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Background Improved control of glycemic control likely lowers the risk of diabetes complications and clinical pharmacy specialist (CPS) services can improve glycemic control. Though the pattern of control may also matter in terms of outcomes. Objectives The objective of this study was to examine the longitudinal trajectories of HbA1c among a large population of Veterans with type 2 diabetes who received CPS-led diabetes management. Methods This is an observational, multicenter cohort study of Veterans with type-2 diabetes managed by CPSs between 7/1/2013 and 7/1/2017 with baseline glycosylated hemoglobin (HbA1c) level ≥8%. Two years of HbA1c measurements were used to group patients into distinct patterns of HbA1c trajectories over time using group-based trajectory modeling. Characteristics associated with successful HbA1c trajectories and association of assigned trajectories with all-cause and diabetes-related hospitalizations were analyzed using logistic regression. Results A total of 4119 Veterans were included and able to be successfully segmented into six distinct HbA1c trajectory groups over time: High Gradually Decreasing (n = 325, 7.9%), Moderate Early Decline (n = 1692, 41.1%), Large Early Decline (n = 231, 5.6%), Uncontrolled Stable (n = 1468, 35.6%), Early Decline/Subsequent Increase (n = 266, 6.5%), and Very Uncontrolled Stable (n = 137, 3.3%). The distinguishing factor between successful and less successful trajectories appears to be the progress made within the first six months of pharmacist management. Conclusions Significant variability exists in the pattern of glycemic control over time of type 2 diabetes patients managed by clinical pharmacy specialists. Limited resources should be first prioritized to managing patients with very elevated HbA1c and into the first six months of CPS management.

Our study aimed to compare the median and average last dose level reached with DA-R-EPOCH, which includes the chemotherapy agents etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin, and rituximab, in patients using filgrastim versus pegfilgrastim as febrile neutropenia primary prophylaxis. A retrospective, single-center chart review from January 1, 2014, to September 30, 2019, at The University of Kansas Health System identified patients > 18 years old who received at least four cycles of DA-R-EPOCH in an inpatient or outpatient setting for any subtype of lymphoma along with at least one dose of filgrastim or pegfilgrastim. Data was collected to compare dosing levels reached, appropriate discontinuation of daily filgrastim when ANC > 5000 cells/mm3, completion of at least twice weekly complete blood count (CBC) monitoring after chemotherapy administration, the incidence of infections, FN, hospitalizations from infections or FN, and bone pain. We hypothesized that patients receiving pegfilgrastim will achieve similar median and average dose levels of DA-EPOCH, event-free survival rates, overall response rates, completion of at least twice weekly CBC monitoring, and incidence of infections, FN, hospitalizations for infections or FN, and bone pain compared to patients receiving filgrastim. The use of pegfilgrastim as a supportive care agent resulted in similar efficacy and safety outcomes compared to filgrastim with DA-R-EPOCH in terms of dose intensity levels and incidence of infections, FN, and bone pain.

Introduction Patients diagnosed with stage III ovarian cancer are at high risk of recurrence and optimal adjuvant therapy is often debated. There is limited literature that directly compares intraperitoneal paclitaxel and cisplatin with dose-dense paclitaxel and carboplatin. Objectives The primary objective was to compare progression-free survival, overall survival, and tolerability of adjuvant intraperitoneal paclitaxel and cisplatin to dose-dense paclitaxel and carboplatin in stage III ovarian cancer patients. Methods A retrospective, IRB-approved, single center chart review was conducted reviewing adult patients with stage III ovarian cancer undergoing adjuvant intraperitoneal therapy or dose-dense therapy between 2010 and 2018. Results Eighty-two patients were included in the final analysis; 44 in the intraperitoneal group and 38 in the dose-dense group. Intraperitoneal therapy was not associated with a longer progression-free survival (35.4 vs. 31.1 months; P = 0.97). The duration of overall survival did not differ between intraperitoneal and dose-dense (56.3 vs. 54.5 months; P = 0.55). Dose reductions were less frequent with intraperitoneal than dose-dense (11.36% vs. 31.58%; P = 0.02). No difference in treatment delays (45.5% vs. 65.8%; P = 0.07), dose cancellations (59.1% vs. 57.9%; P = 0.91), supportive care additions (95.5% vs. 84.2%; P = 0.09), or therapy discontinuation (59.1% vs. 39.5%; P = 0.07) between groups was noted. Conclusions Intraperitoneal therapy with paclitaxel and cisplatin, as compared with dose-dense paclitaxel and carboplatin, did not prolong progression-free or overall survival in the adjuvant setting among stage III ovarian cancer patients. A trend towards decreased tolerability was noted with intraperitoneal therapy.

