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Background : Medication error is a global threat to patient safety, particularly in pediatrics. Yet, this issue remains understudied in this population, in both hospital and community settings. Objectives : To characterize medication errors invo lving pediatrics reported to the French Medication Error Guichet, and compare them with medication errors in adults, in each of the hospital and community settings. Methods : This was a retrospective secondary data analysis of medication errors reported th roughout 2013 - 2017. Descriptive and multivariate analyses were performed to compare actual and potential medication error reports between pediatrics (ag ed 18 and

Background: Antibiotic allergy is an important clinical and social-economical issue. Objective: The main objectives of this study were to determine the incidence, causative drugs, and risk groups of antibiotic allergy as a reason for hospitalization. The secondary objective was to evaluate the treatment of antibiotic allergy through the identification of drug related problems (DRPs). Methods: This retrospective hospital-based study was carried out in one of Lviv city hospitals (Ukraine) from January 2015 to December 2017. Patients with antibiotic allergy as a cause for hospitalization were included in this study. Results: In this study the incidence of antibiotic allergy was 2.0% (95%СI 1.6:2.4) of all admissions to the Unit that provides special medical care for adult inpatients with allergy diseases and allergy reactions. The mean age of patients was 48.5 years (SD=17.0; range 18-83 years) with female predominance (78.2%; 95%СI 68.9:85.2). Antibiotic hypersensitivity reactions manifested as urticaria with angioedema (52.5%; 95%СI 42.3:62.5), urticaria (36.6%; 95%СI 27.8:46.8) or angioedema (10.9%; 95%СI 5.6:18.7). Beta-lactams (48.5%; 95%СI 38.5:58.7), fluoroquinolones (13.9%; 95%СI 7.8%:22.2%) and macrolides (7.9%; 95%СI 3.5:15.0) were specified as the main causative drugs. All patients during hospitalization (a mean of 8.2 days; SD=2.2; range 2-13 days) took at least 3 medicines (a mean of 5.4 medicines per patient; SD=1.2; range 3-12 medicines). The total number of identified DRPs was 400, a mean of 4.0 DRPs per patient (SD=1.8). The most frequently identified type of DRPs was inappropriate route of drug administration (25.0%; 95%СI 20.8:29.5). This was followed by duplicate prescriptions (23.5%; 95%СI 19.4:28.0) and insufficient frequency of drug administration (19.0%; 95%СI 15.3:23.2). Potential drug-drug interactions and inappropriate drug prescriptions each accounted for 16.0% (95% СI 12.6:20.0) of all DRPs. Comparing all above items in 2015, 2016 and 2017 showed no statistically significant changes (p˃0.05). Conclusions: Antibiotic allergy is a common reason for admissions. The treatment of antibiotic allergy is associated with numerous DRPs. Our results could be useful for development of strategies for improving the safety and quality of pharmacotherapy.

International audience; BACKGROUND: Cohorting carbapenemase-producing Enterobacteriaceae (CPE) carriers during hospitalization limits in-hospital spreading.OBJECTIVE: To identify risk factors for CPE acquisition among contacts of an index patient in non-cohorted populations.METHODS: A multicentre retrospective matched case-control study was conducted in five hospitals. Each contact patient (case) who acquired Klebsiella pneumoniae (KP)-OXA-48 from an index patient was compared to three contact (controls) with the same index patients matched with hospitalization in the same unit and similar exposure times.RESULTS: Fifty-one secondary cases and 131 controls were included. By univariate analysis, exposure time (odds ratio: 1.06; 95% confidence interval: 1.02-1.1; P = 0.006), concomitant infection at admission (3.23; 1.42-7.35; P = 0.005), antimicrobial therapy within the last month before hospitalization (2.88; 1.34-6.2; P = 0.007), antimicrobial therapy during the exposure time (5.36; 2.28-12.6; P

Background: Aiming to facilitate the drug dispensing process and patient counseling, specific professional skills are required. The knowledge, skills and attitudes involved in this process can be improved. From 2012 to 2015, a nationwide course was held, in partnership with the Ministry of Health and the Federal University of Rio Grande do Sul (UFRGS) – Brazil, to train pharmacists working in primary health care through the development of their clinical and communication skills. One of the steps in this process involved the simulation of the drug dispensing process and patient counseling. Objective: To evaluate the performance of pharmacists in drug dispensing and counseling through patient simulation role-playing held in a face-to-face meeting at the end of a training course. Methods: A cross-sectional and retrospective study with analysis of patient simulation recordings and data collection using an assessment instrument with scores ranging from 0 to 10 points to assess pharmacist's behavior, skills, and technical knowledge. Results: Participants presented poor-to-regular performance, with median scores equal to or lower than six. The median time of the drug dispensing simulation was five minutes and the patient counseling was eight minutes. Pharmacists had better scores in the simulation of asthma cases. In drug dispensing, 99.5% of pharmacists had difficulty checking the patient's time availability, 98.5% did not know how to use the devices, and 94.7% did not advise the patient on what to do if they forgot to take a dose. In patient counseling simulation, 1.18% of pharmacists remembered to advise on what do with medication leftovers, and 50.6% asked questions that induced the patient's responses. Conclusions: The low-to-regular performance showed that pharmacists had difficulties at improving their skills in the performance of complete and effective drug dispensing and patient counseling.

