The aim of this study was to compare the removal of cardiac troponin T via continuous venovenous haemofiltration (CVVH), continuous venovenous haemodialysis (CVVHD) and continuous venovenous haemodiafiltration (CVVHDF) as a function of circulating blood troponin T levels in critically ill patients. This was a single-centre, prospective observational study conducted at Tallaght University Hospital (Dublin, Ireland). Adult patients admitted to ICU and commenced on continuous renal replacement therapy (CRRT) were included. All patients required a troponin T level > 50 ng/L. All patients were required to have commenced CRRT > 4 h prior to first sample. The aim was to take three serum samples per patient every 24 h, over a total of 72 h, with simultaneous sampling of the waste effluent for troponin T. Our primary outcome measure was estimated troponin T clearance according to CRRT modality. We found no significant difference in estimated troponin T clearance according to CRRT modality (overall median troponin T clearance of 2.6 ml/kg/h). As a secondary outcome, it was noted that the percentage of troponin T clearance was statistically significantly higher for CVVH compared to CVVHD and CVVHDF (16

INTRODUCTION:In the absence of a national framework to inform hospital pharmacist practices, Irish standards of practice relating to education and research are unknown. OBJECTIVES:A national service evaluation was undertaken to establish current standards of practice nationally relating to education and research activities within the hospital pharmacy and to identify barriers to standardising practices in these areas. METHODS:An online questionnaire was distributed to pharmacy department managers between May and August 2025. Questions addressed (1) current education and research practices, including the types and extent of research being conducted; and (2) barriers to pharmacist engagement in education and research. The results were analysed descriptively. RESULTS:Fifty-five of 85 (65%) potential responses were received: 27% of departments had a dedicated pharmacist for education and 7% had a dedicated research role. Regarding gaps in pharmacist education, attainment of skillsets and knowledge required of advanced specialist practice was the gap that achieved the highest level of agreement; 75% of respondents agreed or strongly agreed regarding its lack within current education programmes. Sixty-four percent of respondents agreed or strongly agreed that clinical skills were also a gap within pharmacist education. Regarding research, of 28 specialty areas, 29% reported producing peer-reviewed research publications within the previous 18 months. Significant barriers to increased engagement in education and research practices across the hospital pharmacy were related to time, workload and the absence of both funding and standardised frameworks. CONCLUSIONS:We identified key infrastructural deficits in hospital pharmacist education, including essential and advanced specialist clinical skills. The findings support the need for a harmonised approach to continued pharmacist education and the requirement for dedicated funding to support the provision of high-quality patient care across clinical specialities. This should be supported by the development of a structured competency framework. Similar strategies are required to support improved engagement in pharmacist-led research.

Objectives:The benefits of a collaborative approach to medication management between pharmacists and clinicians in secondary care on patient safety has been demonstrated in clinical trials. However, less is known about the benefit of such collaboration in real-world settings. This study assessed the effectiveness of a collaborative model of pharmaceutical care including pharmacist collaborative prescribing, on discharge medication error, and explored the intervention fidelity. Methods:This stepped wedge cluster-randomised controlled trial was undertaken at a university hospital in Dublin, Ireland. A cluster was one or more medical or surgical specialty, or part thereof, delivering acute care. Adult patients, using five plus regular medicines pre-admission, receiving care from a participating cluster, and discharged alive from that cluster were eligible for inclusion. Patients previously admitted during the study period and enrolled were excluded. The intervention saw a pharmacist aligned to a specialty, delivering collaborative services to patients: medication history taking, admission medication reconciliation, inpatient medication optimisation, discharge medication reconciliation and collaborative prescribing. The comparator was ward-based pharmacist care. Sample size accounting for study design, attrition and effect size in discharge medication error was calculated as 430 participants. The primary analysis was undertaken by the intention-to-treat (ITT) principle and multilevel logistic regression through the Generalised Linear Mixed Model (GLMM) procedure, was used to account for the effect of clustering and adjust for confounders. Results:Eighty-six of 432 (19.9 %) assessable patients experienced a clinically significant discharge medication error, 37 (43 %) of whom were intervention group patients. Intention-to-treat analysis suggested no difference in the likelihood of experiencing this primary outcome between study groups (adjusted odds ratio 1.24, 95 % confidence interval 0.53-2.88). This finding was consistent in the extreme sensitivity and per protocol analyses. Intervention fidelity was poor with six (2.4 %) intervention patients receiving discharge medication reconciliation. Conclusion:Under real-world conditions, this collaborative model of pharmaceutical care including medication reconciliation and collaborative prescribing was equivalent to standard care in protecting against clinically significant discharge medication error. Future research should employ an implementation science framework to better understand how pharmaceutical care at discharge can be spread.