Background: Modern hepatitis C virus (HCV) treatment regimens yield cure rates greater than 90%. However, obtaining approval for treatment through the prior authorization (PA) process can be time consuming and require extensive documentation. Lack of experience with this complex process can delay HCV medication approval, ultimately increasing the amount of time before patients start treatment and in some cases, prevent treatment altogether. Objectives: Assess the impact of incorporating clinical pharmacists into specialty pharmacy and hepatology clinic services on medication access, patient adherence, and outcomes in patients being treated for HCV. Methods: We performed a retrospective cohort exploratory study of patients seen in an academic medical center hepatology clinic who had HCV prescriptions filled between 8/1/15 and 7/31/17. Patients were categorized by whether they filled prescriptions prior to (Pre-Group) or after (Post-Group) the implementation of a pharmacist in clinic. The Post-Group was further divided according to whether the patient was seen by a pharmacist in clinic (Post-Group 2) or if the patient was not seen by the pharmacist, but had their HCV therapy evaluated by the pharmacist before seeking insurance approval (Post-Group 1). Results: The mean time from the prescription being ordered to being dispensed was longer in the Pre-Group (50.8 ± 66.5 days) compared to both Post-Groups (22.2 ± 27.8 days in Post-Group 1 vs 18.9 ± 17.7 days in Post-Group 2; P

Our study aimed to compare the median and average last dose level reached with DA-R-EPOCH, which includes the chemotherapy agents etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin, and rituximab, in patients using filgrastim versus pegfilgrastim as febrile neutropenia primary prophylaxis.A retrospective, single-center chart review from January 1, 2014, to September 30, 2019, at The University of Kansas Health System identified patients18 years old who received at least four cycles of DA-R-EPOCH in an inpatient or outpatient setting for any subtype of lymphoma along with at least one dose of filgrastim or pegfilgrastim. Data was collected to compare dosing levels reached, appropriate discontinuation of daily filgrastim when ANC5000 cells/mmWe hypothesized that patients receiving pegfilgrastim will achieve similar median and average dose levels of DA-EPOCH, event-free survival rates, overall response rates, completion of at least twice weekly CBC monitoring, and incidence of infections, FN, hospitalizations for infections or FN, and bone pain compared to patients receiving filgrastim.The use of pegfilgrastim as a supportive care agent resulted in similar efficacy and safety outcomes compared to filgrastim with DA-R-EPOCH in terms of dose intensity levels and incidence of infections, FN, and bone pain.

e17108 Background: ICI therapy has become the standard of care for many advanced GU cancers, but immune-related adverse events (IRAE) may result in treatment delays or discontinuation. Concurrent vaccine use has been posited to increase the IRAE risk, but safety data is mixed. There are no published data regarding safety of concurrent inactivated vaccines other than influenza, including and especially in the GU cancer population. Methods: We performed a single-institution, retrospective, matched-cohort (1:2, cohort A:B, vaccinated to control) study of all GU cancer patients treated with an inactivated vaccine 30 days prior to or 60 days following ICI therapy from 2015-2019. Baseline clinical characteristics were abstracted from the electronic health record (EHR). Clinically significant IRAEs were defined as any event developing during or 30 days following ICI therapy requiring therapy with ≥ Prednisone 20 mg daily (or equivalent) or other immunosuppression. Delays were defined as ICI therapy given > 14 days past expected date for cycle 2 or beyond. Bivariate analysis with chi-squared statistics were used to describe incidence. Results: Sixty patients were included: 20 in cohort A (vaccinated) and 40 in cohort B (control). Thirty-seven (61.7%) patients had renal cell carcinoma, 17 (31.7%) had urothelial carcinoma, and 4 (6.7%) had prostate cancer. There was no difference in incidence of clinically significant IRAEs between cohorts A and B (15% vs 32.5%, p = 0.148), nor were differences observed in rates of treatment delays (10% vs 12.5%, p = 0.776) or discontinuation (10% vs 12.5%, p = 0.776) due to IRAEs. Most common vaccines were inactivated influenza (n = 18, 90%) and pneumococcal vaccine (n = 3, 15%). Among the 16 patients experiencing clinically-significant IRAEs, the most common were colitis (n = 3), dermatitis (n = 3), and pneumonitis (n = 3). All patients requiring immunosuppressive therapy received systemic corticosteroids. Conclusions: This retrospective cohort study demonstrates that GU cancer patients receiving inactivated vaccines during ICI therapy does not increase IRAE incidence, treatment delays, or discontinuation, suggesting that inactivated vaccines may be safely administered during ICI therapy in this population. Though influenza vaccines were still the most common, this is the first study to include other inactivated vaccines. Limitations include sample size, EHR accuracy and use of surrogate markers for determination of IRAE incidence. Next steps will include a multi-institutional retrospective study.

Introduction Due to enhanced T-cell activity, immune checkpoint inhibitors cause immune-related adverse effects. Corticosteroids are the mainstay of immune-related adverse effect management but the optimal strategy has not been determined, putting patients at risk for steroid-related adverse effects and potentially decreased efficacy of immunotherapy. This study aims to characterize the use of corticosteroids for the management of immune-related adverse effect. Methods and materials A retrospective, single-center evaluation of patients receiving checkpoint inhibitors was conducted. The primary objective was to evaluate corticosteroid use for immune-related adverse effects, including starting dose, taper strategy, total duration, and resumption of immunotherapy. Secondary objective was to describe the incidence and significance of hyperglycemia. Results One hundred and three patients met inclusion criteria and experienced 123 immune-related adverse effects. Prednisone was used most commonly (67%) at an average starting dose of 0.88 mg/kg (range 0.07–17.0). On average, steroid tapers began 9.2 days after initiation (range 0–89) and were continued for a total of 84.2 days (range 3–693). In 21.1% of cases, checkpoint inhibitor therapy was not delayed and 68.6% resumed checkpoint inhibitors, while the patient was taking steroids (30.4 mg prednisone on average, range 5–80). On average, checkpoint inhibitor therapy was resumed 18.6 days after detection of immune-related adverse effect (range 0–150). Clinically relevant hyperglycemia occurred in 8.9%. Conclusion Utilization of steroids for immune-related adverse effect at our institution is highly variable. The majority of patients received prolonged courses of steroids and resumed checkpoint inhibitor therapy with concomitant steroids above recommended doses. Additional monitoring for hyperglycemia and other steroid associated adverse effects should be considered.

