Background: Data comparing the efficacy of alfacalcidol to that of calcitriol in managing secondary hyperparathyroidism in patients with chronic kidney disease (CKD) is scarce. We sought to compare the efficacy of both drugs in managing hyperparathyroidism in patients with CKD. Methods: A retrospective observational cohort study conducted from January 2022 to March 2023 included adults with CKD stages 3 to 5 (non-dialysis) who received alfacalcidol for 3 months followed by calcitriol for another 3 months. Assessments were done at baseline and after 3 months of each treatment. The primary outcome was iPTH suppression, and the secondary outcome was total serum calcium levels. Results: A total of 70 patients were included, with 34 (48.6%) being male. The cohort’s mean age was 65.5 ± 15 years. CKD stage 3 comprised 47.1% of the sample. The median dose of alfacalcidol was 0.5 (0.25-0.8) µg compared to 0.5 (0.25-0.5) µg for calcitriol ( P = .001). Alfacalcidol did not significantly suppress iPTH levels, with median values of 13.31 (8.23-24.4) pg/mL at baseline and 12.5 (8.86-24.7) pg/mL after 3 months ( P = .937). In contrast, calcitriol significantly reduced iPTH levels from 12.5 (8.86-24.7) pg/mL to 10.7 (5.7-19) pg/mL ( P = .017). Additionally, alfacalcidol did not significantly increase calcium levels, while calcitriol did. Throughout the study period, albumin values, the follow-up times, and the use of phosphate binders or non-active vitamin D remained consistent for each drug. The multivariate Generalized Estimating Equations indicated that baseline iPTH [ B = 0.041, 95% CI (0.03- 0.05); P < .001], calcitriol [ B = −0.278, 95% CI (−0.5 to −0.06); P = .014], daily dose of the study drug [ B = −0.45, 95% CI (−0.7 to −0.2); P < .001], and baseline phosphorus level [ B = 0.354, 95% CI (0.004-0.7); P = .047] were independent factors associated with iPTH suppression. Conclusion: Calcitriol, at significantly lower doses, was more effective than alfacalcidol in suppressing iPTH levels and increasing calcium levels over 3 months. A randomized controlled study is needed to confirm these findings.

Purpose: One option recommended by expert guidelines for prompt reversal of anticoagulation-induced hemorrhage is four-factor prothrombin complex concentrate (4F-PCC). Pharmacist presence has been shown to reduce order entry to administration and door-to-needle (DTN) times. However, how pharmacist preparation of 4F-PCC at the bedside in the Emergency Department (ED) can affect times to administration has not been thoroughly studied. The purpose of this study was to assess if pharmacist presence along with preparation of 4F-PCC at the bedside could improve administration times. Methods: This retrospective cohort study included anticoagulated patients requiring emergent reversal with 4F-PCC in the ED from January 2019 to April 2020 (pre-group) to March 2022 to March 2023 (post-group). Patients in the post-intervention group who had 4F-PCC prepared at the bedside were compared to a historical group without bedside 4F-PCC preparation. The primary outcome was time from 4F-PCC order entry to administration. Results: Of 193 patients evaluated, 99 (51.3%) were included (N = 41 pre-group; N = 58 post-group). There was a significant 11 minute difference in median time from order entry to administration favoring the post-group (31 vs 20 minutes, P < .001). The subset of patients with intracranial hemorrhage (ICH) in the post-group also had a significantly shorter order to administration time of 14 minutes (31 vs 17 minutes, P < .001). There was no difference in overall DTN times, in-hospital mortality, or length of stay (LOS) between groups, including in the subset of patients with ICH. Conclusion: 4F-PCC preparation at the bedside by the ED pharmacist significantly reduced 4F-PCC order entry to administration time. However, this intervention did not reduce overall DTN times.