Pharmacy services at surgical pre-assessment clinics and on inpatient wards are well-documented, but services to theatre appear comparatively under-developed. High-risk and high-cost medicines are used routinely in theatre; pharmacists are well-qualified to optimise their use and improve patient care. To determine the range, extent and nature of pharmacy services to theatre internationally, and to describe any reported outcomes of these services. This scoping review was conducted and reported as per PRISMA-ScR and Joanna Briggs Institute methodology. A search was conducted across MEDLINE, Embase, CINAHL, PsycInfo, Bielefeld Academic Search Engine, Canada’s Drug and Health Technology Agency, Google and Google Scholar in April 2023. One reviewer screened titles and abstracts. Two reviewers screened full texts. Data extraction was completed by one reviewer. Two reviewers used the Mixed Methods Appraisal Tool (MMAT) to perform quality appraisal. For work completed by one reviewer, a 10

Background Pharmacy services impact patients throughout the perioperative journey. Pharmacist activities at surgical pre-assessment clinics and on inpatient wards are well-documented, but services to theatre appear comparatively under-developed. High-risk and high-cost medicines are used routinely in theatre; pharmacists are well-placed to optimise their use and improve patient care.Aim To determine the range, extent and nature of theatre pharmacy services and their outcomes.Method This scoping review was conducted and reported as per the Joanna Briggs Institute methodology and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews. A search was conducted across electronic and grey literature databases to identify pharmacy theatre services. One reviewer screened titles and abstracts and carried out data extraction, with a 10% sample screened by a second reviewer. Two reviewers evaluated full texts. Quality appraisal was undertaken using the Mixed Methods Appraisal Tool.Results Ninety-two publications were included from 3924 search results. Fifty-seven were primary research articles. Most of the included publications described services in the United States of America; the remainder were from Australia, several European countries, Egypt, Morocco, Japan, China and Taiwan. Theatre pharmacy services included medication management and various clinical activities. Outcomes related to cost savings, patient safety and staff satisfaction. Nine of the 57 articles were suitable for quality appraisal. Adherence to quality criteria ranged from 40–100%.Conclusion Evidence for theatre pharmacy services is extensive and varied. Empirical research of high methodological quality is required to assess the outcomes of these services.

Abstract Introduction The MA2VER2ICK Tool[1] (see Figure 1) is a clinical pharmacy mnemonic developed in 2016 by the pharmacy department of Tallaght University Hospital, through a combination of literature searching and local expert consensus opinion. The intended purpose of the tool was to guide clinical pharmacists in pharmaceutical care planning. Since inception, the tool has not been formally evaluated. Locally, users report the tool as useful; although, there is scope for improvement, to better support clinical pharmacists. Aim Identify and gain consensus on suggestions to adapt the existing tool. Methods A two-stage mixed-methods approach was adopted. This comprised focus groups to facilitate idea generation and appraise contents of the existing tool, followed by a nominal group technique process[2] to agree the content and structure of the final tool. A purposive sample of clinical pharmacists were selected to participate in the focus groups and nominal group technique panel, based on responses to a screening questionnaire pre-circulated to all clinical pharmacists employed at the study site. Thematic analysis of the focus group transcripts was conducted by two independent researchers, with key themes and related recommendations to improve the tool identified. These recommendations were presented to the nominal group technique panel via an anonymous survey, where numerical rating scores were assigned over two rounds, with an intervening panel discussion. An increase in the mean rating score and convergence of the standard deviation indicated consensus for a recommendation. Results Two focus groups (5 participants each) of 45 minutes duration took place. Both focus groups resulted in similar findings, with seven major themes identified relating to adapting the tool. Overall, eight recommendations were formulated, with suggestions to adapt the content, structure, usability and application of the tool. Consensus agreement was reached on seven recommendations, each receiving a panel rating score > 90%. One recommendation was rejected, receiving a panel rating score < 30%. Conclusion This study demonstrates that the MA2VER2ICK Tool is a comprehensive clinical pharmacy resource. Few amendments were required to the original tool, indicating user satisfaction with and the utility of the tool, together with a high degree of consensus for the adaptations made. VTE: venous thromboembolism; Rx: prescription; CRP: C-reactive protein. References 1. Pharmacy Department Clinical Induction Programme: Tallaght University Hospital; 2016 [cited 06 December 2023]. 2. Bowling A. Research Methods in Health: Investigating Health and Health Services. 4th ed: McGraw Hill/Open University Press; 2014.