Data from solid tumor malignancies suggest that actual body weight (ABW) dosing improves overall outcomes. There is the potential to compromise efficacy when chemotherapy dosages are reduced, but the impact of dose adjustment on clinical response and toxicity in hematologic malignancies is unknown. The purpose of this study was to evaluate the outcomes of utilizing a percent of ABW for acute myeloid leukemia (AML) induction chemotherapy dosing.This retrospective, single-center study included 146 patients who received 7 + 3 induction (cytarabine and anthracycline) for treatment of AML. Study design evaluated the relationship between percentage of ABW dosing and complete response (CR) rates in patients newly diagnosed with AML.Percentage of ABW dosing did not influence CR rates in patients undergoing induction chemotherapy for AML (p = 0.83); nor did it influence rate of death at 30 days or relapse at 6 months (p = 0.94). When comparing patients dosed at 90-100 % of ABW compared to90 % ABW, CR rates were not significantly different in patients classified as poor risk (p = 0.907). All favorable risk category patients obtained CR.Preemptive dose reductions for obesity did not influence CR rates for patients with AML undergoing induction chemotherapy and did not influence the composite endpoint of death at 30 days or disease relapse at 6 months.

Objective/background: Clostridium difficile infection (CDI) is a potential complication during hematopoietic stem cell transplantation (HSCT), and no specific recommendations exist regarding treatment of CDI in allogeneic SCT patients. Use of metronidazole and oral vancomycin has been associated with clinical failure. Fidaxomicin has previously been found noninferior to the use of oral vancomycin for the treatment of CDI, and no studies have compared the use of oral vancomycin with fidaxomicin for the treatment of CDI in allogeneic SCT. Methods: This retrospective chart review included 96 allogeneic SCT recipients who developed CDI within 100 days following transplantation. Participants were treated with oral vancomycin (n = 52) or fidaxomicin (n = 44). The primary outcome was clinical cure, defined as no need for further retreatment 2 days following completion of initial CDI treatment. Secondary outcomes were global cure, treatment failure, and recurrent disease. Results: No differences in clinical cure were observed between patients receiving oral vancomycin or fidaxomicin (75% vs. 75%, p = 1.00). Secondary outcomes were similar between oral vancomycin and fidaxomicin in regards to global cure (66% vs. 67%, p = .508), treatment failure (28% vs. 27%, p = .571), and recurrent disease (7% vs. 5%, p = .747). In a subanalysis of individuals that developed acute graft-versus-host disease following CDI, the difference in mean onset of acute graft-versus-host disease was 21.03 days in the oral vancomycin group versus 32.88 days in the fidaxomicin group (p = .0031). Conclusion: The findings of this study suggest that oral vancomycin and fidaxomicin are comparable options for CDI treatment in allogeneic SCT patients within 100 days following transplant. Keywords: Allogeneic stem cell transplantation, Clostridium difficile, Fidaxomicin, Vancomycin

Cetuximab is approved for treatment of squamous cell carcinoma of the head and neck (SCCHN). Cetuximab is generally well tolerated, but does carry a black box warning for infusion reactions (IRs). Incidence of IR in clinical trials was 15-20% for all grades and 3-5% for grades III-IV. Retrospective studies reported a higher incidence of all grade IRs and grades III-IV IR in areas of the Southeastern United States. Information regarding rechallenge doses after an IR has not been well described. At our institution, we frequently rechallenge on the same day after an initial IR. The primary objective was to determine the incidence, timing, IR grade, and completion of a rechallenge dose in patients who experienced an initial IR. Secondary objectives included: (1) determining the incidence and grade of IR in patients who received a first dose of cetuximab and (2) identifying specific risk factors for cetuximab IR with the first dose. A single-center retrospective chart review was conducted in SCCHN patients treated with cetuximab between June 2008 and September 2015 at the University of Kansas Hospital Cancer Center and inpatient setting. The majority of patients (87.9%) were able to be quickly and successfully rechallenged after an initial IR. Minimal patients (27.6%) experienced a rechallenge IR, resulting in only 1 patient discontinuation. Rechallenge doses were most frequently (37.9%) administered between 30 and 59 min after initial dose discontinuation. This was a single-center retrospective study based on data collected from electronic medical records. Other limitations include interpretation of infusion reactions on a subjective basis by providers. These findings demonstrate the practice of same-day rechallenges in initial IR patients is feasible and safe.

