Evaluation of Student Peer- and Self-Grading in an Integrated Pharmacotherapy Course.

OBJECTIVE: To determine if student peer- and self-grades correlate with faculty grades on case vignettes. METHODS: This study involved first professional-year students enrolled in an Integrated Pharmacotherapy course. The course included three modified team-based learning (TBL) activities (each consisting of individual and team readiness assurance tests, followed by three open-note case vignettes completed in teams). Each student uploaded completed case vignettes to the learning management system and was assigned to complete a self- and a random, anonymous peer-grade using a provided key. Peer- and self-grades were compared to faculty grades using a null multilevel model to determine the intraclass correlation coefficient (ICC). Faculty time spent grading was captured, and students were surveyed to determine the perceived value of peer- and self-grading. RESULTS: Faculty- and peer-grades had a slightly higher correlation than faculty- and self-grades (ICC = 0.75 vs 0.73, respectively). The ICC between all three grader groups was 0.74. Faculty spent an average of 2.5 h grading the cases after each TBL session. Students reported spending a median of 36 min on the peer- and self-grades for each TBL session. Overall, students agreed that both the self- and peer-grading activities helped identify gaps in knowledge (90% and 56%, respectively). A total of 78% of students agreed that self-grading was beneficial for their learning. CONCLUSION: There was a moderate-to-good correlation between peer-, self-, and faculty- grades for case vignettes. Faculty time may be saved through student self- or peer-grading.

Electronic Health Records in Pharmacy Skills-based Curricula.

Electronic health records (EHRs) are integral to contemporary pharmacy practice. The use of EHRs and associated skill development in curricula across pharmacy education is variable. Skills-based courses in the Doctor of Pharmacy curriculum are ideal areas to develop these competencies' and integrate EHR use and skills with the Pharmacists' Patient Care Process. Consideration should be given by each school and college of pharmacy for having an EHR curriculum embedded within skills-based courses to prepare students for advanced pharmacy practice experiences as well as professional practice after graduation. A consensus on what skills or competencies should be consistently included in pharmacy curricula should be developed across pharmacy education to increase consistency in the delivery of EHR skills education and assessment. Emphasis on EHR skills and incorporation of them into national pharmacy education standards would help further guide development and assessment, as well as ensure new pharmacists are on the cutting edge of patient care and technology.

Use of Nonselective ß-Blockers in Patients With End-Stage Liver Disease and Select Complications.

Objective: To review the literature and recommendations for nonselective ß-blockers (NSBBs) in the setting of variceal bleeding prophylaxis and decompensated liver disease. Data Sources: Literature search of MEDLINE was performed (1988 to October 2019) using the following search terms: cirrhosis, advanced cirrhosis, ß-blocker, decompensation, prophylaxis. Abstracts, peer-reviewed publications, clinical practice guidelines, and product monographs were reviewed. Study Selection and Data Extraction: Relevant English language studies and those conducted in humans were considered for analysis and inclusion. Data Synthesis: Evidence that suggests that NSBBs are harmful in advanced cirrhosis is overshadowed by confounding variables and small patient populations. The majority of the available evidence suggests neutral or beneficial effects on mortality with continuation of NSBBs despite liver disease progression. Based on the available literature, guidelines, and expert consensuses, NSBBs can be considered within this patient population and may have a positive impact on the majority of these patients. Relevance to Patient Care and Clinical Practice: This review summarizes current place in therapy for NSBBs in the setting of cirrhosis and variceal bleeding prophylaxis. It also includes a discussion of the literature for use of NSBBs within the setting of different acute decompensations in which the data and recommendations for use are less clear. Conclusions: Recent evidence shows neutral or positive results for NSBB use in particular decompensation subgroups, which suggests that NSBBs can be used cautiously with close monitoring in patients with advanced cirrhosis. Questions still remain regarding optimal agent and dose and whether agents can be safely restarted after an acute decompensation episode.

An individualized approach to residency preparation for fourth professional year pharmacy students.