Background: Previous studies linked metformin use to vitamin B12 deficiency and demonstrated that the prevalence of vitamin B12 monitoring remains low. Objective: This study aimed to assess the occurrence of monitoring vitamin B12 levels in a diverse population. Methods: This was a retrospective chart review of adult patients with type 2 diabetes on metformin doses ≥ 1000 mg for ≥ 6 months at five Federally Qualified Health Centers (FQHC) and one Program of All-Inclusive Care for the Elderly (PACE). Charts were reviewed for occurrence of monitoring vitamin B12 levels in the past 5 years. Data collected included patient demographics, laboratory data, other potential vitamin B12 level lowering agents, active prescription for vitamin B12 supplementation, concomitant diabetes medications and metformin total daily dose. Results: Of the 322 patients included, 25% had a vitamin B12 level measured in the previous five years. Among the patients with a vitamin B12 level, 87.7% were within the normal range (>350 pg/mL), 11.1% were low (200-300 pg/mL), and only one patient (1.2%) was deficient (

Background: Inappropriate medication dosing in patients with chronic kidney disease can cause toxicity or ineffective therapy. Patients are at a high risk of developing related adverse events caused by the altered effect of drugs in conjunction with the use of polypharmacy to treat comorbid conditions. This necessitates adequate renal dosing adjustments. Objective: The current study aims at assessing whether appropriate dosing adjustments were made in hospitalized patients with chronic kidney disease. Methods: A retrospective descriptive study was conducted at two university hospitals in Beirut between January and December 2016. All adult CKD patients with creatinine clearance less than 60 ml/min and receiving at least one medication that require renal dosing adjustment were included. Kidney function was estimated from serum creatinine using Cockcroft-Gault equation, and dose appropriateness was determined by comparing practice with specific guidelines. The rates of renal drug dosing adjustment were investigated, in addition to the influence of possible determinants, such as the severity of renal impairment, reason of hospital admission, and other patient characteristics. Results: 2138 patients admitted in 2016 were screened. 223 adults receiving 578 drug orders that require adjustment were included. Among the 578 orders, 215 (37%) were adjusted adequately, 284 (49%) were adjusted inadequately, and 79 (14%) were not adjusted at all. Beta-blockers were the most inadequately dosed (83.6%) class of medication, whereas lipid-lowering agents had the highest percentage of adequate dosing (65.1%). As per patient, 84.3% of patients appeared to be receiving at least one inappropriate drug dose. Conclusions: Our study confirms that physicians are not prescribing appropriate dosing adjustments in chronic kidney disease inpatients, which may have deleterious effects. This highlights the need for more nephrology consultation and the implementation of physician education programs.

To determine diagnostic precision with magnetic resonance (MR) imaging of the brain, the most predictive MR imaging features, and the added value of comparison with previous data for the diagnosis of asymptomatic progressive multifocal leukoencephalopathy (PML) associated with natalizumab (NTZ).This retrospective study was approved by the institutional review board, and written informed consent was obtained. Eleven consecutive patients with multiple sclerosis (MS) who had received a definitive diagnosis of asymptomatic NTZ-associated PML (NTZ PML, 18 brain lesions) underwent 3-T MR imaging. The control group included 40 patients with MS but without PML who were treated with NTZ. Three readers independently performed blinded analysis of MR images. First, the readers were asked to detect NTZ PML lesions without comparing current images with previously obtained MR imaging data by evaluating MR images for the following features: U fiber and/or cortex involvement, lesion signal intensity and borders, and occurrence of punctate lesions. Second, they reassessed NTZ PML lesions with all the previous MR imaging data available. Diagnostic precision with MR imaging was assessed with and without comparison with previously obtained data. Logistic regression analyses were performed to identify the association of MR imaging features with NTZ PML.Overall interobserver agreement was good (κ = 0.76; 95% confidence interval [CI]: 0.71, 0.81). Hyperintensity on diffusion-weighted images and involvement of U fibers were the most predictive features (odds ratio, 33.7; 95% CI: 4.9, 229.7 [P.0001] and odds ratio, 8.7; 95% CI: 1.2, 61.4 [P = .03], respectively), while punctate lesions were exclusively observed in patients with NTZ PML. Comparison with previous MR imaging data improved specificity of MR imaging for the detection of NTZ PML lesions (from 88% to 100%, P = .05).Recognition of the most predictive imaging features and comparison with previous MR imaging data may facilitate the detection of asymptomatic NTZ PML.

