Direct oral anticoagulants versus warfarin for the treatment of inferior vena cava thrombus.

OBJECTIVE: To evaluate the efficacy and safety of direct oral anticoagulants (DOACs) compared to warfarin in patients with inferior vena cava (IVC) thrombus. METHODS: This was a single-system, retrospective cohort study of hospitalized adult patients with IVC thrombus treated with a DOAC or warfarin therapy. The primary efficacy endpoint was the thrombus resolution on imaging, and the primary safety endpoint was major bleeding, both assessed within 6 months of hospital discharge. Secondary endpoints included hospitalization for a bleeding-related event, pulmonary embolism, or death within 6 months of hospital discharge. RESULTS: A total of 33 patients were included in the study. Twenty-three (70%) patients received a DOAC, and 10 (30%) received warfarin. Of the 10 patients with repeat imaging available, complete resolution was noted in two (33%) DOAC patients and no warfarin patients (p = .5). Major bleeding occurred in two (8.7%) DOAC patients and one (10%) warfarin patient (p = .9). No significant differences in secondary endpoints were observed between groups. CONCLUSIONS: There were no differences in efficacy and safety between patients receiving DOACs or warfarin for the treatment of IVC thrombus, although results are limited by the small patient population and number of patients with repeat imaging available.

Pharmacy Students' Professional Skill Development through a Scaffolded Internship.

Description of the problem: The establishment of hospital pharmacy internships helps promote the growth of student pharmacists alongside the standard pharmacy curriculum. These programs are vital to helping students expand their clinical knowledge, while also benefiting the host institution. Our objective was to characterize the value of a longitudinal internship program to both the institution and its interns. Description of the innovation: The Atrium Health Wake Forest Baptist (AHWFB) Pharmacy Intern Program is a unique program designed with a scaffolded concept that directly complements traditional pharmacy school curriculum and provides interns opportunities to complement tasks of health-system pharmacists. Starting with operational responsibilities in the central distribution pharmacy during the first year of the curriculum, the interns transition to more patient-facing roles during the second and third years. Throughout the course of the program, interns are also given opportunities to participate in research and professional development activities. An IRB-approved, retrospective, observational study was conducted to evaluate the benefits of the program to the institution and interns. Critical analysis: Intern interventions were quantitatively evaluated to determine institutional benefit. From October 2017 to June 2020, 16 interns completed a total of 7,191 interventions, which equates to approximately $1,295,825 of cost avoidance for the institution. A quality assurance survey was also conducted to evaluate the program's benefit to the interns. Fourteen of the 16 eligible interns participated in the survey. Of the 14 participating interns, 85.7% (n=12) strongly agreed with overall satisfaction of the program. Additionally, 71% (n=10) strongly agreed with feeling more professionally prepared than their classmates. Next steps: Implementing a scaffolded internship program has positively benefited AHWFB and the participating interns. The program's design allows for clinical and professional development alongside the pharmacy school curriculum.

Safety of direct oral anticoagulants in patients with mild to moderate cirrhosis: a systematic review and meta-analysis.

To evaluate major bleeding in cirrhosis with use of traditional anticoagulation or direct oral anticoagulants (DOACs), using a standardized definition. Anticoagulation in patients with cirrhosis is often a clinical conundrum for providers as the necessary balance between thrombotic and bleeding risk is complicated by end organ damage. Recent meta-analyses have sought to evaluate the safety and efficacy of direct oral anticoagulants in patients with liver disease. These recent analyses are limited by various bleeding definitions, broad inclusion criteria, and few indications for anticoagulation. We sought to conduct a meta-analysis using a validated definition for major bleeding and compare rates between traditional anticoagulation and DOACs in patients with cirrhosis. Articles were eligible for inclusion if the international society on thrombosis and hemostasis (ISTH) definition of a major bleed was the primary safety outcome. Additionally, only articles including patients with cirrhosis and receiving treatment with anticoagulation for an indication for stroke prevention or venous thromboembolism were eligible. Eligible articles needed a DOAC comparator group against traditional anticoagulant medication. Seven studies met inclusion criteria and compiled data for 683 patients in the meta-analysis. Pooled trial analysis demonstrated no statistically significant difference in the primary outcome of ISTH major bleeding (OR 0.55, 95%CI 0.28-1.07, I2 0%). Individual secondary outcomes of all bleeding, intracerebral hemorrhage, or gastrointestinal bleeding also demonstrated no significant difference between DOACs and traditional anticoagulation. Use of DOACs in patients with mild to moderate cirrhosis carries similar risk to use of traditional anticoagulation.

Longitudinal pharmacy student presentations mentored by pharmacy residents: A pilot study.

