Objective:The objective of this study was to evaluate the impact of pharmacist’s intervention on annual comprehensive medication review (Annual CMR) for Medicare Part D beneficiaries. Background: To develop a new approach to assess Medicare Part D Annual CMR using a technological tool. Methods: One hundred sixty-three (163) eligible Medicare Part D beneficiaries were enrolled. By using an Electronic Health Record (EHR) Program, the pharmacist was able to assess laboratory, pharmacy, diagnosis, and patient information. A post-medication review summary was provided to the medical providers and patients which included a medication action plan. At the end of 3 months, 6 months and 12 months after the medication review, data were collected, assessed and compared. Results: The study showed that pharmacist’s interventions were recommended to seventy-four (74) enrollees which comprised of 45% of the total enrollees. It showed that at 3-month, 6-month, and 12-month intervals after the medication review, the recommended interventions acknowledged and implemented by the medical providers were 20%, 51% and 64% respectively, which showed a significant difference over a 12-month period (P-value <.05). Different types of pharmacist’s interventions that were recommended may include to initiate, to adjust and to discontinue medication. The most common disease states that required interventions were psychiatric disorder, cardiovascular disease, pulmonary disease, gastrointestinal disease, diabetes, dyslipidemia and pain. Conclusion: The finding of this study revealed that such a web-based EHR system was a very meaningful and effective tool in assisting pharmacists to assess the proper and safe use of medication in elderly patients.

Purpose We report a probable case of morbilliform drug eruption secondary to fidaxomicin in a patient with Clostridioides difficile infection (CDI). Summary: A 62-year-old female presented to our institution’s emergency department (ED) with symptoms consistent with Clostridioides difficile infection. The patient was prescribed 2 weeks of oral vancomycin for CDI prior to presentation. Given insufficient response to vancomycin, the patient was started on fidaxomicin with a planned 10-day course. After 2 doses of fidaxomicin, the patient developed a rash on her back that spread within 24 hours. The patient did not experience relief upon administration of a variety of medications for allergic reaction. Improvement was noted upon discontinuation of fidaxomicin. The Food and Drug Administration reports that < 2% of adults treated with fidaxomicin experience a rash as an adverse effect. Conclusion: Fidaxomicin was a probable cause of morbilliform drug eruption in our patient with CDI. The patient improved upon discontinuation of fidaxomicin.

Objective: Examine the impact of a primary care-embedded clinical pharmacist-led intervention (UCMyRx) on hemoglobin A1C and blood pressure control, relative to usual care, among patients with Type 2 diabetes (TD2) and Medicaid, in a large healthcare system. Methods: We used data extracted from the Electronic Health Records system and a Difference-In-Differences study design with a 2:1 propensity-matched comparison group to evaluate the impact of UCMyRx on HbA1c and systolic blood pressure among patients with TD2 and Medicaid, relative to usual care. Results: Having at least one UCMyRx clinical pharmacist visit was associated with a significant reduction in HbA1c; (−.27%, P-value= .03) but no impact on SBP. We do not find differential UCMyRx effects on HbA1c or SBP among the subpopulations with baseline HbA1C ≥9% or SBP ≥150 mmHg, respectively. In Charlson Comorbidity Index (CCI)-stratified analyses we found stronger UCMyRx effects on HbA1C (−.47%, P-value< .02) among the CCI tercile with the lowest comorbidity score (CC1 ≤ 5). Significant UCMyRx effects are only observed among the subpopulation of Medicaid beneficiaries without Medicare (−.35%, P-value= .02). Conclusions: The UCMyRx intervention is a useful strategy for improving HbA1c control among patients with TD2 and Medicaid.