INTRODUCTION: The objective of this study was to evaluate the impact of an individualized residency preparation program and faculty mentorship on student preparedness for pursuing residency training and their ability to successfully match with a postgraduate year one (PGY1) residency position. METHODS: This prospective cohort enrolled fourth professional year pharmacy students from August 2016 to March 2017. Students participated in a faculty-designed residency preparation program, were assigned faculty mentors, and were provided with several residency preparation resources. The primary outcome was change in the median overall perceived level of preparedness, as measured by pre- and post-residency preparation program surveys. A key secondary end point was the correlation between obtaining a PGY1 residency position and the number of residency preparation sessions attended. RESULTS: Fifty-two students participated in the residency preparation program. The median overall perceived level of preparedness increased following the preparation program. Of the 52 students participating, 37 attended over half of the program sessions. Twenty-one of the 37 (56.8%) students participating in more than half of the sessions matched with a PGY1 program compared to three out of 15 (20%) students participating in fewer than half the sessions. Additionally, students reported value in mock interviews, faculty mentorship, and institution-specific residency preparation guidance delivered via a workbook. CONCLUSIONS: Participation in an individualized residency preparation program with faculty mentorship and institution-specific guidance improves the perceived level of preparedness for students pursuing residency training. High attendance at sessions, along with other factors, may contribute to a higher rate of success.

Predictors of Treatment Failure Following De-escalation to a Fluoroquinolone in Culture-Negative Nosocomial Pneumonia.

Background: Little evidence exists for de-escalation of nosocomial pneumonia therapy without positive cultures. Objective: The purpose of this study was to identify potential predictors of treatment failure following de-escalation to a fluoroquinolone in culture-negative nosocomial pneumonia. Methods: The study involved a single-center, retrospective cohort of patients admitted with diagnosis of nosocomial pneumonia and positive chest radiography who received at least 24 hours of fluoroquinolone monotherapy following at least 24 hours of appropriate empirical antibiotics. Treatment failure was defined using a composite of all-cause death within 30 days of discharge, treatment re-escalation, or readmission for pneumonia within 30 days of discharge. The Cox proportional hazards model was used to analyze predictors of treatment failure. Duration of empirical antibiotics and significant univariable exploratory predictors were included in multivariable analysis. Results: Of 164 patients, 23 (14%) failed de-escalation. Duration of empirical antibiotics (68.5 ± 32.1 vs 65.8 ± 35 hours) was not associated with treatment failure in univariable (Hazard Ratio [HR] = 1.002 [95% CI = 0.991-1.013]) or multivariable analyses (HR = 1.003 [95% CI = 0.991-1.015]). Significant exploratory predictors on univariable analysis included active cancer, intensive care unit (ICU) admission at empirical initiation, APACHE II score, and steroid use ≥20-mg prednisone equivalent. ICU admission at empirical initiation (HR = 2.439 [95% CI = 1.048-5.676]) and steroid use ≥20-mg prednisone equivalent (HR = 2.946 [95% CI = 1.281-6.772]) were associated with treatment failure on multivariable analysis. Conclusion and Relevance: Duration of empirical antibiotics does not appear to influence failure of de-escalation to fluoroquinolone monotherapy in culture-negative nosocomial pneumonia.

Direct oral anticoagulants for stroke prevention in atrial fibrillation: treatment outcomes and dosing in special populations.

BACKGROUND: To review data from the pivotal phase III trials evaluating the efficacy and safety of direct oral anticoagulants (DOACs) versus warfarin for stroke prevention in patients with nonvalvular atrial fibrillation (NVAF), and to summarize the major findings with regards to patient subgroups that are at an increased risk for stroke or bleeding. METHODS: A PubMed literature search (January 2009 to January 2017) was performed using the terms 'dabigatran', 'rivaroxaban', 'apixaban', 'edoxaban', 'atrial fibrillation', 'RE-LY', 'ROCKET AF', 'ARISTOTLE', and 'ENGAGE AF-TIMI 48'. All primary publications and secondary analyses in special populations at increased risk of stroke or bleeding from the pivotal phase III clinical trials were evaluated. RESULTS: Available secondary analyses indicate no treatment interactions with regards to stroke or systemic embolic event (SEE) prevention for any of the DOACs in the patient subgroups, including patients with advanced age, impaired renal function, diabetes, prior stroke, concomitant antiplatelet therapy, heart failure, prior stroke, history of hypertension, myocardial infarction (MI), coronary artery disease, and peripheral artery disease (PAD). Although higher bleeding incidence was reported with dabigatran and rivaroxaban in patients aged 75 years and over with apixaban in patients with diabetes, and with rivaroxaban in patients with previous MI or PAD, no changes in dosing are recommended. CONCLUSIONS: Overall, results of secondary analyses indicate that the recommended dosing strategy for each of the DOACs produces a consistent anticoagulant effect across a diverse patient population, including those at increased risk of stroke or bleeding.