Purpose The impact of an innovative medication reconciliation and discharge education program on 30-day readmissions and emergency department (ED) visits was evaluated. Methods An observational pre–post analysis was conducted at an academic medical center to compare rates of hospital readmissions and return to ED visits during three-month periods before and after implementation of a restructured pharmacy practice model including (1) medication reconciliation at transitions of care for every patient and discharge education for a high-risk subgroup, (2) new or expanded services in the preanesthesia testing clinic and ED, (3) a medication reconciliation technician team, and (4) pharmacist-to-patient ratios of 1:30 on acute care floors and 1:18 on critical care units. The primary outcome was the composite of rates of readmissions and return to ED visits within 30 days of discharge. Results A total of 3,316 patients were included in the study. Pharmacy teams completed medication reconciliation in 95.8% of cases at admission and 69.7% of cases at discharge. Discharge education was provided to 73.5% of high-risk patients (defined as those receiving anticoagulation therapy or treatment for acute myocardial infarction, chronic obstructive pulmonary disease, congestive heart failure, or pneumonia). No significant difference was observed between the preimplementation and postimplementation groups with regard to the primary outcome. In the high-risk subgroup, there was a significant reduction in the 30-day rate of hospital readmissions, which declined from 17.8% to 12.3% ( p = 0.042); cost projections indicated that this reduction in readmissions could yield annual direct cost savings of more than $780,000. Conclusion Implementation of a team-based pharmacy practice model resulted in a significant decrease in the rate of 30-day readmissions for high-risk patients.

Background Abstract presentations at professional meetings provide a medium for disseminating the findings of scholarly activity. Rates of abstract publication from various biomedical disciplines have been evaluated, with pharmacy noted to be lower than other specialties. Previous research on pharmacy abstract publication rates was conducted for a limited number of professional meetings but has not been assessed using Google Scholar. Objective To determine the full publication rate of abstracts presented at the 2005 American College of Clinical Pharmacy (ACCP) Spring and Annual Meetings, American Pharmacists Association (APhA) Annual Meeting, and American Society of Health-System Pharmacists (ASHP) Summer and Midyear Clinical Meetings. Methods Publication status was assessed for abstracts presented during the 2005 ACCP Spring and Annual Meetings, APhA Annual Meeting, and ASHP Summer and Midyear Clinical Meetings using PubMed and Google Scholar. Data collected included abstract category, study category, practice site, database(s) in which publication appeared, time in months to publication, publication type, and journal of publication. Results Evaluation of 2,000 abstracts presented in 2005 revealed an overall full publication rate of 19.8% (n = 384). Nearly all pharmacy abstracts were published as manuscripts (98.4%; n=378) and indexed in PubMed and Google Scholar (91.9%; n = 353), although a significant percentage were indexed in Google Scholar only (7.8%; n = 30). The mean time to full publication was 16.8 months (SD ±11.9 months). Conclusions Results were consistent with previously reported full publication rates of abstracts from pharmacy association meetings, indicating that abstracts presented at pharmacy meetings continue to have a lower full publication rate than other health disciplines.

Weekly paclitaxel, carboplatin, and cetuximab (PCC) has been found to be efficacious and well-tolerated in patients with squamous cell carcinoma of the head and neck (SCCHN) with good performance status (PS) when used as induction chemotherapy. Use of PCC in incurable SCCHN in patients with poor PS or in a non-induction setting is an area which warrants further evaluation. Current recommendations for incurable disease consist of a platinum-based regimen with fluorouracil and cetuximab. Studied in patients with PS of 0 to 1, the fluorouracil-based regimens were associated with significant toxicities. Therefore, weekly PCC may offer an appealing, less toxic alternative for incurable patients with poor PS. This retrospective analysis evaluated 41 patients with very advanced or metastatic head and neck cancer who had received PCC (paclitaxel 80 mg/m(2), carboplatin AUC 2, and a cetuximab 400 mg/m(2) loading dose, followed by 250 mg/m(2) weekly) for up to 6 cycles between April 2008 and September 2014. Maximal response achieved and progression-free survival (PFS), as well as dose intensity and adverse effects, were evaluated. Of the 41 patients evaluated, baseline PS ranged as follows: PS of 2 (41 %), PS of 1 (54 %), and PS of 0 (5 %). Patients received 2 to 6 cycles, averaging 4 cycles. Thirty-one patients (76 %) required treatment to be held, delayed or dose reduced, most commonly for hematologic toxicities. Grades 3/4 neutropenia occurred in 16 patients (39 %), grades 1/2 neutropenia in 12 patients (29 %), with grades 3/4 thrombocytopenia in 1 patient (2 %), and grades 1/2 thrombocytopenia in 2 patients (4 %). No patients developed febrile neutropenia or required hospitalization due to treatment. Partial radiographic response occurred in 15 patients (37 %), complete radiographic response in 2 patients (5 %), stable disease in 14 patients (34 %), and progression in 8 patients (20 %). PFS ranged from 1.6 to 45 months, with a median duration of 4.6 months, and median overall survival of 5.25 months. Analysis indicates that use of weekly PCC appears to be an effective and well-tolerated treatment option for patients with incurable squamous cell carcinoma of the head and neck, specifically with PS of 0 to 2.