Background: Recurrent acute pancreatitis can be influenced by a variety of factors, including metabolic and lifestyle triggers. This case report presents a 30-year-old Asian woman whose episodes of pancreatitis were complicated by hypertriglyceridemia, Type 2 diabetes mellitus (T2DM), and occasional alcohol use. Medication-related risks, such as semaglutide, were also identified as possible contributors. Case Presentation: The patient experienced three distinct episodes of acute pancreatitis. Initially admitted in June 2020, she presented with no prior medical history and denied alcohol use. During subsequent admissions in April 2023 and January 2024, the patient reported alcohol consumption. The second admission showed significantly elevated triglyceride (TG) levels (>5680 mg/dL), and the third occurred after New Year’s Eve alcohol consumption, with TG >3000 mg/dL. Treatment across all episodes involved NPO status, IV fluids, and ICU admission with insulin therapy to lower TG levels. After the recurrence of pancreatitis, her T2DM treatment was changed from semaglutide to dapagliflozin. Conclusion: This case underscores the importance of comprehensive patient education on lifestyle factors, medication risks, and adherence to treatment plans to reduce the recurrence of acute pancreatitis. Tailoring interventions, such as switching diabetes medications (from semaglutide to dapagliflozin) and emphasizing TG management through gemfibrozil, atorvastatin, and icosapent ethyl, proved essential in stabilizing her condition. The patient’s case serves as a reminder of the multiple potential causes of pancreatitis and the need for ongoing monitoring to prevent further complications.

Legionnaires’ disease (LD), caused by Legionella pneumophila, often presents with pneumonia, gastrointestinal symptoms, and confusion. Severe LD can lead to a triad of pneumonia, rhabdomyolysis, and acute kidney injury (AKI), with less common complications such as liver injury. We report a case of a 32-year-old male with no prior medical history who presented with LD complicated by severe rhabdomyolysis, AKI requiring hemodialysis (HD), and acute liver injury. The patient reported 6 days of gastrointestinal symptoms, reduced mobility, and minimal urine output. The patient also reported a history of vaping. Diagnostic imaging revealed pneumonia and enterocolitis, while laboratory findings included leukocytosis, hyponatremia, significantly elevated creatinine kinase (201 000 U/L), and acute transaminitis. A positive Legionella urine antigen confirmed the diagnosis. Initial treatment with azithromycin for 7 days showed partial improvement; however, clinical and laboratory deterioration necessitated a switch to levofloxacin for an additional 7 days. This case highlights rare, severe multi-organ involvement in LD, with rhabdomyolysis and AKI being particularly pronounced. The possible association between vaping and Legionella infection is explored, given the patient’s history of vaping and limited prior documentation of such a link. Prompt recognition, accurate diagnosis, and escalation of therapy are critical in managing severe LD and reducing associated morbidity.

Introduction: Clinical pharmacists bring unparalleled medication expertise, but quantifying their impact on a health system’s bottom line remains unestablished. Objective: To classify interventions by pharmacists with and without board certification and quantify the cost avoidance (CA) from accepted interventions. Methods: This multicenter prospective observational study, conducted between August 2018 and January 2019, included board certified (BPS) and non-board certified (Non-BPS) emergency medicine (EM) and intensive care unit (ICU) clinical pharmacists from 89 U.S. institutions. Primary outcomes included the quantity, type, and acceptance of interventions and the CA generated by BPS pharmacists compared to Non-BPS pharmacists. Results: 287 pharmacists (227 BPS, 60 Non-BPS) at 89 centers provided care throughout 4184 shifts. BPS pharmacist provided more interventions (overall: 63 693 vs 8690; per shift: 18.8 vs 10.9, P < .001) with higher acceptance (98.2% vs 97.6%, P < .001). Accepted interventions per shift included adverse drug event prevention (2.0 vs 1.6, P = .17), resource utilization (3.6 vs 1.7, P = .007), individualization of patient care (9.7 vs 5.3, P = .05), prophylaxis (0.4 vs 0.3, P = .99), hands-on care (1.4 vs 0.9, P = .99), and administrative/supportive tasks (1.8 vs 1.1, P = 0.). BPS pharmacists generated greater mean CA per intervention ($873 vs $801), patient day ($961 vs $501), shift ($8112 vs $4828) and annum ($1 946 942 vs $1 158 784) ( P < .001 for all). The CA to salary ratio was 10.5:1 for BPS and 6.3:1 for Non-BPS pharmacists. Conclusion: BPS pharmacists in the ED and ICU generated greater CA and a higher monetary CA to salary ratio than Non-BPS pharmacists.