Introduction: Previous literature showed an association between hyperthermia and dexmedetomidine (DEX) use for ongoing sedation in non-obese patients. The purpose of this study is to evaluate DEX’s effect on temperature in obese critically ill patients. Methods: This single center, retrospective, cohort study included patients ≥18 years, admitted to a surgical or medical ICU, received DEX for ≥8 hours as a single continuous infusion sedative, and weighed ≥120% of ideal body weight. Patients were excluded if they had a fever (≥38°C) and positive cultures within 48 hours of DEX initiation. The primary endpoint was a fever (Tmax of ≥38°C) within 48 hours of DEX initiation. Results: A total of 186 patients were included for evaluation. Forty-two patients (22.5%) had a fever during the first 48 hours of DEX initiation. Median weight was not different between the febrile and afebrile groups (99.4 [90.6-122.4] vs 97.6 [81.6-114.2] kg, P = .6). Median change from baseline temperature for all patients within 48 hours was an increase of .5 (.1-.8) °C, P < .001. In multiple regression analysis, duration of DEX and baseline temperature were the only significant predictors of fever development with an adjusted odds ratio of 1.041 (95% CI 1.009-1.074, P = .012) and 7.058 (95% CI 3.307-15.064, P < .001), respectively. Conclusions: This study suggests that there is a significant increase in body temperature from baseline for obese patients on DEX. Duration of DEX and baseline temperature were found to be risk factors for fever development in this population. Further studies are warranted.

Introduction: Calciphylaxis is a lethal and rare disease characterized by ischemic and necrotic skin lesions caused by vascular calcification of adipose tissue. There have been many risk factors analyzed in the literature; however, the pathogenesis of calciphylaxis is still not well understood and treatment options are limited due to the lack of interventional studies. Our objectives were to describe risk factors, prevalence, incidence, and outcomes for calciphylaxis in hemodialysis patients within the Fraser Health Renal Program. Methods: This was a retrospective matched case-control study of hemodialysis patients within the Fraser Health Renal Program. Hemodialysis patients with calciphylaxis were matched to hemodialysis patients without calciphylaxis in a 1:2 ratio for age and sex from September 2, 2017 to July 3, 2020. Findings: There was a total of 40 calciphylaxis cases matched to 80 controls. In the univariate analysis, peritoneal dialysis, higher body mass index, lower serum iron, lower transferrin saturation, sevelamer, cinacalcet, warfarin, iron (PO), and insulin were associated with increased risk of calciphylaxis. In the multivariate analysis, only peritoneal dialysis, serum iron, sevelamer, and warfarin were identified as significant and strong risk factors associated with calciphylaxis. A low prevalence of 1.9% and high mortality rate of 57.5% at 12 months was found for calciphylaxis cases. Discussion: Significant risk factors associated with calciphylaxis were peritoneal dialysis, serum iron, sevelamer, and warfarin. Future studies should further investigate the impact of minimizing exposure to these risk factors to reduce calciphylaxis development.

Purpose: To determine the impact of a business intelligence dashboard tool to optimize automated dispensing cabinets (ADCs). Methods: A pre-post implementation design was used to evaluate key performance indicators (KPI) before and after the implementation of a dashboard tool to optimize ADCs. Eleven ADCs were optimized in 2 phases according to dashboard recommendations: (1) removal of unused medications over 90 days, (2) adjusting periodic automatic replenishment (PAR) levels, and (3) addition of commonly dispensed medications. The KPI measures that were assessed included inventory cost, no. of stocked medications, stockout percentage, vend to refill ratio, and missing dose messages from nursing. An interrupted-time-series regression was used to quantify the impact of ADCs on the means of measured KPIs. Results: Differences in mean distribution of all KPIs, except missing dose, between the pre- and post-ADC periods during the Phase 1 period were statistically significant: inventory cost (54.2 vs 56), stockout percentage (1.55 vs 1.12), vend to refill ratio (6.83 vs 6.14), and missing dose messages (221 vs 229). Only the mean ADC utilization (57.3 vs 64) and missing dose (228 vs 179) were statistically different between the pre- and post-ADC periods in Phase 2. The interrupted-time-series analysis showed that Phase 1 optimization significantly reduced the cost of inventory (β = −$1.238.00, P < .01), no. Stocked medications (β = −8.2, P < .01), percent stockout (β = −.49%, P < .01), vend-to-refill ratio (β = −1.29%, P<.01) and ADC utilization (β = −.2, P < .01). Conclusion: Automated dispensing cabinets optimization, through the use of a dashboard tool, had a positive impact on almost all measured KPIs.