Purpose To measure the impact of an individual pharmacist performance report (IPPR) program on pharmacist-related medication order entry errors (MOEEs) at an academic medical center. Methods The number and type of pharmacist-related MOEEs were collected at 2 different times: immediately following implementation of an electronic medical record (baseline) and following completion of the IPPR program. Three different collection methods were utilized to identify and categorize pharmacist-related MOEEs: 1) Patient Safety Net (PSN) incident reporting system, 2) manual event reporting, and 3) a nursing to pharmacy electronic messaging system. The IPPR program consisted of mandatory educational sessions for pharmacist staff. The program content focused on strategies to reduce pharmacist-related MOEEs identified in the baseline data collection period as well as an individualized report generated for each pharmacist having caused an MOEE that showed their performance compared to the department's performance. Results The percentage of event reports containing a pharmacist-related MOEE decreased from baseline to post IPPR program (13.7% and 6.3%, respectively; P < .001). In addition, the total number of pharmacist-related MOEEs was halved after the IPPR program (321 vs 148; P < .001). Significant reductions were noted in the following MOEE categories: duplicate orders, missed orders, wrong frequency, wrong dose, and other. Nonsignificant reductions were noted in errors related to no order and wrong drug. Conclusion Based on the observations and results of this study, it is proposed that individualized performance feedback can be a successful method to improve MOEE performance by pharmacists.

BackgroundPostoperative hypertension after cardiac surgery is associated with substantial morbidity. Both sodium nitroprusside (SNP) and nicardipine (NIC) are effective in its management. Outcomes data for NIC and SNP in persons undergoing cardiac surgery are limited, and there are no data characterizing the influence of drug choice on postoperative costs.ObjectiveOur aim was to compare the effectiveness of NIC versus SNP in the management of hypertension after cardiac surgery and evaluate the influence of drug choice on postoperative costs.MethodsWe conducted a retrospective, cohort study using our hospital's financial and electronic medical records. Adults admitted to a cardiothoracic surgical intensive care unit after coronary artery bypass grafting (CABG) and/or valve surgery who developed hypertension requiring ≥30 minutes of NIC or SNP were included. We evaluated drug effectiveness by assessing infusion rate stability, blood pressure and heart rate, and concomitant antihypertensive agent use. Activity-based postoperative costs were compared between study groups.ResultsOne hundred twelve subjects were included (NIC = 72, SNP = 40). Hypertension-related demographics were balanced between the groups. NIC was associated with improved infusion rate stability that required fewer dose changes per hour (1.2 ± 1.6) versus SNP (1.7 ± 1.8) ( P = .004). Heart rates and blood pressures did not differ significantly. The number of antihypertensive medications used before and during the NIC or SNP infusions was the same. However, persons who were prescribed SNP required significantly more medications to manage blood pressure after infusions were discontinued ( P = .001). NIC use did not significantly increase postoperative cost. NIC use may be associated with cost increases in isolated CABG but with cost savings in isolated valve or combined CABG/valve surgeries; however, these differences were not statistically significant.ConclusionsBlood pressure was equally controlled using NIC or SNP. NIC was associated with improved infusion rate stability. Despite a higher acquisition cost, NIC did not significantly influence postoperative costs. Larger, prospective cost-effective analyses in surgical subgroups are needed.

Purpose The use of recommended practices for preventing and detecting diversion of prescription controlled substances at U.S. acute-care institutions, as reported by a sample of pharmacy service providers, were characterized. Methods A 41-item questionnaire was developed for an online survey of directors of pharmacy regarding strategies to combat controlled-substance diversion at their institutions. The survey questions were based on recommendations presented in a 2007 series of articles in the professional literature focusing on diversion control in three areas (the pharmacy, the operating room, and nursing units). Only institutions that had an accredited pharmacy residency program or were members of the University HealthSystem Consortium (UHC), an alliance of U.S. academic medical centers and affiliated hospitals, were targeted for the survey. Four hundred ninety-nine pharmacists were invited to participate in the survey, and 140 survey responses were received; all respondents did not answer all questions. Results The survey responses indicated considerable variation among the institutions in the use of 37 specific recommended practices, as reported by the pharmacy providers. Statistical analysis of comparative data suggested that larger institutions (400 or more licensed beds) were more likely to be using more of the recommended practices. Conclusion The results of a survey of directors of pharmacy at a sample of U.S. institutions (hospitals that had pharmacy residency programs or were UHC members) suggest wide variation in facilities’ use of recommended practices for the prevention and detection of controlled-substance diversion.

Study Objectives. To assess the effectiveness of prophylactic albumin for the prevention of ifosfamide-induced encephalopathy (IIE), and to describe risk factors for IIE and investigate the predictive potential of a novel risk-stratification model for IIE. Design. Retrospective analysis. Setting. Single academic medical center. Patients. Forty-one adults who received 93 chemotherapy cycles of regimens that included ifosfamide for the treatment of hematologic or solid tumor malignancy between November 2007 and November 2008. Patients were divided into two groups based on the use of albumin for IIE prophylaxis: albumin group (32 cycles) and no albumin group (61 cycles). Measurements and Main Results. Overall occurrence of neurotoxicity during therapy served as the primary outcome measure. Proposed risk factors for IIE were assessed by conducting a subgroup analysis of patients who did and those who did not experience IIE. A novel risk-stratification model was developed in an attempt to predict patients at risk for IIE. The validity of the scheme was assessed by comparing the occurrence of IIE among high- and low-risk patients as identified by the model. Overall, among the 93 cycles, six cases of IIE (6.5%) were identified. The occurrence of IIE was more common in the albumin group compared with the no albumin group (15.6% [5/32] vs 1.6% [1/61], p=0.01). Baseline albumin level was significantly lower, and serum creatinine and aspartate and alanine aminotransferase concentrations were significantly higher among patients experiencing IIE. All cases of IIE occurred among patients identified as high risk according to the risk-stratification model (p=0.01). Conclusion. Prophylactic therapy with exogenous albumin is not an effective strategy for the prevention of IIE. The novel risk-stratification model appears to be an effective method for predicting patients with the greatest potential for developing this adverse effect.