Background: Area under the curve to minimum inhibitory concentration (AUC/MIC) has been recommended by the 2020 updated vancomycin guidelines for dosing vancomycin for both efficacy and safety. Previously, AUC/MIC has been cumbersome to calculate so surrogate trough concentrations of 15-20 mg/dL were utilized. However, trough-based dosing is not a sufficient surrogate as AUC/MIC targets of 400-600 can usually be reached without achieving troughs of 15-20 mg/dL. Targeting higher trough levels may also lead to adverse events including acute kidney injury (AKI) and nephrotoxicity. Objective: To compare the mean total first day vancomycin dose in traditional trough-based dosing versus dosing recommended by an AUC/MIC dosing program. Methods: Adult inpatients who received at least 24 hours of IV vancomycin treatment were included in this single-center, retrospective cohort study. The primary endpoint was difference in mean total first day vancomycin dose in milligrams (mg) received between patients’ traditional trough-based dosing and recommended dose via AUC/MIC electronic dosing calculator. Patients served as their own control by analyzing both actual dose received and dose recommended by the electronic AUC/MIC program. Rates of vancomycin induced adverse events, including acute kidney injury, elevated steady-state trough concentrations, and Red Man’s syndrome were also compared between patients who received doses consistent with the AUC/MIC dosing recommendation versus those who did not. Results: 264 patients were included in this study. Initial 24-hour vancomycin exposure was significantly lower with the recommended AUC/MIC dose versus the dose received (2380.7; SD 966.6 mg vs 2649.6; SD 831.8 mg, [95% CI 114.7:423.1] p=0.0007). Conclusions: Utilizing an electronic AUC/MIC vancomycin dosing calculator would result in lower total first day vancomycin doses.

Background: Diabetic retinopathy (DR) is a progressive, sight-threatening long-term complication of diabetes. Diabetes disease management reduces the risk of developing or progression to a severe form of DR. However, there are no reports of the potential role of pharmacists in DR progression. Objective: For this study, we performed a retrospective data analysis of patients with diabetes seen at cardiovascular risk reduction services provided by pharmacists with an objective to determine the potential role of pharmacists in the DR progression. These services involve pharmacists working in collaborative drug therapy management (CDTM), using a collaborative practice agreement (CPA) with primary care physicians. Methods: Patient records and ophthalmological notes were collected for 317 individuals seen by the pharmacists (intervention group) and 320 individuals seen only by a physician (control). Results: Statistical analysis was performed on 148 individuals in an intervention group and 120 individuals in the control group for which complete records were available. Retinopathy progression remained stable in 89.6 % of individuals in the intervention group compared to 87.9% in the control group. Moreover, the relative risk of retinopathy progressing to a severe form was 1.17 for the control group compared the intervention group. Conclusions: Our studies provide a proof-of-concept that pharmacists-managed care possesses a potential role in protection from DR, and paves a way for future pharmacists managed care with an emphasis on reducing diabetic complications.

© 2019, Grupo de Investigacion en Atencion Farmaceutica. All rights reserved. Background: Drug utilisation studies from paediatric hospitals that do not have access to patient level data on medication use are limited by a lack of standardised units of measures that reflect the varying daily dosage requirements among patients. The World Health Organization’s defined daily dose is frequently used in adult hospitals for benchmarking and longitudinal analysis but is not endorsed for use in paediatric populations. Objective: Explore agreement between standard adult-based defined daily doses (DDD) and paediatric estimates of daily injectable antibiotic use in a Paediatric Intensive Care Unit that does not have access to individual patient-level data. Methods: Hospital pharmacy antibiotic use reports and age-specific occupied bed-day data from 1 January 2010 to 31 May 2016 were extracted. Paediatric reference dosages and frequencies for antibiotics were defined and applied to three paediatric units of measure. Measures were applied to extracted data, agreement between antibiotic use measured in the adult DDD and each of the paediatric measures was assessed visually via Bland-Altman plots and linear regression for each antibiotic. Results: Thirty one different antibiotics were used throughout the study period. Despite varying daily dosages in grams, the daily use of vials was unchanged from birth to 18 years for thirteen antibiotics. Agreement between DDD and vial-based measures was closer than the total recommended daily dose that did not account for wastage during preparation and administration. Vial-based measures were unaffected by vial size changes due to drug shortage. Conclusions: Agreement between the DDD and vial-based measures of use supports the use of DDD for select antibiotics that may be targeted by antimicrobial stewardship programs. Vial based measures should be further explored in hospitals with single vial policies; detailed understanding of hospital practice is needed before inter-hospital comparisons are made.