Background: Chronic care management (CCM) can significantly impact the management of chronic diseases in rural patient populations. To date, few practice models have addressed its impact on clinical outcomes and access to care in rural practice settings. Objective: Implement a sustainable pharmacist-led CCM practice model while tracking clinical outcomes and healthcare access at a rural, medically underserved family medicine clinic. Methods: This study retrospectively examined data from the clinic’s CCM program from October 2020 through May 2021 and included total clinical encounters at three- and 6-months intervals, as well as changes in clinical outcomes like A1c and systolic blood pressure (SBP) at three- and 6-months intervals. Results: Over an 8-month period, 46 patients were enrolled in pharmacist-led CCM services. Those with a CCM encounter or office visit within 3 months of enrollment showed a mean A1c reduction of 1.07% after 3 months (95% CI −1.70 to −.44, P = .0016), while those with an encounter or office visit within 6 months of enrollment displayed a mean A1c reduction of 1.64% after 6 months (95% CI −2.35 to −.92, P < .001). There was a 73.8% increase in total clinical encounters in the 6 months after CCM enrollment compared to the 6 months preceding it, signifying increased access to care. Conclusion: Patients with CCM encounters or office visits within the first 3-6 months experienced statistically significant reductions in A1c. Moreover, total clinical encounters markedly increased in the 6 months after enrollment, allowing for more frequent engagement between ambulatory pharmacists and traditionally challenging rural patients.

Introduction: A risk of amphetamine use is amphetamine-induced psychosis (AIP). Symptoms of AIP include hallucinations, delusions, and agitation. While AIP may resolve with abstinence from amphetamines, antipsychotics are commonly used despite not being FDA approved. The primary objective of this study was to compare length of stay (LOS) for patients with AIP treated with antipsychotics vs untreated. Secondary aims were to determine antipsychotic prescribed, proportion of patients utilizing as needed doses, time to initiation, and readmissions. Methods: A retrospective chart review conducted at an academic medical center identified adult participants who were diagnosed with AIP, admitted to inpatient psychiatry service, and had a urine drug screen (UDS) positive for amphetamines. Patients were excluded if they were already taking an antipsychotic, had active prescriptions for amphetamine salts, or were in the emergency department for more than 48 hours. Demographics were assessed with descriptive statistics. Length of stay was compared between treatment groups using Kruskal-Wallis. Secondary aims were assessed using chi-square, Mann-Whitney U, and Kruskal-Wallis. Results: Sixty-nine patients were included. Median LOS for patients treated with antipsychotics (n = 35) was longer than untreated patients (n = 34), (5 days vs 2.5 days, P = .001). Type of antipsychotic used and time to initiation of antipsychotic were not found to affect LOS. There was no difference in readmissions rates and positive UDS on readmission between groups. Conclusion: This study found patients with scheduled antipsychotics for AIP had a longer LOS than patients who did not receive scheduled antipsychotics. Future studies are needed to evaluate antipsychotic use in AIP.

The high morbidity and mortality rates associated with invasive fungal infections have led to the overutilization of empiric antifungal therapies. With increasing antibiotic resistance, the careful consideration of prophylactic or empiric antifungal use is critical. The purpose of this review is to evaluate the available literature regarding the current practice of utilizing antifungal agents for intra-abdominal infections based on specific surgical procedures and patient risk factors. Relevant articles were identified through a comprehensive literature search of several databases using the keywords antifungal agents, postoperative period, preoperative care, surgical procedures, and intra-abdominal infections. Only articles that evaluated the use of empiric antifungals for suspected or confirmed intra-abdominal infections and surgical procedures were included in this review. Based on the available literature, antifungal prophylaxis is appropriate in patients who meet the criteria for high-risk invasive candidiasis, kidney or liver transplant recipients, severely-immunocompromised patients with perforated peptic ulcer, peritonitis, and patients on peritoneal dialysis who are failing on a therapeutic antibiotic regimen. We acknowledge that the evidence for using antifungal therapy empirically for all surgical procedures is lacking, and the following review is based on available literature and current guidelines.

Intravenous (IV) administration of calcineurin inhibitors, cyclosporine (CsA) and tacrolimus (TAC), has been associated with spuriously high serum concentrations collected from central venous catheters (CVCs) used for medication administration, secondary to reversible adsorption of medication to the catheter. Thus, therapeutic drug monitoring of IV CsA and TAC via CVCs previously exposed to these agents should be interpreted cautiously and ideally avoided. The duration of this effect is poorly characterized and the risk for extension of this effect to unexposed lumens of the same central catheter remains uncertain. We describe a case of a pediatric patient with artificially elevated serum TAC concentrations obtained from previously exposed and unexposed lumens of a central catheter, 27days after last IV TAC administration.