Studies have shown the benefit of 28days of extended postoperative venous thromboembolism (VTE) prophylaxis for patients undergoing major cancer surgery in the abdomen or pelvis. We retrospectively evaluated the VTE incidence at the University of Kansas Hospital between gynecologic (GYN) cancer patients, who receive extended prophylaxis, and gastrointestinal (GI) cancer patients, who do not.Patients were evaluated between January of 2010 and December of 2013, and VTE data for eligible patients were collected for 30 and 90days postoperatively.The study population composed of 190 GYN and 204 GI patients. Colon and endometrial cancers were the most common diagnoses. For GYN and GI patients respectively, VTE occurred in 4.2% and 5.4% at 30days (p=0.584) and 7.4% and 7.8% at 90days (p=0.514). One VTE-related death occurred in the GI group. GI patients underwent more open surgeries, 77.9% versus 66.3% (p=0.010) and had longer postoperative hospital stay, median of 7 versus 4days (p0.0001). Out of all cancer patients combined, 40% versus 17.9% had stage IV disease and 10.2% versus 0.9% had open surgery in the VTE and non-VTE groups, respectively.There were no significant differences in overall VTE incidence between the two patient groups at 30 and 90days postoperatively. A majority of VTEs occurred in stage IV patients and patients who underwent open surgeries regardless of diagnosis.

Background Amiodarone prophylaxis (AMP) reduces the prevalence of postoperative atrial fibrillation (POAF) after cardiac surgery. We investigated the impact of AMP on the frequency and duration of POAF, the intensive care unit and hospital length of stay, and its cost-effectiveness in a risk-stratified cohort. Methods A retrospective, observational analysis of 509 patients who underwent cardiac surgery in 2003 was performed. Data sources included The Society of Thoracic Surgeons national database; medical and medication administration records; and the activity-based cost data from our institution. Risk stratification for POAF was determined using a validated risk index. Cost-effectiveness was determined from the hospital's perspective. Results The mean patient age was 63 years, 27% were female, 80% underwent coronary artery bypass grafting, and 29% underwent valve surgery. When a risk-stratified evaluation was made, 50% of patients were at an elevated risk for having POAF develop. When compared with nonprophylaxed patients, those receiving AMP (59%) experienced less POAF (31% vs 22%; p = 0.027) and shorter durations of POAF (4.7 vs 2.7 days; p = 0.025). In the elevated-risk group, AMP clinically (but not significantly) reduced length of stay in the intensive care unit (101 vs 68 hours; p > 0.05) and post-procedural hospital length of stay (9.7 vs. 7.9 days, p > 0.05). In the elevated-risk group, AMP was robustly cost-effective in reducing POAF. Conclusions Amiodarone prophylaxis reduced the prevalence and duration of POAF. Baseline risk for POAF was a major determinant of the overall cost-effectiveness of AMP. The greatest cost savings with AMP was seen in patients at an elevated risk for POAF. These findings suggest the need for risk stratification when prescribing AMP.

Background Invasive fungal infections remain problematic in immunosuppressed allogeneic stem cell transplant recipients and the use of corticosteroids for the treatment of graft-versus-host-disease can increase the risk threefold. Although antifungal prophylaxis has been shown to decrease the incidence of infection, the optimal antifungal prophylactic regimen in this patient population has yet to be identified. Since early diagnosis of fungal infections might not be possible and the treatment of established fungal infections might be difficult and associated with high infection-related mortality, prevention has become an important strategy in reducing overall morbidity and mortality. While triazoles are the preferred agents, some patients are unable to tolerate them and an alternative drug is warranted. Objectives To assess the tolerability of once weekly liposomal amphotericin B as a prophylactic strategy in patients undergoing stem cell transplantation by evaluating any adverse events leading to its discontinuation. In terms of efficacy, to also compare the outcome and incidence of invasive fungal infections in patients who received amphotericin B, triazoles, and echinocandins. Results A total of 101 allogeneic transplant recipients receiving corticosteroids for the treatment of graft-versus-host-disease and antifungal prophylaxis were evaluated from August 2009 to September 2012. Liposomal amphotericin B 3 mg/kg intravenous once weekly was found to be well tolerated. The incidence of invasive fungal infections was 19%, 17%, and 7% in the liposomal amphotericin B, echinocandin, and triazole groups, respectively. Two deaths occurred in the liposomal amphotericin B group and one death occurred in the echinocandin group. None of the deaths were fungal infection related. Conclusion Antifungal prophylaxis with liposomal amphotericin B was well tolerated, but the incidence of invasive fungal infections in patients receiving liposomal amphotericin B was higher than other antifungal agents in this study. The optimal dose and schedule of liposomal amphotericin B for antifungal prophylaxis in this patient population are still not known and considering its broad spectrum activity, prospective trials in comparison to triazoles are warranted.