Purpose: Optimal dosing of VTE prophylaxis for specific patient populations remains an area of concern as insufficient evidence exists regarding dosing for underweight patients. The purpose of this study is to compare the incidence of major bleeding events in underweight patients given different prophylactic doses of enoxaparin. Methods: This is a retrospective analysis performed at multiple hospitals within a single health care system. Patients with a BMI < 18.5 kg/m2 were divided into 2 groups depending on whether they received at least 1 prophylactic dose of enoxaparin 30 mg subcutaneously once daily or enoxaparin 40 mg subcutaneously once daily. Underweight adult patients were included if they were admitted to an ICU for at least 48 hours and received at least 1 dose of enoxaparin for VTE prophylaxis during their ICU admission. The primary aim was to compare the incidence of clinically significant bleeding between dosing strategies. Secondary aims included the incidence of VTE during admission, ICU length of stay, overall hospital length of stay, and all-cause mortality 30 days post-discharge. Results: A total of 310 patients met inclusion criteria for this study, with 80 patients in the 30 mg group and 230 patients in the 40 mg group. There was no significant difference in major bleeding events between the 2 groups ( P = .61). No significant differences in incidence of VTE ( P = .455 ), ICU length of stay ( P = .466), overall hospital stay ( P = .502), or all-cause mortality ( P = .925) were found between groups. Conclusions: No difference was found in clinically significant bleeding between underweight critically ill patients receiving VTE prophylaxis with enoxaparin 30 mg once daily or 40 mg once daily. Further studies are needed to evaluate the optimal dosing of VTE prophylaxis with enoxaparin in underweight patients.

We describe a case of a 67-year-old man with bioprosthetic aortic valve endocarditis secondary to Rhizobium radiobacter, a rare Gram-negative plant pathogen. The initial source was assumed to be due to soil exposure. The patient was successfully managed with ceftriaxone following aortic valve replacement. Upon review of the literature, failure to recover R. radiobacter from blood cultures occurred in 57% (4/7) of reported endocarditis cases and 86% (6/7) were managed with antimicrobial monotherapy. Notably, all the published case reports to date of R. radiobacter endocarditis have reported survival following treatment.

Each month, subscribers to The Formulary Monograph Service receive 5 to 6 well-documented monographs on drugs that are newly released or are in late phase 3 trials. The monographs are targeted to Pharmacy and Therapeutics Committees. Subscribers also receive monthly 1-page summary monographs on agents that are useful for agendas and pharmacy/nursing in-services. A comprehensive target drug utilization evaluation/medication use evaluation (DUE/MUE) is also provided each month. With a subscription, the monographs are available online to subscribers. Monographs can be customized to meet the needs of a facility. Through the cooperation of The Formulary, Hospital Pharmacy publishes selected reviews in this column. For more information about The Formulary Monograph Service, contact Wolters Kluwer customer service at 866-397-3433.

Drug-induced hypertension, though rare, often presents diagnostic challenges, particularly when the causative drug is not typically associated with hypertension. We describe a case involving a 55-year-old woman who presented with anxiety, confusion, and significantly high blood pressure unresponsive to standard treatments. Despite increasing medication doses, her blood pressure remained poorly controlled, leading to an investigation for secondary causes. Elevated plasma and urinary catecholamines were found. It was determined that the recent initiation of buspirone for anxiety was the cause. Discontinuation of buspirone normalized her catecholamine levels and improved blood pressure control. This case underscores the importance of considering drug-induced hypertension, particularly in instances of abrupt and severe blood pressure elevation, where elevated catecholamine levels may suggest conditions such as pheochromocytoma. It highlights the necessity for healthcare practitioners to be vigilant regarding the uncommon side effects of commonly prescribed medications, thereby ensuring accurate diagnosis and appropriate management.

