Lama Nazer

A Formal Mentorship Program for Faculty Development

Objective. To describe the development, implementation, and evaluation of a formal mentorship program at a college of pharmacy. Methods. After extensive review of the mentorship literature within the health sciences, a formal mentorship program was developed between 2006 and 2008 to support and facilitate faculty development. The voluntary program was implemented after mentors received training, and mentors and protégés were matched and received an orientation. Evaluation consisted of conducting annual surveys and focus groups with mentors and protégés. Results. Fifty-one mentor-protégé pairs were formed from 2009 to 2012. A large majority of the mentors (82.8%-96.9%) were satisfied with the mentorship program and its procedures. The majority of the protégés (≥70%) were satisfied with the mentorship program, mentor-protégé relationship, and program logistics. Both mentors and protégés reported that the protégés most needed guidance on time management, prioritization, and work-life balance. While there were no significant improvements in the proteges’ number of grant submissions, retention rates, or success in promotion/tenure, the total number of peer-reviewed publications by junior faculty members was significantly higher after program implementation (mean of 7 per year vs 21 per year, p=0.03) in the college’s pharmacy practice and administration department. Conclusions. A formal mentorship program was successful as measured by self-reported assessments of mentors and protégés.

Predictors of ICU Admission in Patients with Cancer and the Related Characteristics and Outcomes: A 5-Year Registry-Based Study

Objective:To identify factors predictive of admission of patients with cancer to an ICU. In addition, the study aimed to describe the characteristics and outcomes, both short-term and long-term, of patients with cancer admitted to the ICU. Design:Retrospective case-control study, utilizing the institution’s cancer registry. Setting:Comprehensive cancer center. Patients:Patients with cancer. The case group consisted of patients who required ICU admission during the study period, whereas the control group consisted of patients who did not require ICU admission. Intervention:None. Measurements and Main Results:The patient characteristics and outcomes were recorded. Univariate and multivariate analyses were conducted to determine factors associated with ICU admission. The registry included 10,792 patients, and among those, 2,439 patients (22.6%) required ICU admission after a median of 10.1 months (interquartile range, 3.28–25.2). The following factors were associated with ICU admission: hematologic malignancy (odds ratio, 1.51; 95% CI, 1.26–1.81), chemotherapy (odds ratio, 1.74; 95% CI, 1.48–2.03), advanced cancer (odds ratio, 2.57; 95% CI, 1.44–4.60), and smoking (odds ratio, 1.38; 95% CI, 1.20–1.61). The most common ICU admission diagnoses were sepsis (21.5%) and respiratory insufficiency/failure (25.7%). The ICU mortality was 36.5%, whereas the 1-year and 5-year survival rates were 22.8% and 14.2%, respectively. Conclusion:In a comprehensive cancer center, about one fourth of the patients required ICU admission. Addressing modifiable risk factors associated with ICU admission is essential to potentially reduce ICU admissions and improve long-term survival.

Adverse Drug Events in Critically Ill Patients With Cancer Incidence, Characteristics, and Outcomes

Objective: To determine the incidence, characteristics, and outcomes of adverse drug events (ADEs) in critically ill patients with cancer. Methods: This was a 5-month prospective observational study. Patients who were admitted to the adult medical/surgical oncology intensive care unit (ICU) were evaluated for any drug-related adverse events during their ICU stay. An ADE was defined as injury or patient harm resulting from medical intervention related to a drug. Results: The incidence rate of ADEs was 96.5 per 1000 patient days and 35.3 per 100 ICU admissions. Of the reported ADEs, 57 (64.8%) were serious/life threatening, 30 (34.1%) were significant, 1 (1.1%) was fatal, and 14 (15.9%) of all ADEs were considered preventable. The most common drug classes associated with ADEs were antidiabetics, antibiotics, and analgesics/sedatives. The length of stay and presence of renal or respiratory failure were significantly associated with an increased number of ADEs. The length of stay and female sex were significantly associated with the likelihood of developing an ADE. Conclusion: Critically ill patients with cancer are at high risk of developing ADEs. Strategies that reduce the incidence and severity of ADEs are essential to improve the outcomes of this patient population.

