Alex N. Isaacs

Association between application scores and positive onsite interviews of pharmacy residency applicants

Application to pharmacy residency programs has become increasingly competitive over the past several years. Although successful candidates must excel in the various stages of the application process, preparing written applications and securing onsite interviews are early and arguably the most

Antihypertensive therapy for the prevention of nephropathy in diabetic hypertensive patients.

Although antihypertensive recommendations exist for diabetic nephropathy, there is less guidance for diabetics with normoalbuminuria. Therefore, this review evaluates antihypertensives in preventing nephropathy in diabetic hypertensive patients.

Continuous Infusion Ketorolac for Postoperative Analgesia Following Unilateral Total Knee Arthroplasty

Background: Previous clinical trials have demonstrated benefit with the addition of continuous infusion (CI) ketorolac to a multimodal pain regimen in surgical patients. Data following major orthopedic surgery are minimal and conflicting. Objectives: To evaluate CI ketorolac use following unilateral total knee arthroplasty (TKA) through assessment of patient-reported pain scores, opioid consumption, and safety outcomes. Methods: This was a retrospective, open-label cohort study that included patients undergoing unilateral TKA at a single-center teaching hospital. Participants were categorized into 2 study groups based on postoperative management: CI ketorolac or opioid protocol (OP). The first group received a ketorolac 30-mg bolus followed by CI 3.6 mg/h plus as-needed (PRN) opioids. The OP group received PRN narcotics in a tiered protocol. The primary end point was comparison of median pain scores. Secondary end points included opioid consumption (morphine equivalent units [MEUs]) in the first 48 hours postoperatively, length of stay, and adverse effects. Results: Of 447 patients screened, 191 were analyzed (CI ketorolac, n = 116; OP, n = 75). Median pain scores were significantly lower in the CI ketorolac group at 48 hours postoperatively (3 [2-4] vs 3.5 [2.5-5], P = 0.033). Cumulative MEUs at 48 hours were significantly lower in the CI ketorolac group (33.9 ± 38.5 mg vs 301.6 ± 36.6 mg, P < 0.001). Patients in the CI ketorolac group experienced less respiratory depression (5.2% vs 25.3%, P < 0.001) and less naloxone administration (0% vs 8%, P = 0.002) compared with the OP group. Other adverse effects were similar among groups. Conclusions: Postoperative CI ketorolac improved pain control while reducing opioid consumption and adverse effects.

Medication utilization evaluation of dabigatran and rivaroxaban within a large, multi-center health system

OBJECTIVE The objective of this medication utilization evaluation (MUE) was to determine the appropriateness of dabigatran and rivaroxaban while also reviewing outcomes for safety and effectiveness within a large, multi-center health system. METHODS A retrospective chart review was performed using the systems electronic medical record. A data inquiry was requested and generated for dabigatran usage from July 28, 2011 through July 28, 2012 and for rivaroxaban from March 1, 2012 to July 31, 2012 at eight health system hospitals. All patients receiving at least one dose were eligible for inclusion in the MUE. RESULTS For dabigatran, 78 of 390 unique patient encounters were analyzed (20%). All 62 rivaroxaban encounters were included in the analysis. Dabigatran was used for appropriate indications in 94% of encounters and 82% for rivaroxaban. Based on indication and renal function, 87% of dabigatran patients and 92% of rivaroxaban patients received correct dosing. For patients transitioning to or from another anticoagulant, appropriate transitions occurred in 44% of dabigatran transitions and 48% of rivaroxaban transitions. At discharge, 83% of dabigatran and 86% of rivaroxaban therapy was continued. There were no reported strokes or systemic embolism with dabigatran, but one reported deep vein thrombosis occurred during hospitalization with rivaroxaban therapy. Documented bleeds in 5% of dabigatran and 3% of rivaroxaban patients. Patient education was documented for 37% of dabigatran and 26% of rivaroxaban patients receiving therapeutic anticoagulation. CONCLUSION This MUE revealed the appropriate use of dabigatran and rivaroxaban therapy with few safety outcomes within a large, multi-center health system.

Interactive Web-based Learning Modules Prior to General Medicine Advanced Pharmacy Practice Experiences

Objective. To implement and evaluate interactive web-based learning modules prior to advanced pharmacy practice experiences (APPEs) on inpatient general medicine. Design. Three clinical web-based learning modules were developed for use prior to APPEs in 4 health care systems. The aim of the interactive modules was to strengthen baseline clinical knowledge before the APPE to enable the application of learned material through the delivery of patient care. Assessment. For the primary endpoint, postassessment scores increased overall and for each individual module compared to preassessment scores. Postassessment scores were similar among the health care systems. The survey demonstrated positive student perceptions of this learning experience. Conclusion. Prior to inpatient general medicine APPEs, web-based learning enabled the standardization and assessment of baseline student knowledge across 4 health care systems.