Background: Opioids are often part of the post-operative pain regimen after orthopaedic surgery. Novel multimodal post-operative pain control regimens have been developed to decrease the amount of opioid usage due to their negative side effects including nausea, constipation, and addiction. The purpose of this study was to compare the cost of postoperative pain management treatment methods after orthopaedic surgery between opioid/acetaminophen therapy and an opioid-free, multidrug, multimodal pathway. Methods: This is a secondary analysis of data collected from 2 IRB approved prospective studies that evaluated pain control after elective orthopaedic surgery from a single institution. The first study analyzed the use of opioid medication after hallux valgus surgery and calculated the total cost of opioid pain medication consumed. The second study assessed the pain of patients after elective foot and ankle surgery utilizing a novel opioid-free multimodal pain pathway that included 5 medications. The postoperative prescription costs of these 2 pain management groups were totaled, analyzed, and compared. A paired t-test was used to compare the means of these 2 groups and to evaluate whether significant differences might exist between them. Results: We noted that the opioid group had an average cost of $8.92 (SD $5.74), while the opioid-free multimodal group had an average total cost of $25.60 (SD $10.49), P < .001. The average difference in cost between the 2 regimens was $16.68. Conclusion: There was a statistically significant difference between the costs of an opioid-free multimodal post-operative pain regimen when compared to an opioid/acetaminophen therapy, irrespective of public vs private insurance. This 17-dollar cost difference may or may not be clinically significant depending on the financial situation of the patient, but it may be important for the clinician to consider to provide appropriate individualized patient care after orthopaedic surgery. Level of Evidence: II.

Background: Most antibiotics administered via intermittent IV infusion are diluted in 50 to 100 ml of diluent. The primary infusion set for the BD Alaris® pumps can hold 25 ml of volume in its tubing, potentially contributing up to a 50% drug loss if residual volume is present after administration is complete. In the case of antibiotics, this may lead to significant underdosing, potentially contributing to reduced therapeutic response and emergence of antimicrobial resistance. Many organizations lack departmental policies and procedures for the administration of small-volume intermittent infusions. Developing a clear policy and procedure can increase drug delivery efficiency. Previous studies propose several recommendations, such as using a secondary infusion set, adding carrier fluids, and flushing the line to account for overfill. Objective: Our aim was to implement pilot new guidance in 2 patient units (an ICU and a non-ICU) to address the administration of small-volume intermittent infusions and determine if this results in more complete medication administration. Methods: This was an observational quality improvement initiative assessing the new guidance established for the administration of small-volume intermittent infusions to current practices. The primary outcome of this study was the incidence of residual drug volume in the IV line before the air-detector, IV bag, or IV vial. This was done through observation, and data collected through a survey. Results: In total, 203 IV administrations were observed, 86% of which were antibiotics. There were 124 IV administrations being observed before policy guidance initiation and 79 after initiation. The results showed a statistically significant reduction in the incidence of fluid remaining in the IV line before the air-detector (85% vs 27%; P < .001), the IV bag (59% vs 7.6%; P < .001), and in the IV vial (47% vs 24%; P < .001.). Conclusion: The proposed interventions significantly decreased the incidence of fluid remaining in the IV line before the air detector in the BD Alaris Pump, IV bag, and IV vial, presumably decreasing medication loss.

