifteen patients were treated at three dose levels. The MTD of CP-870,893 was 0.15 mg/kg, and was exceeded at 0.2 mg/kg with one grade 4 splenic infarction and one grade 3 confusion and hyponatraemia. Cytokine release syndrome (CRS) occurred in most patients (80%) following CP-870,893. Haematological toxicities were consistent with cisplatin and pemetrexed chemotherapy. Six partial responses (40%) and 9 stable disease (53%) as best response were observed. The median overall survival was 16.5 months; the median progression-free survival was 6.3 months. Three patients survived beyond 30 months. CD19+ B cells decreased over 6 cycles of chemoimmunotherapy (P < 0.001) with a concomitant increase in the proportion of CD27+ memory B cells (P < 0.001) and activated CD86+CD27+ memory B cells (P < 0.001), as an immunopharmacodynamic marker of CD40 activation.

CONCLUSIONS

CP-870,893 with cisplatin and pemetrexed is safe and tolerable at 0.15 mg/kg, although most patients experience CRS. While objective response rates are similar to chemotherapy alone, three patients achieved long-term survival.

AUSTRALIA NEW ZEALAND CLINICAL TRIALS REGISTRY NUMBER

ACTRN12609000294257.

Hypoxemia associated with nimodipine in a patient with an aneurysmal subarachnoid hemorrhage

PURPOSE

A case of probable nimodipine-induced hypoxemia in a patient undergoing treatment for aneurysmal subarachnoid hemorrhage (SAH) is reported.

SUMMARY

A 62-year-old man hospitalized for SAH developed symptoms of respiratory distress on several occasions within days of initiation of nimodipine therapy (60 mg every four hours, with three doses withheld during intubation for intracranial surgery). Several hours after extubation (on hospital day 5), the patient had rapidly worsening tachypnea and declining arterial oxygen saturation (SPO2) despite increased oxygen delivery by mask, necessitating reintubation. When a nurse noted that the declines in SPO2 occurred soon after nimodipine administration, the patient's respiratory and hemodynamic functions were closely monitored after a single dose of nimodipine via nasogastic tube; the monitoring results supported the suspicion that nimodipine's vascular effects were a causal or contributory factor in the hypoxemia episodes. With subsequent fractionated dosing (30 mg every two hours), the patient completed the prescribed 21-day course of nimodipine therapy. Using the rating scale of Naranjo et al., this case was assigned a score of 7, indicating a probable pulmonary adverse reaction to nimodipine. As nimodipine is commonly used in cases of SAH to reduce delayed neurologic deficits due to persistent cerebral vasospasm, clinicians should be mindful of its potential hypoxemic effects in vulnerable patients.

CONCLUSION

A patient with aneurysmal SAH developed hypoxemia associated with the administration of nimodipine. Hypoxemia is a known complication of treatment with other vasodilatory agents, particularly in patients who have concomitant pulmonary disease.