Evaluation of adherence and persistence with oral versus long-acting injectable antipsychotics in patients with early psychosis

Introduction: Despite the theory that long-acting injectable (LAI) antipsychotics should be more likely to improve adherence, reduce gaps in therapy, and prevent relapse compared with oral antipsychotics, there is little published evidence on this issue, specifically in patients with early psychosis. Methods: Patients with a new diagnosis for a psychotic disorder between July 1, 2013, and August 31, 2014, were retrospectively evaluated during a 12-month duration. The primary outcomes were adherence and persistence. Adherence was determined by proportion of days with medication, and persistence was defined as zero gaps in medication therapy. The secondary outcome was the number of times a psychiatric acute care service was used. Patients were divided into 3 groups based on their antipsychotic prescription history: oral only, LAI only, or both formulations at separate times throughout the study period. Results: Forty-seven patients met inclusion criteria. The average proportions of days with medication were 32%, 76%, and 75% for the oral, LAI, and both formulations groups, respectively (P < .001). For medication persistence, there were 32 patients (91%), 3 patients (75%), and 5 patients (63%) with at least 1 gap in therapy for the oral, LAI, and both formulations groups, respectively (P = .098). For acute care services, there was a median number of zero acute care visits for each of the 3 groups (P = .179). A post hoc subgroup analysis found medication adherence to be statistically different between the oral and LAI groups. Discussion: Long-acting injectable antipsychotics were associated with better adherence compared with oral antipsychotics in patients with early psychosis.

Continuous Infusion Nonsteroidal Anti-Inflammatory Drugs for Perioperative Pain Management:

Purpose: To review the use of continuous infusion (CI) nonsteroidal anti-inflammatory drugs (NSAIDs) as an alternative modality for pain control in surgical patient populations. Methods: A PubMed and MEDLINE search was conducted from 1964 through February 2016 using the following search terms alone or in combinations: continuous, infusion, nonsteroidal anti-inflammatory drug, diclofenac, ibuprofen, indomethacin, ketoprofen, ketorolac, and surgery. All English-language, prospective and retrospective, adult and pediatric studies evaluating intravenous or intramuscular CI NSAIDs for surgical pain were evaluated for inclusion in this review. Results: Twenty four prospective and retrospective publications evaluating CI NSAIDs were identified: 12 in abdominal surgery, 7 in orthopedic surgery, and 5 in pediatric surgery. Specific CI NSAIDs utilized included diclofenac, indomethacin, ketoprofen, and ketorolac. Most studies compared the CI NSAID to placebo or an alternative analgesic and evaluated pain control, supplemental opioid use, and related adverse effects. In these surgical populations, CI NSAIDs decreased opioid consumption, alongside provision of adequate pain control. While long-term adverse effects were rarely collected, a decrease in nausea and sedation was often seen with the CI NSAID groups. Conclusions: In the abdominal, orthopedic, and pediatric surgical populations, CI NSAIDs represent a feasible alternative modality for perioperative pain control.

Student-generated e-learning for clinical education.

Within clinical education, e‐learning facilitates a standardised learning experience to augment the clinical experience while enabling learner and teacher flexibility. With the shift of students from consumers to creators, student‐generated content is expanding within higher education; however, there is sparse literature evaluating the impact of student‐developed e‐learning within clinical education. The aim of this study was to implement and evaluate a student‐developed e‐learning clinical module series within ambulatory care clinical pharmacy experiences.

Analysis of a Standardized Perioperative Pain Management Order Set in Highly Opioid-Tolerant Patients.

Supplemental digital content is available in the text. Objective The aim was to assess a standardized order set for perioperative pain management in highly opioid-tolerant patients undergoing elective orthopedic surgery. Methods This retrospective chart review evaluated a pain order set in highly opioid-tolerant patients undergoing elective total knee or total hip arthroplasty from January 2010 through August 2012. Based on the date of the surgery, patients were allocated into preimplementation or postimplementation order set groups. The primary outcome assessed whether an adjustment in daily opioid dosage was required within the first 48 hours postoperatively. Secondary outcomes included pain scores, length of hospitalization, and safety outcomes. Results Sixty patients were included in the analysis. An adjustment to postoperative opioid therapy occurred in 62% of the patients in the preimplementation group and in 56% of postimplementation group patients (P = 0.786). There were no differences in median pain scores 48 hours postoperatively (P = 0.348). Cumulative toxicity was increased after order set implementation compared with previous patients (44% versus 5%, P < 0.005); however, opioid doses held for sedation was the only individual toxicity to reach statistical significance (P = 0.011). Conclusions This study is the first to evaluate a standardized order set for pain management in highly opioid-tolerant patients undergoing elective orthopedic surgery. The order set demonstrated similar efficacy to previous treatment modalities, but opioid-induced sedation was of concern with the order set. After the initial analysis, the order set was modified to minimize opioid-induced sedation. Continual safety analysis is warranted for quality improvement to enhance perioperative pain management in highly opioid-tolerant patients.