Background: Enteral vasopressor therapies have been used to facilitate the weaning of intravenous (IV) vasopressors in critically ill patients. Studies have shown mixed results in the medically critically ill population; however, this practice is still common. The use of enteral vasopressors in the acute traumatic spinal cord injury is less well-described. Methods: This was a retrospective review of adult patients at a Level 1 trauma center. Adult patients were included if they were admitted to the trauma and surgical ICU for acute traumatic spinal cord injury; required hemodynamic support for more than 24 hours; and received concomitant administration of IV vasopressor(s) and midodrine. The primary endpoint was overall success in weaning of IV vasopressors and successful weaning at <24 and <48 hours after midodrine initiation. Secondary endpoints were bradycardic events and IV vasopressor-free days in patients with a defined mean arterial pressure (MAP) augmentation duration. Results: Out of 48 patients evaluated, 79.2% successfully weaned off IV vasopressors after the addition of midodrine, with 22.9% and 43.8% discontinuing IV vasopressors at <24 and <48 hours, respectively. Bradycardia occurred in 50% of patients, but only 8.3% required treatment. Among patients with a defined MAP goal duration, midodrine was associated with a median of 3 IV vasopressor-free days (interquartile range: 1-5). Conclusion: Enteral vasopressor therapy with midodrine can be used to facilitate weaning of IV vasopressor therapy in critically ill, acute traumatic spinal cord injury patients. Midodrine may also be beneficial in reducing IV vasopressor days in patients with MAP augmentation. Future prospective studies are needed to confirm this finding.

Purpose: This study examines the correlation between time-in-therapeutic range (TTR) and anticoagulation-related adverse events (AEs) in patients with atrial fibrillation (Afib) in a pharmacist-managed ambulatory care clinic. Methods: A single-center, retrospective cohort study was conducted at a community hospital-based outpatient anticoagulation clinic to investigate the predictive value of suboptimal TTR percentages for hemorrhagic or thromboembolic events in Afib patients. Eligible participants were aged 18 years or older, diagnosed with Afib, and receiving warfarin therapy as current or past enrollees in the anticoagulation management program. Patients seen at the clinic between April 2017 and June 2023 were included and categorized into 2 groups based on their TTR: TTR < 65% or TTR ≥ 65%. The primary outcome assessed was the TTR achieved by clinic patients. Secondary outcomes included the duration of warfarin therapy, percentage of thromboembolic events, percentage of hemorrhagic events, CHADs-VASc score, HAS-BLED score, and reasons documented for suboptimal TTR. Results: A total of 193 patients were included, with an average TTR of 66.17%. Baseline characteristics were similar between groups. Five patients in the TTR < 65% group and 3 in the TTR ≥ 65% group ( P = .391) experienced thromboembolic events; 19 and 15 patients ( P = .291) experienced hemorrhagic events, respectively. Those with TTR ≥ 65% had longer warfarin durations and lower HAS-BLED scores. CHADs-VASc scores were comparable. Main reasons for suboptimal TTR included drug-drug interactions, missed warfarin doses, dietary vitamin K intake changes, held warfarin doses, and incorrect warfarin dosing. Conclusion: This study found that at an outpatient pharmacist-managed anticoagulation clinic, the average TTR for atrial fibrillation patients with an INR goal range of 2 to 3 was greater than 65%. Additionally, there were no differences in bleeding or stroke events for patients whose TTR < 65% when compared to those patients whose TTR was  ≥ 65%.