Abstract Introduction Guidelines recommend that pharmacists contribute to perioperative patient care.[1,2] Expansion of perioperative pharmacy services was considered in Tallaght University Hospital following the appointment of a Critical Care & Anaesthesia Chief II Pharmacist. Preliminary research indicated that activities at surgical pre-assessment clinics, in critical care and on inpatient wards are well-documented, while theatre pharmacy services appear comparatively under-developed. Pharmacists are well-placed to promote the safe and cost-effective use of medicines in this high-risk environment. An understanding of the evidence base could provide a foundation on which pharmacy departments seeking to expand their clinical services can build. Aim To determine the range, extent and nature of theatre pharmacy services internationally, and to describe any reported outcomes of these services. Methods This scoping review was conducted and reported as per the Joanna Briggs Institute methodology for scoping reviews and the PRISMA-ScR checklist. The review protocol was registered on Open Science Framework. A search was conducted across electronic (Ovid® MEDLINE, Embase, CINAHL and PsycInfo) and grey literature databases (Google Scholar, BASE, CADTH, and Google) without limitations on date of publication, study type or language (where English translation available). A manual search of the citation lists of all included publications supplemented the electronic search. One reviewer screened titles and abstracts and carried out data extraction, with a 10% sample screened by a second reviewer. Two reviewers evaluated full texts. Critical appraisal was performed using the Mixed Methods Appraisal Tool where appropriate. A narrative approach to evidence synthesis was employed. Extracted data about the type of pharmacy service(s) and associated outcomes were studied to inform development of key concepts through which results were presented. Results Ninety-two publications were included from 3924 results. Fifty-seven were primary research articles. Most publications were descriptive in nature. Over half of the included publications described services in the United States; the remainder were from Australia, several European countries, Egypt, Morocco, Japan, China and Taiwan. The majority of theatre pharmacy services involved medication management, i.e. procurement, spending, storage, formulary development and distribution of medicines. Clinical services incorporated provision of medicines information, protocol and guideline development, antimicrobial stewardship, education and training of healthcare professionals, engagement with health informatics and medication safety projects, practice-based research and intraoperative emergency support. Reported outcomes included financial savings, improved accountability of controlled substances, improved patient safety and staff satisfaction with the service. Many publications highlighted improved inter-departmental relationships between pharmacy and anaesthesiology. Of the 57 primary research articles, 48 lacked a clear research question and so did not satisfy the MMAT screening criteria. Of the nine assessed, adherence to quality criteria ranged from 40-100%. Conclusion Evidence for theatre pharmacy services is extensive and varied. Empirical research of high methodological quality is required to assess the outcomes of these services. Strengths of this review include the use of reporting guidelines and quality appraisal of the evidence. This review may have been limited by the exclusion of non-English language publications. This review collates practical guidance on the development of theatre pharmacy services and highlights facilitators of successful service establishment. References 1. Bickham P, Golembiewski J, Meyer T et al. ASHP guidelines on perioperative pharmacy services. Am J Health Syst Pharm 2019;76(12):903-820. 2. Bui T, Fitzpatrick B, Forrester T et al. Standard of practice in surgery and perioperative medicine for pharmacy services. J Pharm Pract Res 2022;52(2):139-58.