Background: Pharmacist managed warfarin clinics can improve the anticoagulation status ofnon-valvular patients. The first of such services was implemented at the Cornwall Regional Hospital in Jamaica in 2013. Objectives: To assess the anticoagulation control of patients on warfarin therapy over six months in the pharmacist managed warfarin clinic at Cornwall Regional Hospital. Methods: Retrospective docket review for the period January 2014 to December 2016 was done to include data of patients attending routine clinic appointments for at least six months. Age, gender, date of visit, indication for warfarin therapy, warfarin dose and International Normalized Ratio readings were extracted. Percentage time spent in therapeutic range (TTR) was calculated by month for six months using the Rosendaal linear interpolation method. Patient anticoagulation status was categorized as poor (TTR40% and sustaining these values over six months. The services should therefore be encouraged.

Background: There remains variability in both practice and evidence related to optimal initial empiric dosing strategies for vancomycin. Objective: Our primary objective was to describe the percentage of obese patients receiving vancomycin doses consistent with nomogram recommendations achieving targeted initial steady-state serum vancomycin concentrations. Secondary objectives were to describe the primary endpoint in subgroups based on patient weight and estimated creatinine clearance, to describe the rate of supratherapeutic vancomycin accumulation following an initial therapeutic trough concentration, and to describe the rate of vancomycin-related adverse events. Methods: This single-center, IRB-approved, retrospective cohort included adult patients ≥ 100 kilograms total body weight with a body mass index (BMI) >30 kilograms/m2 who received a stable nomogram-based vancomycin regimen and had at least one steady-state vancomycin trough concentration. Data collected included vancomycin regimens and concentrations, vancomycin indication, serum creatinine, and vancomycin-related adverse events. Patients were divided into two cohorts by goal trough concentration: 10-15 mcg/mL and 15-20 mcg/mL. Results: Of 325 patients screened, 85 were included. Goal steady-state concentrations were reached in 42/85 (49.4%) of total patients. Conclusions: Achievement of initial steady-state vancomycin serum concentrations in the present study (approximately 50%) was consistent with the use of published vancomycin dosing nomograms.

Background: Benzodiazepine and z-hypnotic prescribing has slowly decreased over the past 20 years, however long-term chronic prescribing still occurs and is at odds with prescribing guidance. Objectives: To identify the pattern of benzodiazepine and z-hypnotic prescribing in psychiatric inpatients at discharge and 12 months post-discharge. Methods: Retrospective observational longitudinal cohort study of patients admitted to two adult psychiatric wards between June and November 2012 (inclusive) who were discharged with a prescription for a benzodiazepine or z-hypnotic drug. Routinely collected prescription data available from NHS Scotland Prescribing Information System was used to identify and follow community prescribing of benzodiazepine and z-hypnotics for a 12 month period post-discharge. Data were entered in Excel® and further analysed using SPSS 23. Ethical approval was not required for this service evaluation however Caldicott Guardian approval was sought and granted. Results: Eighty patients were admitted during the study period however only those patients with a single admission were included for analysis (n=74). Thirty per cent (22/74) of patients were prescribed a benzodiazepine or z-hypnotics at discharge; 14 of whom received ‘long-term’ benzodiazepine and z-hypnotics i.e. continued use over the 12 month period. Seven patients received a combination of anxiolytics and hypnotics (e.g., diazepam plus temazepam or zopiclone). Long-term use was associated with a non-significant increase in median benzodiazepine or z-hypnotic dose, expressed as diazepam equivalents. Conclusions: One in three patients were prescribed a benzodiazepine or z-hypnotics at discharge with 1 in 5 receiving continuous long-term treatment (prescriptions) for 12 months post-discharge. As chronic long-term B-Z prescribing and use still remains an issue, future strategies using routine patient-level prescribing data may support prescribers to review and minimise inappropriate long-term prescribing.