Background: Fibrinolysis is more commonly used to manage ST-segment elevation myocardial infarction (STEMI) in rural versus urban areas. However, little is known about the outcomes associated with this treatment strategy in rural individuals. We sought to compare in-hospital outcomes associated with the use of fibrinolysis versus primary percutaneous coronary intervention (PCI) among patients residing in rural areas presenting with STEMI. Methods: We identified adult patients with STEMI between 2016 and 2021 using the United States National Inpatient Sample. The cohort was restricted to individuals residing in rural areas. Patients were divided into 2 cohorts based on the receipt of initial fibrinolysis versus primary PCI. In-hospital outcomes were compared between cohorts, with in-hospital mortality serving as the primary outcome and length of stay (LOS) serving as a secondary outcome. Results: We identified 13 475 rural STEMI encounters receiving either initial fibrinolytic therapy (n = 1095) or primary PCI (n = 12 380). The average age and number of comorbidities were similar between cohorts. In-hospital mortality occurred in 5.2% of patients, and mean LOS for initial fibrinolysis and primary PCI patients was 3.73 ± 3.739 days and 3.45 ± 3.974 days, respectively. After adjusting for covariates, initial fibrinolysis was not associated with higher in-hospital mortality (odds ratio [OR] = 0.913; 95% confidence interval [CI] = 0.679-1.228). Initial fibrinolysis was associated with a small increase in LOS compared to primary PCI (Mean difference = 0.079 days; 95%CI = 0.035-0.123). Conclusions: In this analysis of approximately 13 000 STEMI encounters among rural individuals, patient characteristics between those treated with initial fibrinolysis versus primary PCI were similar. Observed outcomes were not meaningfully different between cohorts. Fibrinolytic therapy should not be an overlooked treatment strategy in rural STEMI patients facing delays in receipt of primary PCI.

Background and Aims: The purpose of this study is to review the 2020 Substance Abuse and Mental Health Services Administration Guideline for Opioid Use Disorder recommendations to continue buprenorphine perioperatively by evaluating the total morphine milligram equivalents (MME) requirements in the first 24 hours postoperatively of patients who continued their buprenorphine therapy to those who discontinued their buprenorphine therapy perioperatively. Methods: This IRB approved study is a multicenter retrospective chart review of 80 surgical inpatients on buprenorphine prior to admission at participating sites from January 2015 to October 2022. The primary outcome is MME administered 24 hours postoperatively in patients who continued buprenorphine perioperatively versus those who discontinued buprenorphine perioperatively. Secondary efficacy outcomes included MME administered 48 and 72 hours postoperatively and daily average pain scores. Safety outcomes included rate of respiratory depression and mortality. Findings: Patients who continued buprenorphine perioperatively required significantly less MME in the first 24 hours postoperatively compared to those who discontinued buprenorphine perioperatively (median [IQR]; 23.25 [6-74.35] vs 93.38 [49.8-156.26]; P < .001). Secondary outcomes of MME administered at 48 hours (10.4 [0-40.5] vs 66.15 [27.94-143.5], P < .001) and 72 hours (0 [0-31.13] vs 66 [22.5-144], P < .001) postoperatively were also significantly less in those whose buprenorphine was continued versus those whose buprenorphine was discontinued perioperatively. Patients whose buprenorphine was continued perioperatively experienced significantly lower average pain scores at 48 (median [IQR]; 4.74 [2.9-7.08] vs 6 [4.93-7.4], P = .028) and 72 hours (3.78 [1.78-5.85] vs 5.75 [4.15-7.45], P = .002) postoperatively. Conclusion: Continuation of buprenorphine in the perioperative setting results in significantly lower utilization of MME in patients whose buprenorphine is continued compared to those whose buprenorphine is discontinued perioperatively.

Each month, subscribers to The Formulary Monograph Service receive 5 to 6 well-documented monographs on drugs that are newly released or are in late phase 3 trials. The monographs are targeted to Pharmacy and Therapeutics Committees. Subscribers also receive monthly 1-page summary monographs on agents that are useful for agendas and pharmacy/nursing in-services. A comprehensive target drug utilization evaluation/medication use evaluation (DUE/MUE) is also provided each month. With a subscription, the monographs are available online to subscribers. Monographs can be customized to meet the needs of a facility. Through the cooperation of The Formulary, Hospital Pharmacy publishes selected reviews in this column. For more information about The Formulary Monograph Service, contact Wolters Kluwer customer service at 866-397-3433.

