Lindsay E. Davis

Proton Pump Inhibitors and the Risk for Hospital-Acquired Clostridium difficile Infection.

OBJECTIVE To examine the relationship between proton pump inhibitor (PPI) usage and nosocomial Clostridium difficile infection (CDI) and determine the duration of therapy at which CDI risk increases. PATIENTS AND METHODS This retrospective case-control study included consecutive adult patients in whom nosocomial CDI developed after hospitalization for 3 or more days at one of 2 affiliated hospitals between June 1, 2010, and October 31, 2011. These patients were matched to patients hospitalized within 6 months who did not have CDI development in a 1:2 ratio using age, sex, and antibiotic usage. Potential risk factors for CDI, including PPI use and duration, were evaluated. Multivariate analysis was performed to control for confounding variables and identify risk factors. RESULTS A total of 201 patients were evaluated, 67 with CDI and 134 matched controls. Patients in whom CDI developed were more likely to have received a PPI (76% vs 39%; P<.001) and had a longer duration of PPI therapy (median [range], 5 [0-20] days vs 0 [0-11] days; P<.001) than those who did not have CDI development. After controlling for prior hospital admission, intensive care unit admission, admission from a skilled nursing facility, immunosuppression, number of antibiotics received, PPI duration, and time to event via multivariate analysis, PPI duration was found to be a risk factor for CDI (odds ratio, 1.14; 95% CI, 1.02-1.27; P=.018). The probability for CDI was higher when PPI use exceeded 2 days in patients without a prior hospital admission and 1 day in patients with a prior admission. CONCLUSION The duration of PPI therapy is significantly associated with CDI. Clinicians should strongly consider restricting PPI use given the short exposure time associated with this increased risk.

High-fidelity simulation for advanced cardiac life support training.

Objective. To determine whether a high-fidelity simulation technique compared with lecture would produce greater improvement in advanced cardiac life support (ACLS) knowledge, confidence, and overall satisfaction with the training method. Design. This sequential, parallel-group, crossover trial randomized students into 2 groups distinguished by the sequence of teaching technique delivered for ACLS instruction (ie, classroom lecture vs high-fidelity simulation exercise). Assessment. Test scores on a written examination administered at baseline and after each teaching technique improved significantly from baseline in all groups but were highest when lecture was followed by simulation. Simulation was associated with a greater degree of overall student satisfaction compared with lecture. Participation in a simulation exercise did not improve pharmacy students’ knowledge of ACLS more than attending a lecture, but it was associated with improved student confidence in skills and satisfaction with learning and application. Conclusions. College curricula should incorporate simulation to complement but not replace lecture for ACLS education.

Key Articles and Guidelines in the Primary Prevention of Ischemic Stroke

Ischemic stroke is a prevalent disease with a large burden on the health system. Preventive strategies, therefore, are paramount. Primary prevention is aimed at reducing the risk of stroke in asymptomatic people. The most effective prevention is through control of modifiable risk factors. Due to the large amount of literature available on this topic, this bibliography (the first of a 2‐part series) aims to provide a comprehensive resource for medical practitioners charged with caring for this population.

Real-world use of PCSK-9 inhibitors by early adopters: cardiovascular risk factors, statin co-treatment, and short-term adherence in routine clinical practice