Purpose The implementation of standardized dosing units for six i.v. medications at an academic medical center is described. Summary During the implementation of an electronic health record system at an academic medical center, it was noticed that providers could order some i.v. medications in multiple dosing units, including epinephrine, isoproterenol, midazolam, nitroglycerin, norepinephrine, and phenylephrine. Possible options to standardize i.v. medications along with their pros and cons were presented for discussion to key providers in all of the intensive care units. Once the providers agreed on a solution, the information was presented to the pharmacy and therapeutics committee for final approval. A nursing education plan was created and administered before the standardization of dosing units was implemented. A nursing survey was conducted before and after implementation of dosing-unit standardization to determine the effectiveness of nursing education on compliance with the standardization of the dosing units for the listed medications. The survey was designed to evaluate, when given a choice, what dosing units nurses would use to administer epinephrine, isoproterenol, midazolam, nitroglycerin, norepinephrine, and phenylephrine. The decision was made by the key providers to use weight-based dosing—micrograms per kilograms per minute—to allow for consistency of use of these medications for pediatric and adult patients. Nursing education was completed to ensure that nurses were aware of how to safely administer these medications using the new dosing units. Conclusion Dosing-unit standardization for dose-adjustable i.v. infusions can provide improved consistency and decrease the potential for dosing errors when administering epinephrine, isoproterenol, midazolam, nitroglycerin, norepinephrine, and phenylephrine.

Lack of standardization in antibiogram (ABGM) preparation (the overall profile of antimicrobial susceptibility results of a microbial species to a battery of antimicrobial agents) has not been addressed until recently. The objective of this study was to analyze current antibiograms using the recently published NCCLS M39-A guidelines for preparation of antibiograms to identify areas for improvement in the reporting of antibiogram susceptibility data. Antibiograms from across the United States were obtained by various methods, including direct mailings, Internet searches, and professional contacts. Each ABGM collected was analyzed using prospectively defined elements from the M39-A guidelines. Additionally, seven quality indicators were also evaluated to look for the reporting of any atypical or inappropriate susceptibility data. The 209 antibiograms collected from 149 institutions showed at least 85% compliance to 5 of the 10 M39-A elements analyzed. Clinically relevant elements not met included annual analysis, duplicate isolate notation, and the exclusion of organisms with fewer than 10 isolates. As for the quality indicators evaluated, unexpected results included the 7% of antibiograms that reported Staphylococcus aureus , 24% that had inconsistent beta-lactam susceptibility for Staphylococcus aureus , 20% that reported Escherichia coli , and 37% that reported >0% ampicillin susceptibility for Klebsiella pneumoniae . These findings suggest that antibiograms should be reviewed thoroughly by infectious disease specialists (physicians and pharmacists), clinical microbiologists, and infection control personnel for identification of abnormal findings prior to distribution.

The determinant attribute approach is a research method commonly used in marketing to identify the wants of various consumer groups. The objective of this study was to determine the value of using ...

This review described and compared empirical investigations of adherence to pediatric antiretroviral therapy (ART) and predictors/correlates of adherence with regard to methodology and outcome. Thirteen empirical studies of children's adherence to ART, conducted between the years 1981 and 2002 were identified. Investigations varied by age of participant, drug therapy regimen, method of adherence assessment, and by the reporting of predictors/correlates of adherence. Conclusions from the literature are limited by the lack of common sample characteristics and adherence assessment methodologies. Nevertheless, consistent with much of the pediatric adherence literature, adherence to antiretroviral medications among children and adolescents appears to be frequently suboptimal. Few investigations identified predictors/correlates of adherence, but these appear generally similar to those found in adult samples. Recommendations for future investigations are proposed.

Prior studies have investigated the association between generic health-related quality of life and medication adherence. The objective of this study was to assess the association between medication adherence and health-related quality of life using both a disease-specific and generic metric in a community setting. Overall, the authors' study findings show no association between adherence and health-related quality of life, supporting the results by Cote and colleagues that factors other than medication adherence are important in explaining health-related quality of life. Furthermore, adherence was not significantly associated with asthma severity, although the strong association between asthma control and health-related quality of life, and asthma control and adherence indicates that asthma control is an important vital sign.

e11618 Background: Adjuvant systemic treatment of breast cancer is primarily determined by tumor prognostic markers (ER, PR, HER2) obtained on primary breast cancer. Several studies have shown a di...

Purpose. A study was conducted to identify discrepancies between medication histories taken by emergency department (ED) providers (physicians, nurses, and medical students) and medication histories taken by clinical pharmacists. Methods. During a three-month period, a clinical pharmacist was assigned to the ED in a 475-bed, tertiary care teaching facility that serves as a level I trauma center. On the arrival of a patient, ED providers completed a standard assessment that included the patient’s medication history. Patients to be admitted through the ED were interviewed by the clinical pharmacist. In addition to a medication history, the pharmacist collected the patient’s height, weight, immunization history, and allergy information. The medication history obtained by the ED provider was compared with the history obtained by the clinical pharmacist, and discrepancies were documented. Results. The clinical pharmacists in the ED performed 286 medication histories; 34 were excluded. The remaining 252 histories taken were used in the study. The pharmacists identified 1096 home medications versus 817 home medications documented by ED providers. Of the 817 home medications documented by the ED, the regimens of 637 (78%) were incomplete and were supplemented with dosing information by the pharmacists. Pharmacists reported 375 medication allergies versus 350 reported by ED providers. Immunization histories were obtained in 252 of the 252 (100%) pharmacist-acquired medication histories versus 45 of the 252 (18%) acquired by ED personnel. Conclusion. Pharmacist-acquired medication histories in the ED were more complete than those acquired by other health professionals.