International audience; BackgroundRight-sided infective endocarditis (RSIE) is an uncommon diagnosis accounting for less than 10% of cases of infective endocarditis. Optimal management for severely ill patients with RSIE remains challenging because few studies reported on management and outcome. The goal of our study was to determine outcome and associated prognostic factors in a population of ICU patients with a diagnosis of definite, active and severe RSIE.MethodsWe performed a retrospective study in 10 French ICUs between January 2002 and December 2012. Main outcome was mortality at 30 days after ICU admission. Significant variables associated with 30-days mortality in the bivariate analysis were included in a logistic regression analysis.ResultsA total of 37 patients were studied. Mean age was 47.9 ± 18.4 years. Mean SAPS II, SOFA score and Charlson comorbidity index were 32.4 ± 17.4, 6.3 ± 4.4 and 3.1 ± 3.4, respectively. Causative pathogens, identified in 34 patients, were mainly staphylococci (n = 29). The source of endocarditis was a catheter related infection in 10 patients, intravenous drug abuse in 8 patients, cutaneous in 7 patients, urinary tract related in one patient and has an unknown origin in 7 patients. Vegetation size was higher than 20 mm for 14 patients. Valve tricuspid regurgitation was classified as severe in 11 patients. All patients received initial appropriate antimicrobial therapy. Aminoglycosides were delivered in combination with β-lactam antibiotics or vancomycin in 22 patients. Surgical procedure was performed in 14 patients. Eight patients (21.6%) died within 30 days following ICU admission. One independent prognostic factor was identified: use of aminoglycosides was associated with improved outcome (OR = 0.1; 95%CI = 0.0017–0.650; p = 0.007).ConclusionMortality of patients with RSIE needing ICU admission is high. Aminoglycosides used in combination with β-lactam or vancomycin could reduce 30 days mortality.

Background: Medication discrepancies are a common occurrence following hospital admission and carry the potential for causing harm. However, little is known about the potential risk factors involved in medication discrepancies. Objective: The objective of this study was to determine how frequently medication discrepancies occur and their associated risk factors, in patients hospitalized via the emergency department of the Spaarne Gasthuis Hospital, located in The Netherlands. Methods: This retrospective observational study examines 832 hospital admissions which took place between April 1st and June 30th, 2015. Medication reconciliation was performed within 24 hours of admission and medication discrepancies were registered. The primary outcome recorded in the study was the proportion of patients experiencing one or more medication discrepancies, as verified by the physician. As a secondary outcome, the association between these discrepancies and pre-specified variables was analyzed using univariate and multivariate logistic regression. Results: At least one medication discrepancy was found to have occurred with 97 of the 832 patients (11.7%), the most common discrepancies involving incorrect drug dose (44.9%) and omission of medication (36.4%). In the univariate analysis, age (OR=1.03 [95% CI 1.02:1.04] p

Background: Many institutions have guidelines for initiation and monitoring, but not timing, of vancomycin. Objective: Our objective was to evaluate vancomycin trough collection appropriateness before and after an initiative to change the dosing and trough collection times in ward patients. Methods: A retrospective cohort study of ward patients from May 2014-16 who received scheduled intravenous vancomycin was performed. Nurse managers and pharmacists provided staff education. Differences between pre- and post-intervention groups were compared using student’s t-test for continuous data and chi-square test for categorical data. Results: Baseline characteristics were similar between the pre-intervention (n=124) and post-intervention (n=122) groups except for weight-based maintenance dose (15.3 mg/kg vs. 16.5 mg/kg, p=0.03) and percentage of troughs collected with morning labs (14% vs. 87%, p

Background: Acid suppression therapy (AST) is routinely used in critically ill patients to prevent stress-related mucosal bleeding (SRMB). Objective: Our objective was to determine the impact of a structured educational intervention on AST used for prevention of SRMB on appropriateness of AST. Methods: A single-center, retrospective, cohort study of appropriate use of AST in critically ill patients admitted to the medical intensive care unit (ICU) at an academic medical center between January to June of 2014 (no intervention) and January to June of 2015 (intervention) was conducted. The percentage of patients prescribed inappropriate AST, inappropriate AST at ICU transfer and hospital discharge, doses of inappropriate AST, and adverse effects associated with AST use were compared between periods using chi-square tests. Results: Patients in the intervention group (n=118) were 5 years older than patients in the no intervention group (n=101). AST was inappropriately initiated more frequently in the no intervention group (23% vs. 11%, p=0.012). Continuation of inappropriate AST at ICU transfer and hospital discharge was similar between groups (60% vs. 53%, p=0.277 and 18% vs. 14%, p=0.368, respectively). Conclusion: Patients had appropriate AST initiated and inappropriate AST withheld more frequently when formal education was provided. This low-cost intervention strategy can be implemented easily at institutions where pharmacists interact with physicians on rounding services and should be evaluated in institutions where interactions between pharmacists and physicians occur more frequently in non-rounding situations.