Abstract Introduction Literature searching has revealed a lack of high-quality research outlining the use of tools or checklists in hospitalised patients. Additionally, few tools identified relate directly to clinical pharmacy practice. The tools identified focus on specific disciplines (e.g. critical care) or specific tasks (e.g. handover). The MA2VER2ICK Tool is a novel clinical pharmacy tool which has recently undergone review and adaptation.[1] The tool is unique as it is comprehensive and applicable to all hospitalised patients, regardless of clinical discipline. The intended purpose of the tool is to assist clinical pharmacists in comprehensive pharmaceutical care planning. Aim Demonstrate the utility of the MA2VER2ICK tool in pharmaceutical care planning, by outlining the type and frequency of drug-related problems occurring in hospitalised patients. Methods A prospective, observational, cross-sectional study was conducted in a 560-bed acute university teaching hospital. Clinical pharmacists adopted the tool in their daily practice, in a mixed medical-surgical inpatient population, over four weeks. All drug-related problems identified were recorded and assigned to the applicable category within the tool, by the clinical pharmacist. Additionally, all drug-related problems were retrospectively assigned to applicable categories of the Pharmaceutical Care Network Europe Classification for Drug Related Problems Version 9.1,[2] for comparison, by two independent researchers. Results All identified drug-related problems identified were successfully categorised using the MA2VER2ICK Tool. In total, 753 drug-related problems were identified in 180 patients over four weeks, with 233 patient-pharmacist encounters occurring. The mean age of patients was 68.9±16 years, while 51.7% (93/180) were female and 48.3% (87/180) were male. The mean number of drug-related problems identified per patient was 4.2±3.6. The highest number of drug-related problems experienced by an individual was 20, while 17 patients experienced no drug-related problem. The majority of drug-related problems identified using the tool related to medication reconciliation (52.7%; 397/753), followed by prescription endorsement and administration (17.3%; 130/753) and pharmacotherapy optimisation (9.3%; 70/753). In comparison with the MA2VER2ICK Tool, the Pharmaceutical Care Network Europe classification system has a much larger range of categories for assigning drug-related problems. Despite this, a proportion of identified drug-related problems 1.6% (12/753) could not be categorised using this tool, while there were also several categories within the tool 43.2% (19/44) whereby no drug-related problems were assigned. Conclusion This study demonstrates that the MA2VER2ICK Tool is a robust clinical pharmacy tool, that is effective and practical in assisting clinical pharmacists with the identification of drug-related problems and thus is a useful guide to facilitate pharmaceutical care planning at the patient’s bedside. This is in comparison with the Pharmaceutical Care Network Europe classification system, which has less utility as a clinical pharmacy tool, but is better placed as a research instrument. Despite demonstrating the usefulness of the MA2VER2ICK Tool in identifying drug-related problems, the clinical significance of those identified was not assessed during this study. However, data collection occurred in real time, facilitating the identification of actual and potential problems, thus reducing the likelihood of underestimating the incidence rate. References 1. O’Donovan C, Henman M, McManamly C et al. A mixed-methods review and adaptation of a novel clinical pharmacy tool: The MA2VER2ICK Tool Study. 2024. International Journal of Pharmacy Practice. 2024;32(S1):i45. 2. PCNE Classification for Drug-Related Problems V9.1: Pharmaceutical Care Network Europe; 2020 [cited 06 December 2023]. Available from: https://www.pcne.org/upload/files/417_PCNE_classification_V9-1_final.pdf

Aims Irish haemodialysis (HD) units operate the electronic Kidney Disease Clinical Patient Management System (KDCPMS). KDCMPS is not always used as the primary electronic patient record. At this study setting, KDCPMS information accuracy has not been examined to date. This study aims to identify, characterise and quantify medication discrepancies within KDCPMS records of HD outpatients. Methods Prospective, observational study conducted on the HD unit of Tallaght University Hospital. Medicine reconciliation was conducted to identify KDCPMS discrepancies with medication review to document Drug Related Problems (DRPs). Clinical pharmacists issued recommendations to resolve DRPs. Results All KDCPMS records examined contained intentional and unintentional discrepancies (n=36). Unintentional discrepancies corresponding to 8.8 discrepancies per patient (5.13SD) was observed. One-hundred-and-forty-three DRPs were identified in 34 patients (94.4%). Sixty-five per cent (65%) of pharmacist recommendations were accepted (n=93), 22.4% rejected (n=32), 8.4% (n=12) referred to the renal multidisciplinary team (MDT) and 4.2% not actioned (n=6). Conclusion KDCPMS contains inaccuracies potentially leading to systemic error. Robust clinical governance supported by national policy is required to support KDCPMS as the primary platform for renal patients. Enhanced pharmaceutical care by specialist clinical pharmacists should be supported within national models of care for chronic disease management to improve patient outcomes.