BACKGROUND AND PURPOSE: Alignment of pharmacy student and resident experiences provides a unique opportunity for near-peer mentorship. The purpose of this pilot study was to assess pharmacy resident mentorship and feedback skills through participation in a longitudinal pharmacy student and resident seminar series. EDUCATIONAL ACTIVITY AND SETTING: A longitudinal, near-peer mentorship experience was developed in which first- and second-year pharmacy residents mentored advanced pharmacy practice experience student seminar presentations. Following seminar presentations, residents provided verbal and written feedback to students and faculty pharmacists provided feedback to residents. Student and resident learners were then surveyed to assess resident near-peer mentorship. FINDINGS: Over a single academic year, 26 students delivered 45 seminar presentations that were mentored by 20 residents. Student and resident survey responses were similar and provided favorable feedback on resident mentorship. SUMMARY: The structured near-peer mentorship experience embedded into our longitudinal seminar series provided residents the opportunity to develop and strengthen their mentorship and feedback skills. Resident mentors were found to be effective in near-peer mentorship of a single activity.

Characterization of clinical knowledge and problem-solving assessments employed in postgraduate year 1 pharmacy residency interviews.

PURPOSE: Attainment of postgraduate year 1 (PGY1) residency positions has become increasingly competitive. Inclusion of clinical knowledge and problem-solving assessments in onsite interviews has increased in recent years. Characterization of these assessments is necessary for applicants to best prepare for interviews and for mentors to provide guidance. METHODS: An online survey was emailed to program directors of PGY1 pharmacy residency programs accredited by the American Society of Health-System Pharmacists (ASHP). Data were analyzed using descriptive statistics. Chi-square and Fisher's exact tests were used to compare categorical data. The Mann-Whitney U test was used to analyze nonparametric continuous data. RESULTS: Of the 221 respondents, most identified their programs as based at community (48%) or academic (39%) medical centers. Ninety percent of programs reported inclusion of clinical knowledge and problem-solving assessments in the onsite interview process. The most common assessments included asking clinical questions (70%), development of a SOAP (subjective, objective, assessment, plan) note or care plan (42%), and formal presentations that applicants prepared prior to arrival (39%). Most programs (71%) reported incorporating multiple assessments, with 2 assessments included most commonly (43%). Clinical assessment performance accounted for 10% to 25% of the overall interview score in approximately half of programs. CONCLUSION: During onsite PGY1 residency interviews, applicants must be prepared to participate in at least 1 clinical knowledge and problem-solving assessment, including answering clinical questions, developing a SOAP note or care plan, and/or delivering a presentation. Applicants should expect that these assessments will account for a substantial portion of the interview evaluation.

Development and implementation of a clinical decision support tool for treatment of uncomplicated urinary tract infections in a family medicine resident clinic.

OBJECTIVES: Outpatient antimicrobial stewardship has become increasingly important. While clinical decision support (CDS) tools have been effective in improving guideline-directed antibiotic prescribing, most notably for upper respiratory tract infections, their use for uncomplicated urinary tract infections (UTIs) has been less extensively studied. The objective of this study was to develop and implement a CDS tool to optimize antimicrobial prescribing for uncomplicated UTIs. SETTING: University-affiliated family medicine resident clinic. PRACTICE DESCRIPTION: This outpatient clinic is the practice site for 24 medical residents, 12 full-time faculty physicians, 1 nurse practitioner, and 1 full-time clinical pharmacist. PRACTICE INNOVATION: An interdisciplinary team including physicians, pharmacists, quality coordinator, and a coding and billing specialist collaborated to develop and implement a CDS tool into the clinic electronic health record to guide diagnosis, documentation, and antibiotic prescribing for uncomplicated UTIs. Prescribing practices were characterized, and a clinic-specific antibiogram was developed to identify focus areas for the CDS tool. EVALUATION: A retrospective chart review was conducted to evaluate empiric antibiotic prescribing before and after implementation of the CDS tool and after implementation when the tool was used or not used. RESULTS: Utilization of the tool clinic-wide was 29%. Overall fluoroquinolone use decreased from 42% to 15% after tool implementation (odds ratio [OR] 0.25; 95% CI 0.13-0.5; P < 0.001). Specifically, when the CDS tool was used, no patients received empiric therapy with fluoroquinolones (P = 0.005). With use of the tool following implementation, trimethoprim/sulfamethoxazole use decreased by 20% (OR 0.21; 95% CI 0.45-0.955; P = 0.003), nitrofurantoin for cystitis increased by 31% (OR 3.83; 95% CI 1.32-11.1; P = 0.01), and guideline-directed duration of therapy increased 32% (OR 4.34; 95% CI 1.48-12.73; P = 0.005). CONCLUSION: In an attempt to optimize empiric antimicrobial treatment for uncomplicated UTIs, we developed and implemented a CDS tool into the electronic health record in a family medicine resident clinic. Despite a 29% usage rate, many benefits were seen after tool implementation.