Objectives: The purpose of this study was to describe the rate of medication short-term supply dispensings (tider), patient and medication characteristics associated with a tider, and costs for tider dispensings in an integrated healthcare delivery system in Colorado, United States. Methods: This was a retrospective study conducted in an integrated healthcare delivery system’s outpatient clinics. All patients who had a prescription dispensed for a study medication at any of the system’s 28 outpatient pharmacies during the first quarter of 2016 were included. A tider was identified as a 3-day supply of a prescription medication that was dispensed at no charge to a patient. The quarterly tider rate and the per member per month (PMPM) cost of tiders were estimated. Patient and medication characteristics associated with a tider were assessed. Results: A total of 444,225 study medications were dispensed for 135,907 patients during the study period. There were 3,430 (0.77%, 95%CI 0.75%:0.80%) medications dispensed as a tider. The PMPM cost of tider medications and their dispensing fees was USD 0.03. There were 1,092 (0.8%) and 134,815 (99.2%) patients who did and did not, respectively, have at least one tider dispensed during the study period. Patient characteristics strongly associated with having had a tider dispensed included being older, male, and a Medicare beneficiary. Cardiovascular and neuromuscular medications had the highest rates of tider dispensing. Conclusions: The rate of tider dispensing was relatively low; however, approximately one out of 125 patients had at least one tider. Patients who had a tider were more likely to be older, female, a Medicare beneficiary, and having had a previous tider dispensing and a higher burden of chronic disease. The tider medication was more likely to be a cardiovascular or neuromuscular medication class and more likely to be dispensed on a weekend. The total cost of dispensing a tider appears reasonable since the benefits of providing patients with needed medications likely outweigh the cost. Future studies should be performed to assess the impact of tider dispensing on health outcomes.

Background: Direct oral anticoagulants (DOACs) are preferred for stroke prevention in atrial fibrillation (AF). However, off-label doses have been associated with increased risk of adverse events. Objective: The objective of this study was to compare the frequency and outcomes of labeled versus off-label DOAC dosing in patients with AF. Methods: This retrospective cohort study included adults diagnosed with nonvalvular AF (NVAF), discharged from University of Utah Health on DOAC therapy between 7/1/2017 and 9/30/2017. The primary outcome was off-label DOAC dosing frequency, defined as dosing inconsistent with manufacturer labeling. Secondary outcomes included variables associated with off-label dosing and a composite of adverse events (major bleeding, thromboembolism, and all-cause mortality) in the 90 days following the index hospital discharge. Results: Of 249 included patients, 16.1% were discharged with off-label dosing. Factors associated with off-label dosing included advanced age, lower body mass index, decreased renal function, use of rivaroxaban, and hepatic impairment. The majority of off-label patients (70%) received lower-than-recommended DOAC dosing. Prescriber rationale for off-label prescribing was documented in 25% of patients and included anti-Xa guided dosing, high risk for bleeding or thromboembolism, and prior history of on-therapy adverse events. The rate of adverse events between labeled and off-label DOAC doses was not statistically different (10.0% vs. 6.7%, p=0.299), although this is likely due to small sample size. Conclusions: Off-label DOAC prescribing for stroke prevention in NVAF at University of Utah Health was consistent or lower than previously published studies. Off-label dosing most often involved under-dosing of rivaroxaban. Future research should investigate the role of provider rationale and insight in optimizing DOAC therapy outcomes.

Background: Clinical pharmacists have demonstrated their ability to improve patient outcomes over usual care for patients with type 2 diabetes and glycemic levels above goal, though reasons for this are not well defined. Numerous medications exist for the management of patients with type 2 diabetes and different patterns of medication use by clinical pharmacists may explain these benefits. Objective: The objective of this study was to compare pharmacotherapy approaches to managing patients with uncontrolled type 2 diabetes receiving basal insulin by a clinical pharmacist versus usual care by a physician or advanced practice provider in a federally qualified health center. Methods: A retrospective cohort study of patients 18 to 85 years old with type 2 diabetes, A1C ≥9%, receiving basal insulin was conducted. Patients were grouped into two cohorts (1) those who received clinical pharmacist care and (2) those who received usual care from a physician or advanced practice provider. The primary outcome evaluated the proportion of patients treated with the addition of a non-basal insulin medication. Type of medication changes or additions as well as change in A1C and change in weight were also analyzed. Outcomes were evaluated at six months post-index A1C. Results: A total of 202 patients were identified (n=129 in the usual care group and n=73 in the clinical pharmacist group). A non-basal insulin medication was added in 29% of patients receiving usual care versus 41% of patients receiving clinical pharmacist care (adjusted p=0.040). Usual care providers more frequently added metformin, sulfonylureas and thiazolidinediones, while clinical pharmacists more frequently added prandial insulin, DPP-4 inhibitors, GLP-1 agonists, and SGLT-2 inhibitors. A1C decreased 1.6% in the clinical pharmacist group versus 0.9% in the usual care group (adjusted p=0.055). No significant change in weight was observed between the clinical pharmacist and usual care group (0.2 kg versus -1.0 kg, respectively; adjusted p=0.175). Conclusions: Pharmacotherapy approaches to managing patients with uncontrolled type 2 diabetes varied between clinical pharmacists and other clinician providers. For patients already on basal insulin, clinical pharmacists were more likely to intensify therapy with the addition of non-basal insulin, including more frequent initiation of prandial insulin and by adding newer antihyperglycemic agents.