Rifampicin as Adjunct to Colistin Therapy in the Treatment of Multidrug-Resistant Acinetobacter baumannii

Objective: To evaluate the available evidence regarding the efficacy and safety of rifampicin, as adjunct to colistin, in the treatment of multidrug resistant Acinetobacter baumannii (MDR-AB). Data Sources: We searched MEDLINE (1966 to January 2014) using the following search terms: A baumannii, drug resistance, treatment, colistin, and rifampicin and combinations. In addition, the bibliographies of relevant articles were searched for additional citations. Study Selection and Data Extraction: The search was limited to English-language references and adults. Studies in which colistin was not administered intravenously were excluded. In addition, we excluded meeting abstracts and single case reports. Data Synthesis: The search strategy identified 5 observational studies and 2 randomized controlled trials that evaluated the combination of intravenous colistin and rifampicin for the treatment of MDR-AB. All observational studies included a small sample size, and the microbiological clearance associated with the combination therapy ranged from 60% to 100%. The randomized controlled trials reported reduced time to microbiological clearance and higher microbiological eradication rate in the colistin/rifampicin group compared with colistin alone. However, there was no difference between both groups in the overall mortality, infection-related mortality, and the length of stay. Furthermore, rifampicin was associated with a higher incidence of hepatotoxicity. Conclusions: Studies evaluating the combination of rifampicin and colistin in the treatment of MDR-AB are limited. The currently available evidence does not support the addition of rifampicin to colistin because of the lack of improved clinical outcomes with the combination therapy and the risk of rifampicin-induced hepatotoxicity.

Adverse drug events resulting in admission to the intensive care unit in oncology patients: Incidence, characteristics and associated cost

Purpose: Describe the incidence, characteristics and cost of adverse drug events that necessitate admission to the intensive care unit in oncology patients. Methods: This was a prospective observational 5-months study at a medical/surgical intensive care unit of a comprehensive teaching cancer center. Patients admitted to the intensive care unit were screened to determine whether the admission was due to an adverse drug event. The adverse drug events were characterized based on the suspected medication, system involved and preventability. Patient demographics, length of stay, mortality and the total patient charges during their intensive care unit stay were recorded. Results: During the study period, 249 patients were screened and an adverse drug event was the primary cause of 57 (22.9%) admissions. The most common medications associated with an adverse drug event requiring intensive care unit admission were antineoplastics (n = 37), analgesics (n = 9) and anticoagulants (n = 4). Ten adverse drug events were considered preventable. The average length of stay for patients with adverse drug events resulting in intensive care unit admission was 6.2 days ±9.8 (SD) and the mortality rate was 28.1%. Hematological malignancy was independently associated with adverse drug events resulting in intensive care unit admission. The average patient charges for the intensive care unit stay was US

Fatal agranulocytosis associated with psychotropic medication use

11,692 ± 17,529 (SD), which corresponded to about US

Vancomycin pharmacokinetics and predicted dosage requirements in pediatric cancer patients

1.5 million in annual patient charges for a 12-bed intensive care unit at a cancer institution. Conclusions: Adverse drug events resulting in intensive care unit admission in oncology patients are common and often associated with significant morbidity, mortality, and cost.

Characteristics and Outcomes of Acinetobacter baumannii Infections in Critically Ill Patients with Cancer: A Matched Case-Control Study

PURPOSE A patients death due to severe hematologic adverse effects of the concomitant use of four psychotropic medications is reported. SUMMARY A 40-year-old Caucasian woman with a 9-year history of depression and anxiety (managed with alprazolam) was admitted to a psychiatric hospital for the treatment of acute psychotic symptoms. After nine days, the patient was discharged home on a regimen of lamotrigine, mirtazapine, quetiapine, and venlafaxine. Five weeks later, the development of severe ocular cellulitis, severe oral thrush, and febrile neutropenia necessitated the womans urgent rehospitalization; on admission, her white blood cell count was 600 cells/mm(3), her absolute neutrophil count was 18 cells/mm(3), and microbial pathogens were isolated in peripheral blood and tracheal aspirate cultures. Despite treatment with antibiotics and filgrastim, the patient developed multiorgan dysfunction and died five days later from septic shock. The womans concomitant use of multiple psychotropics and the late recognition of drug-induced agranulocytosis likely contributed to her severe symptoms and ultimate death. The application of the Naranjo scale to this case yielded a score of 6, indicating a probable adverse drug reaction. Although hematologic adverse effects have been reported with the use of each of the four drugs implicated in the womans death, this is thought to be the first report of fatal agranulocytosis associated with any of the drugs. CONCLUSION A 40-year old woman with a history of acute psychotic symptoms developed agranulocytosis and neutropenia after starting therapy that included lamotrigine, mirtazapine, quetiapine, and venlafaxine.