Background:Patients are at risk of experiencing medication errors during each transition of care (TOC), which can result in adverse drug events and readmissions. Implementing a pharmacist-led TOC service can optimize medication safety and patient outcomes by identifying and correcting medication discrepancies prior to hospital discharge. A pharmacist-led TOC service at a tertiary care center expanded services to review medications at discharge for all enrolled hospitalized patients, but data collection and review had yet to be performed. Objective: The purpose of this study was to evaluate the number of patients with a medication discrepancy identified at hospital discharge in a pharmacist-led TOC service. Methods: This was a single center, retrospective cohort study conducted at a tertiary care facility. Admission medication histories were completed by pharmacists in the emergency department and inpatient units. TOC discharge medication reconciliations were completed by pharmacists prior to hospital discharge. The study included hospitalized adult patients with a pharmacist-completed admission medication history and discharge medication reconciliation between July 1, 2021, to September 30, 2021. Patients readmitted within the study period were included more than once if study criteria were met. Patients who left against medical advice, discharged to hospice, or expired were excluded from the study. Results: A total of 213 patients met inclusion criteria for this study, with 214 patient encounters included in the analysis after accounting for readmissions. More patients had a TOC medication discrepancy identified at discharge when admission medication histories were completed less than or equal to 24 hours after hospital admission versus greater than 24 hours after hospital admission (28.2% vs 23.6%, OR: 1.269, 95% CI: 0.658, 2.448). Fewer patients had a TOC discrepancy at discharge when fewer PTA medications were changed versus more PTA medications were changed during the admission medication history (0-1 medication changes vs ≥10 medication changes: 19% vs 29.4%, OR: 1.780, 95% CI: 0.730, 4.339). Fewer patients had a TOC discrepancy at discharge when admission medication histories were completed in the emergency department versus on the inpatient units (22.4% vs 28.6%, OR: 0.721, 95% CI: 0.366, 1.420). A similar number of patients had a TOC discrepancy at discharge regardless of the number of unit transitions throughout their hospital stay (1-2 transitions vs ≥4 transitions: 25.9% vs 25.5%, OR: 0.977, 95% CI: 0.456, 2.096). Conclusions: One in four patients enrolled in the pharmacist-led TOC service had a medication discrepancy identified at discharge. This was irrespective of when the admission medication history was completed, how many changes were made, or how many times the patient transitioned units. Therefore, medication reconciliation at discharge should be a service provided to all admitted patients.

Background: Utilization of guideline-directed medical therapy in patients hospitalized for acute heart failure is suboptimal during the hospitalization and after discharge. An inpatient heart failure order set may be a convenient and useful intervention to improve heart failure therapy in the inpatient setting. Methods: This is a retrospective study that assessed the use of an inpatient heart failure order set on pharmacologic therapy in patients hospitalized for acute heart failure from May to August 2022. Patients with heart failure with an ejection fraction less than 50% were included in the analysis. The co-primary endpoints were maintenance or optimization of guideline-directed medical therapy during the hospitalization. Results: Maintenance of guideline-directed medical therapy was significantly greater when providers used the heart failure order set (OR 2.35, 95% CI 1.03-5.33, P = .041). Optimization of guideline-directed medical therapy was also statistically greater with use of the order set (OR 11.31, 95% CI 4.37-29.31, P < .001). Conclusions: An inpatient heart failure order set may be an effective strategy to improve heart failure pharmacotherapy in patients hospitalized with acute heart failure.

Purpose. To determine if implementation of an enhanced clinical pharmacy service (ECPS) at a community hospital could improve patient experience as measured by medication-related Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores. Methods. A cohort study of 260 patients at a community hospital was conducted. Patients in the intervention group received additional pharmacy services from the standard of care (SOC) group, including daily medication counseling, pharmacist-driven medication administration, discharge medication reconciliation and education, consistent offers to enroll in a bedside medication delivery program (BMDP), and a telephone call following discharge. The primary outcome of patient experience was assessed through patients’ responses to a care transitions HCAHPS survey question regarding understanding of the purpose of taking medications following discharge. Results. Among patients in the ECPS cohort, 75.8% had a top-box response to the care transitions HCAHPS question, compared to 63.3% of patients in the SOC cohort (OR = 1.81; 95% CI [0.61-5.37]). Top-box responses increased for all assessed HCAHPS questions but were not statistically significant. The HCAHPS survey response rate was 29.3% in the SOC cohort and 29.9% in the ECPS cohort. Conclusion. Following an ECPS intervention, patient experience as determined by HCAHPS scores increased, but the results did not reach statistical significance. Further, larger studies are needed on this topic.