Background: High intensity statin therapy (HIST) is the gold standard therapy for decreasing the risk of recurrent atherosclerotic cardiovascular disease (ASCVD); however, little is known about the use of HIST in older adults with ASCVD. Objectives: The aim of this cross-sequential study was to determine trends in statin intensity in older adults over a 10-year timeframe. Methods: The study was conducted in an integrated healthcare delivery system. Patients were 76 years or older with validated coronary ASCVD. Data were collected from administrative databases. Statin intensity level was assessed in eligible patients on January 1st and July 1st from January 1, 2007 to December 31, 2016. Results: Overall, a total of 5,453 patients were included with 2,119 (38.9%) and 3,334 (61.1%) categorized as HIST and Non-HIST, respectively. Included patients had a mean age of 79.8 years and were primarily male and white and had a cardiac intervention. The rate of HIST use increased from 14.5% to 41.3% over the study period (p

Objectives: The primary objective of the study was to assess the mean change in hemoglobin A1c (HbA1c) when acarbose was added to insulin and non-insulin regimens in patients with type 2 diabetes mellitus (T2DM). Secondary objectives were to evaluate the discontinuation rate of acarbose, and to assess the number of patients who were placed on insulin despite the addition of acarbose. Methods: A retrospective chart review was conducted on veterans with T2DM initiated on acarbose between October 1, 2013 and December 31, 2013. To be included, patients must have had a refill history indicating at least 3 months of acarbose use and HbA1c readings within 6 months prior to initiation and after at least 3 months of use. Excluded patients were those with type 1 diabetes mellitus, serum creatinine ≥2 mg/dL at acarbose initiation, or a diagnosis based on ICD-9 codes for an existing gastrointestinal condition or liver cirrhosis. The two-tailed, paired t-test was used for analysis of the primary objective and descriptive statistics were used for all other outcomes. Results: Of the 146 patients screened, 102 patients were included in the study. Exclusions were primarily due to patients not being on acarbose for at least 3 months (n=43). The average HbA1c before and after acarbose initiation was 9.08% (SD=1.74) and 8.43% (SD=1.74) respectively, with an average HbA1c reduction of 0.65% (n=102, p=0.0005). Forty patients (39.2%) discontinued acarbose after at least 3 months of use. Of the 73 patients not on insulin at the time of acarbose initiation, 19 (26%) were started on insulin therapy despite addition of acarbose. Conclusion: Acarbose can be considered in patients who may reach their HbA1c goal with minimal HbA1c reduction. However, adverse effects are a limitation to use. Potential risks and benefits should be assessed and discussed with the patient prior to prescribing acarbose.

International audience; AIM: To characterize the profile of patients seeking baclofen treatment for alcohol dependence in France. METHOD: We compared retrospectively baclofen seekers and baclofen non-seekers within a cohort of consecutive outpatients with alcohol dependence who attended a first appointment for alcohol treatment at two French addiction centres between September 2012 and March 2014. We documented socio-demographic characteristics; comorbid psychiatric, addiction, alcohol dependence features; patients' initial drinking goal, and referral status; and treatment retention at 6 and 12 months. RESULTS: Of the 289 patients identified, 107 were baclofen seekers and 182 were baclofen non-seekers. The only parameters significantly associated with baclofen seekers in multivariate analyses were a greater baseline alcohol consumption (β = 15.4, 95% CI: 0.18-30.65, P = 0.05), a controlled-drinking initial goal (OR = 14.9, 95% CI: 7.7-29, P < 0.0001) and self-referral (OR = 6.6, 95% CI: 3.7-12, P < 0.0001), baclofen seekers being eight times more likely to be self-referred and treatment-naïve (OR = 8.8, 95% CI: 4.1-18.9, P < 0.0001). Baclofen seekers were more likely to be retained in treatment at 6 months (OR = 3.5, 95% CI: 1.8-6.7, P < 0.0001) and 12 months (OR = 1.9, 95% CI: 1.1-3.2, P = 0.019). CONCLUSION: In France, the perspective of controlled drinking offered by baclofen treatment may have attracted more self-referred patients, including those without previous alcohol treatment, to attend treatment, than the usual treatment options. These findings raise the question as to whether future public health strategies on alcohol should more prominently promote some aspects of alcohol treatment, such as patient's preference and treatment options, in order to reduce the treatment gap in alcohol dependence.