Edoxaban: A Comprehensive Review of the Pharmacology and Clinical Data for the Management of Atrial Fibrillation and Venous Thromboembolism.

Historically, vitamin K antagonists have been the only class of oral anticoagulants available. Despite our experience with warfarin over the past 60 years, its use is associated with several pharmacokinetic and clinical disadvantages including unpredictable dosing, frequent monitoring, and delayed onset and offset. Edoxaban, an oral direct Xa inhibitor, may provide clinicians with an additional option in patients requiring chronic anticoagulation. This review examines the pharmacology and clinical data of edoxaban as a therapeutic alternative.

The Use of Edoxaban in Patients with Nonvalvular Atrial Fibrillation and Venous Thromboembolism: A Pharmacist's Perspective.

Until 2010, the vitamin K antagonist warfarin was the only available oral anticoagulant for the prevention of stroke or systemic embolic events (SEE) in patients with nonvalvular atrial fibrillation (NVAF) and the treatment of venous thromboembolism (VTE) in the United States. Despite its proven efficacy, the use of warfarin is limited by numerous disadvantages, including a delayed onset of action and variable efficacy resulting from interactions with genetic and environmental factors. Consequently, optimal anticoagulation with warfarin requires dose adjustments based on frequent monitoring. In contrast to warfarin, direct oral anticoagulants (DOACs) including dabigatran, rivaroxaban, apixaban, and edoxaban have predictable pharmacokinetic profiles, few drug-drug interactions, no known interactions with food, and can be administered at fixed doses without the requirement for routine monitoring. All DOACs have received US Food and Drug Administration (FDA) approval for the prevention of stroke or SEE in patients with NVAF and the treatment of VTE based on phase 3 trials demonstrating that they are at least as efficacious as warfarin. In addition, the incidence of clinically relevant bleeding associated with DOACs is comparable to or lower than with warfarin. In this article, the preclinical and clinical data that led to the FDA approval of once-daily edoxaban in January 2015 are presented. Furthermore, practical considerations for edoxaban use including dosing recommendations, transitions of care, reversal of anticoagulation, precautions, contraindications, and cost-effectiveness are discussed. Edoxaban is an important addition to oral anticoagulation options available for the therapeutic management of patients with NVAF or VTE.

Evaluation of N-acetylcysteine for the prevention of contrast-induced nephropathy.

BACKGROUND: Contrast-induced nephropathy (CIN) remains a leading cause of acute renal failure in hospitalized patients. N-Acetylcysteine has been studied previously for the prevention of CIN, resulting in mixed findings. OBJECTIVE: The objective of this study was to determine the impact of N-acetylcysteine on the development of CIN in order to guide its use at community, teaching hospitals. METHODS: Patients admitted between January 1 and December 31, 2011, receiving intravenous radiocontrast dye were included if they were compliant with two or more of the following conditions: baseline serum creatinine >1.2 mg/dL or estimated creatinine clearance <50 mL/min, age ≥75 years, diabetes mellitus, heart failure, or hypertension. The primary outcome was the difference in the proportion of patients in each group (N-acetylcysteine or no N-acetylcysteine) who developed CIN, which was defined as a ≥0.5 mg/dL increase in serum creatinine or a ≥25% increase in serum creatinine within 12-96 hours post-exposure to contrast. RESULTS: A total of 302 patients were included, 151 who received N-acetylcysteine and 151 who did not receive N-acetylcysteine. Patients who received N-acetylcysteine had significantly worse renal function at baseline than those who did not receive N-acetylcysteine (mean pre-contrast serum creatinine, 1.41 vs. 0.95 mg/dL, p<0.0001). A lower proportion of patients developing CIN was observed between those who received N-acetylcysteine and those who did not receive N-acetylcysteine (10.2% vs. 21.8%, p=0.0428). CONCLUSIONS: The use of N-acetylcysteine was likely associated with a reduced incidence of CIN in patients at risk for CIN development. Based on these results, hospitals may benefit from the development of a protocol to guide the appropriate use of N-acetylcysteine.