High-dose colistin for microbiologically documented serious respiratory infections associated with carbapenem-resistant Acinetobacter baummannii in critically ill cancer patients: a retrospective cohort study

Purpose To determine the pharmacokinetic parameters and compare pharmacodynamic target attainment at different dosing strategies of vancomycin in pediatric cancer patients. Methods Pediatric patients who received vancomycin and had at least two steady-state concentrations taken within the same dosing interval were identified. Vancomycin minimum inhibitory concentrations (MICs) for methicillin resistant staphylococcus aureus (MRSA) isolates from our institution were determined using E-test. The population-based pharmacokinetic modeling was performed using NONMEM 7.2. A one-compartment model with first-order kinetics was used to estimate clearance (CL) and volume of distribution (Vd). Monte Carlo simulations (N = 9800) were performed to compare area-under-the-curve over 24 h (AUC24)/MIC and trough concentration at different doses. Results Forty-nine patients, with 120 vancomcyin serum concentrations, were included in the analysis, mean age was 6 ± 2.5 (SD) years, mean weight was 19.6 ± 6.9(SD) kg, mean baseline serum creatinine was 0.4 ± 0.11(SD) mg/dl, and mean initial vancomycin dose was 205 mg/day (range 100–460). Final model pharmacokinetic parameters were: CL (L/h) = 0.381 × weight0.75 and Vd (L) = 0.663 × weight. Mean baseline (±SD) vancomycin CL was 0.20 ± 0.07 L/h/kg and Vd 0.66 ± 0.001 L/kg. . Renal function, sex, age, stay in the intensive care unit, and co-administration of nephrotoxic medications did not have an effect on the calculated parameters. Using Monte Carlo simulation with reported MICs, a dose of 60 mg/kg/day achieved AUC24/MIC ≥400 and trough concentration ≥15 mcg/mL in only 21.5% and 11% of virtual subjects, respectively. Conclusions Higher than usual vancomycin doses may be required to treat serious MRSA infections in pediatric patients. The currently recommended dose of 60 mg/kg/day is unlikely to achieve the targets in most subjects. The optimal vancomycin dosing in pediatric cancer patients requires further investigations.

Augmented Renal Clearance Using Population-based Pharmacokinetic Modeling in Critically Ill Pediatric Patients*

AIM To describe the characteristics and outcomes of Acinetobacter baumannii (AB) infections in critically ill cancer patients and to evaluate the impact of AB on mortality and length of stay (LOS). RESULTS In a 4-year case-control study of critically ill cancer patients, we identified 161 patients with AB infections and 232 matched patients who were treated in the intensive care unit (ICU) during the same time period, but had no AB cultures. The case and control groups were matched for APACHE II, age, gender, type of malignancy, and mechanical ventilation. Most AB isolates were carbapenem-resistant (n=142, 88.2%). The majority of positive cultures were collected from the respiratory tract (58%) and blood (21.8%). The median ICU LOS and mortality rate for patients with AB infections were higher than those for the control group (12 days [IQR 6-23] vs. 3 days [IQR 1-7], p<0.0001 and 73.3% vs. 61.5%, p=0.015, respectively). AB infection was independently associated with ICU LOS and mortality: OR 1.108 (95% CI, 1.077-1.139), OR 1.658 (95% CI, 1.017-2.703), respectively. CONCLUSION AB infections in critically ill cancer patients were independently associated with increased mortality and increased ICU LOS. Measures to improve the outcomes of critically ill cancer patients infected with AB are necessary.