Duplicate Staphylococcus aureus isolates were analyzed to determine the impact of multiple isolates from the same patient on annual antibiogram data. During a 6-year period (1996 to 2001), 3,227 patients with 4,844 S. aureus isolates were evaluated. A total of 39% of patients with methicillin-resistant S. aureus (MRSA) ( n = 860) and 23% of patients with methicillin-susceptible S. aureus (MSSA) ( n = 2,367) infections had duplicate isolates. Cumulative data show that 91% of the patients during this 6-year period with duplicate isolates (2 to 13 duplicates/year) did not switch between MSSA and MRSA but retained the original S. aureus strain whether it was MSSA or MRSA. Rates of MRSA were calculated for each year by using all isolates and then eliminating duplicates. The impact of duplicate MRSA and MSSA isolates was evaluated by using the ratio of isolates per patient such that ratios of >1.0 indicate >1 isolate per patient. The 6-year ratio for MRSA was 1.90 isolates/patient, and the ratio for MSSA was 1.35. A significant difference ( P < 0.05) was noted in the MRSA rates in 4 of 6 years when duplicate isolates were removed. Common phenotypic antibiogram patterns were compared for all MRSA isolates during the 6-year period, and 64% were of a single antibiogram phenotype. Eighty-eight percent of patients with duplicate MRSA isolates had phenotypically identical multiple isolates. The rate of MRSA differs when duplicate isolates are removed from the antibiogram data.

This review described and compared empirical investigations of adherence to pediatric antiretroviral therapy (ART) and predictors/correlates of adherence with regard to methodology and outcome. Thirteen empirical studies of children's adherence to ART, conducted between the years 1981 and 2002 were identified. Investigations varied by age of participant, drug therapy regimen, method of adherence assessment, and by the reporting of predictors/correlates of adherence. Conclusions from the literature are limited by the lack of common sample characteristics and adherence assessment methodologies. Nevertheless, consistent with much of the pediatric adherence literature, adherence to antiretroviral medications among children and adolescents appears to be frequently suboptimal. Few investigations identified predictors/correlates of adherence, but these appear generally similar to those found in adult samples. Recommendations for future investigations are proposed.

This study examines the relationships between department values, service user closeness and marketing effectiveness as perceived by hospital pharmacy directors. Data from 171 hospital pharmacy directors, representing a cross-section of hospitals, revealed that departments of pharmacy characterized as having superior perceived marketing effectiveness also have shared department value profiles. However, no significant relationship was found between perceived level of marketing effectiveness and perceived service user closeness. More years of experience as a director and the larger the size of pharmacist staff each positively influence the director's perception of marketing effectiveness. The results of the study indicate that hospital pharmacy directors generally perceive the services offered by their respective departments are marketed effectively.

Objectives. The study assessed pharmacy clerkship student attitudes toward a series of cardiology case studies using either a web-based or paper-based format. Methods. Twenty-four cardiology case studies were developed that included patient-specific information followed by a series of self-assessment questions. For the paper-based cases, students were given hardcopies and later met with the instructor to review answers. With the web-based version, students completed cases online and received immediate standardized instructor responses. Results. Thirty-four clerkship students used each format in random order for half of the cases and then completed an evaluation questionnaire. The web-based cases were preferred by 24 students and by more males than females. Among students preferring the paper method, the most commonly identified advantage was convenience. Conclusions. Web-based case studies appear to be a well-accepted method for teaching clerkship students; however, additional strategies are needed to ass...

Background Medication Reconciliation and Medication Safety are two themes emphasized in a variety of healthcare organizations. As a result, health care facilities have established methods for obtaining a patient's medication history. However, these methods may vary among institutions or even among the health care professionals in a single institution, and studies have shown that patients are reluctant to disclose their complementary and alternative medicine use to any health care professional. This lack of disclosure is important in surgical patients because of potential herbal interactions with medications and drugs used during the surgical procedure; and the potential for adverse reactions including effects on coagulation, blood pressure, sedation, electrolytes or diuresis. Therefore, the objectives of this study are to identify patterns of natural product use, to identify potential complications among patients scheduled for surgery, to improve existing medication reconciliation efforts, and to develop discontinuation guidelines for the use of these products prior to surgery. Methods A retrospective review of surgery patients presenting to the Anesthesia Preoperative Evaluation Clinic (APEC) at the University of Kansas Hospital was conducted to identify the prevalence of natural product use. The following data was collected: patient age; gender; allergy information; date of medication history; number of days prior to surgery; source of medication history; credentials of person obtaining the history; number and name of prescription medications, over-the-counter medications and natural products; and natural product dosage. Following the collection of data and analysis of the most common natural products used, possible complications and interactions were identified, and a protocol regarding the pre-operative use of natural products was developed and implemented. Results Approximately one-fourth of patients seen in the APEC indicated the use of natural products. Patients taking natural products were significantly older, were more likely to undergo cardiac or chest surgery, and were more likely to be taking more prescription and non-prescription medications (all p < 0.001). Conclusion Based on the results of this study, it is concluded that there is a need for established guidelines regarding discontinuation of selected natural products prior to surgery and further education is needed concerning the perioperative implications of natural products.