International audience; Background: Outcome of patients with streptococcal prosthetic joint infections (PJIs) is not well known.Methods: We performed a retrospective multicenter cohort study that involved patients with total hip/knee prosthetic joint (THP/TKP) infections due to Streptococcus spp. from 2001 through 2009.Results: Ninety-five streptococcal PJI episodes (50 THP and 45 TKP) in 87 patients of mean age 69.1 ± 13.7 years met the inclusion criteria. In all, 55 out of 95 cases (57.9 %) were treated with debridement and retention of the infected implants with antibiotic therapy (DAIR). Rifampicin-combinations, including with levofloxacin, were used in 52 (54.7 %) and 28 (29.5 %) cases, respectively. After a mean follow-up period of 895 days (IQR: 395–1649), the remission rate was 70.5 % (67/95). Patients with PJIs due to S. agalactiae failed in the same proportion as in the other patients (10/37 (27.1 %) versus 19/58 (32.7 %); p = .55). In the univariate analysis, antibiotic monotherapy, DAIR, antibiotic treatments other than rifampicin-combinations, and TKP were all associated with a worse outcome. The only independent variable significantly associated with the patients’ outcomes was the location of the prosthesis (i.e., hip versus knee) (OR = 0.19; 95 % CI 0.04–0.93; p value 0.04).Conclusions: The prognosis of streptococcal PJIs may not be as good as previously reported, especially for patients with an infected total knee arthroplasty. Rifampicin combinations, especially with levofloxacin, appear to be suitable antibiotic regimens for these patients.

Objective: The objective of this study is to compute the potential benefit of Pramipexole ER on total levodopa equivalent dose (LED) and Unified Parkinson Disease Rating Score (UPDRS-III) compared to mono- or combined therapy of pramipexole IR and/or carbidopa/levodopa. Methods: This is a retrospective observational study conducted in a specialized PD (Parkinson Disease) and movement disease center in Lebanon between January and December 2017. Results: A total of 176 patient’s record was reviewed. Pramipexole ER showed a significant difference on the mean changes in LED and UPDRS-III score. After 13 weeks of initiating Pramipexole ER, the mean decrease in LED was -49.42 mg for all patients (p < 0.001, CI 95% [35.28-63.55]) and the mean decrease in UPDRS-III score for all patients was -6 points (P< 0.001). According to the subgroup analysis, patients aged 65 years and below, the change in mean total LED from baseline (350.80 mg) was a decrease of 63.19 mg with a p

Introduction Patients with advanced chronic obstructive pulmonary disease (COPD) are at risk for developing invasive pulmonary aspergillosis. A clinical algorithm has been validated to discriminate colonization from putative invasive pulmonary aspergillosis (PIPA) in Aspergillus-positive respiratory tract cultures of critically ill patients. We focused on critically ill patients with COPD who met the criteria for PIPA. Methods This matched cohort study included critically ill patients with COPD from two university hospital intensive care units (ICUs). We studied the risk factors for PIPA as well as the impact of PIPA on short- and long-term outcomes. Whether PIPA was associated with a pattern of bacterial colonization and/or infection 6 months before and/or during ICU stay was assessed. In addition, antifungal strategies were reviewed. Results Fifty cases of PIPA in critically ill patients with COPD in the ICU were matched with one hundred control patients with COPD. The ICU short- and the long-term (at 1 year) mortality were significantly increased in the PIPA group (p p p = 0.004 and p Conclusions PIPA was a strong death predictor in critically ill patients with COPD. The use of corticosteroids and antibiotics before ICU admission was a risk factor for PIPA. PIPA was not associated with a specific bacterial pattern of colonization or infection. Prompting antifungal treatment in critically ill patients with COPD who have PIPA may not be the only factor involved in prognosis reversal.

The aim of this study was to assess the role of European ambulatory pediatricians in caring for asthmatic children, especially in terms of their therapeutic education. We developed a survey that was observational, declarative, retrospective and anonymous in nature. 436 ambulatory pediatricians in Belgium, France, Germany, Italy, Luxembourg and Slovenia were asked to participate in the survey providing information on three children over 6 years old suffering from persistent asthma, who had been followed for at least 6 months. We considered the pediatricians' profile, and their role in the therapeutic education of children. 277 pediatricians (64%) responded: 81% were primary care pediatricians; 46% participated in networks; 4% had specific training in Therapeutic Patient Education; 69% followed more than 5 asthmatic children per month, and over long periods (7 ± 4 years). The profiles of 684 children were assessed. Answers diverged concerning the provision of a Personalized Action Plan (60-88%), training the child to measure and interpret his Peak Expiratory Flow (31-99%), and the prescription of pulmonary function tests during the follow-up programme of consultations (62-97%). Answers converged on pediatricians' perception of their role in teaching children about their condition and its treatment (99%), about inhalation techniques (96%), and in improving the children's ability to take preventive measures when faced with risk situations (97%). This study highlights the role of European pediatricians in caring for asthmatic children, and their lack of training in Therapeutic Patient Education. Programmes and tools are required in order to train ambulatory pediatricians in Therapeutic Patient Education, and such resources should be integrated into primary health care, and harmonized at the European level. 10