Purpose: The optimal anticoagulation regimen for atrial fibrillation (AF) in critically ill patients is challenging as these patients may be at an increased risk for bleeding and clotting despite an absence or presence of anticoagulation. The purpose of this study was to compare bleeding and thrombotic rates in critically-ill adults with pre-existing AF receiving therapeutic anticoagulation versus chemical or mechanical venous thromboembolism prophylaxis. Methods: A retrospective, observational study was conducted. The primary outcome identified rate of International Society of Thrombosis and Hemostasis bleeding, and secondarily assessed all venous or arterial thromboembolic events. To determine risk-factors associated with bleeding and to account for differences in baseline characteristics, a multivariable logistic regression model was used. Results: A total of 199 patients were included, 100 receiving therapeutic anticoagulation and 99 receiving venous thromboembolism prophylaxis. Patients receiving therapeutic anticoagulation compared to chemical or mechanical prophylaxis had a median (IQR) CHA2DS2VASc score of 4 (3-5) versus 4 (2-5) ( P = .5499) and HAS-BLED score of 3 (3-4) versus 3 (2-4) ( P = .0013); respectively. There was almost a threefold adjusted increased risk of bleeding in patients receiving therapeutic anticoagulation compared to venous thromboembolism prophylaxis (adjusted odds ratio [aOR] 2.7 [95% CI 1.1-9.9]; P = .0349). One stroke occurred in a patient receiving therapeutic anticoagulation, and none occurred in patients in the prophylaxis group ( P = 1.000). Conclusion: Use of therapeutic anticoagulation in critically ill patients with pre-existing AF may increase bleed rates without protecting against stroke development.

Background: Doravirine (DOR) is a non-nucleoside reverse transcriptase inhibitor (NNRTI) approved for use in combination antiretroviral therapy (cART) for treatment of human immunodeficiency virus (HIV) in treatment-naive patients. Doravirine-based regimens are an option for patients with limited alternatives due to drug-drug interactions, toxicities, or resistance. A paucity of data exists for use of two-drug DOR-based regimens in treatment-experienced individuals. Methods: This is a retrospective case series of two treatment-experienced HIV-1 infected patients switched to two-drug doravirine-based regimens. Baseline HIV-RNA and CD4 cell count were measured at the time of switch to the DOR-based regimen. HIV-RNA and CD4 cell count were measured again more than a month after initiating therapy to determine efficacy of the DOR-based regimens. Results: Patient 1 was transitioned to once daily DOR and darunavir with cobicistat (DRV/c). The baseline HIV-RNA was 370,070 copies/mL and CD4 cell count was 196 cells/mm3. After 2 years of treatment, the viral load was less than 30 copies/mL and the CD4 cell count was 239 cells/mm3. Patient 2 was transitioned to once daily DOR and dolutegravir (DTG). The baseline HIV-RNA was <30 copies/mL and CD4 cell count was 229 cells/mm3. After 11 months of therapy, the patient’s HIV viral load remained <30 copies/mL and the CD4 cell count was stable at 236 cells/mm3. Conclusions: Two-drug cART including DOR appears to be an acceptable option for patients who may be limited to alternative ART regimens due to drug-drug interactions, resistance mutations, or toxicities. Additional evidence from case reports or clinical trials are needed to further evaluate the long-term efficacy and safety of DOR as part of a two-drug cART regimen.