Background Inconsistency of real-world medication use with labeled indications may affect cost and clinical value of pharmacotherapy. PCSK-9 inhibitors are labeled in the US for use with statins to reduce low-density lipoprotein cholesterol in patients with atherosclerotic cardiovascular disease (ASCVD) or familial hypercholesterolemia (FH). Objective To assess consistency with labeled indications and treatment persistency for early (first 5 post-launch months) adopters of PCSK-9 inhibitor pharmacotherapy. Methods Retrospective analysis of commercially insured cohorts derived from the Truven Health MarketScan® database was performed. Subjects were aged 18–64 years, initiated PCSK-9 inhibitor or highest-intensity statin (rosuvastatin 40 mg/day or atorvastatin 80 mg/day) pharmacotherapy from August to December 2015, and were enrolled throughout 2015 and during separate baseline (pre-treatment) periods of 6 and 18 months. Baseline ASCVD, FH, and ASCVD events (myocardial infarction, transient ischemic attack, and cerebrovascular occlusion) were measured. Persistency was measured through December 2015 for subcohorts of patients initiating treatment from August to September 2015. Results Baseline disease rates were higher for patients treated with PCSK-9 inhibitors (n=390) compared with highest-intensity statins (n=26,306): ASCVD (68.5% vs 33.4%, respectively); FH (39.7% vs 15.5%); both P<0.001. In 18 months pre-treatment, 35.6% of PCSK-9 inhibitor-treated patients had ≥1 ASCVD event, and 87.9% had a labeled indication. Rates of 60-day nonpersistency for PCSK-9 inhibitors and highest-intensity statins were 33.3% and 39.8%, respectively (P=0.207). During PCSK-9 inhibitor pharmacotherapy, 33.8% of patients had evidence of statin supply and, of those initiating treatment from August to September, 40.9% filled ≥1 statin prescription. Of those with sustained pre-treatment statin use, 34.8% had no statin supply during PCSK-9 inhibitor pharmacotherapy. Conclusion Among early-adopting PCSK-9 inhibitor-treated patients, the off-label diagnosis rate was 12%; a majority lacked statin co-treatment; and one third filled prescriptions for ≤60 days. Inconsistency with labeled uses may reflect prescriber/patient decisions, health-insurance coverage determinations, or statin intolerance not reported on claims.

Constructive ways to prevent, identify, and remediate deficiencies of “challenging trainees” in experiential education

The practice of pharmacy is highly influenced by the training pharmacy clinicians receive through experiential education (EE) programs, for it is within this “total practice immersion” that their skills are shaped, honed, and refined.[1][1] However, not all rotation experiences are positive for

A Workshop Series Using Peer-grading to Build Drug Information, Writing, Critical-thinking, and Constructive Feedback Skills

Objective. To utilize a skills-based workshop series to develop pharmacy students’ drug information, writing, critical-thinking, and evaluation skills during the final didactic year of training. Design. A workshop series was implemented to focus on written (researched) responses to drug information questions. These workshops used blinded peer-grading to facilitate timely feedback and strengthen assessment skills. Each workshop was aligned to the didactic coursework content to complement and extend learning, while bridging and advancing research, writing, and critical thinking skills. Assessment. Attainment of knowledge and skills was assessed by rubric-facilitated peer grades, faculty member grading, peer critique, and faculty member-guided discussion of drug information responses. Annual instructor and course evaluations consistently revealed favorable student feedback regarding workshop value. Conclusion. A drug information workshop series using peer-grading as the primary assessment tool was successfully implemented and was well received by pharmacy students.

A Pilot Study on an Interprofessional Course Involving Pharmacy and Dental Students in a Dental Clinic

Objective. To assess the effect of a dental clinical rotation program involving pharmacy students and dental students. Methods. An interprofessional education (IPE) course was offered as an elective to second-year pharmacy students and required for third-year dental students. The course included two in-class sessions, one online lecture, and five clinic sessions. Program evaluation analyses included a comparison of participating versus nonparticipating students on a knowledge survey of pharmacotherapy and IPE, and a descriptive analysis of IPE course evaluation results. Results. Among pharmacy students, mean scores were significantly higher for participants than nonparticipants on the 31-item pharmacy knowledge component of the survey. On the eight-item IPE component of the survey, scores were significantly higher for participants than for nonparticipants, both among pharmacy students and among dental students. Awareness and attitudes about IPE were generally high among course participants. Conclusion. An IPE course that integrates second-year pharmacy students with third-year dental students in the dental clinic to provide medication history, education, and identification of potential drug-related problems improved pharmacy students’ knowledge of pharmacotherapy related to or associated with dental conditions and improved pharmacy and dental students’ knowledge and attitudes about IPE.