Abstract BACKGROUND AND AIMS Haemodialysis (HD) units in Ireland operate a national electronic Kidney Disease Clinical Patient Management System (KDCPMS). KDCMPS is not always used as the primary electronic patient record (EPR) but in conjunction with other electronic and paper record systems across the healthcare setting. HD patients on average have 6 comorbidities and have the largest pill burden for any chronic disease; consuming 19 oral doses/day, comprising of 12 different medicines [1, 2]. Frequent medication changes, polypharmacy, comorbidities and non-adherence, increase the risk of drug-related problems (DRPs). In the HD population, DRPs are prevalent at a rate of 1 for every three medication exposures and can elicit negative outcomes, including worsening morbidity, mortality and increased healthcare expenditure [3]. In this study setting, KDCPMS information accuracy has not been examined to date. This study aims to describe medication discrepancies within KDCPMS records of HD outpatients. METHOD This prospective, observational study was conducted in the HD unit of Tallaght University Hospital, Dublin. Medicine reconciliation was conducted to identify KDCPMS discrepancies, followed by medication review to document DRPs. Recommendations were issued by the clinical pharmacist to resolve DRPs. RESULTS All KDCPMS records examined contained intentional and unintentional discrepancies (n = 36). Unintentional discrepancies corresponding to 8.8 discrepancies per patient (5.13SD) were observed. A total of 143 DRPs were identified in 34 patients (94.4%) (Table 1). Out of these, 65% of pharmacist recommendations were accepted (n = 93), 22.4% were rejected (n = 32), 8.4% (n = 12) were referred to the renal multidisciplinary team (MDT) and 4.2% were not actioned (n = 6). Discrepancies and DRPs by therapeutic area are shown in Fig. 1. Parenteral anticoagulants and thrombolytics were the most common undocumented intentional discrepancies (48.6%, n = 50/103) followed by iron (32%, n = 33/103). A total of 16 (44.4%) patients had at least one medicine de-prescribed. New prescriptions were issued for 26 patients (72.2%) for 81 medicines. CONCLUSION KDCPMS contains inaccuracies that could lead to systemic error. Robust clinical governance supported by the national policy is required to improve the accuracy of information contained in KDCPMS and support its use as the primary platform for renal patients. Specialist clinical pharmacists working collaboratively within the renal MDT reduce discrepancies, improve KDCPMS accuracy and resolve DRPs. Enhanced pharmaceutical care by specialist pharmacists should be supported within national models of care for chronic disease management to enhance patient outcomes.

Our objective was to determine the prevalence, severity and preventability of adverse drug reactions (ADRs), ADRs causing or contributing to hospitalization (cADRs) and preventable ADRs (pADRs) in middle-aged patients aged 45–64 years presenting acutely to hospital. This was a prospective observational pilot study. The sampling frame was middle-aged patients in the acute medical unit of an Irish university teaching hospital. In total, 100 patients using three or more medicines were screened for ADRs present at hospitalization. Potential ADRs were assessed for causality, preventability, severity and relationship to hospitalization using validated tools and clinician assessment. The associations between ADRs and potentially inappropriate prescribing (PIP) and polypharmacy (five or more medicines) were investigated using Pearson’s χ2 test. Multivariate logistic regression analyses examined associations between ADRs and sex, age, polypharmacy, comorbidity and PIP. Of the 100 patients, 21 experienced 23 ADRs. The prevalence of cADRs and pADRs was 14% and 11% of patients, respectively. Over one-half of ADRs identified (n = 14) were sufficiently severe to prompt presentation to hospital for urgent medical review. PIP was associated with the occurrence of any ADR (adjusted odds ratio 3.49; 95% confidence interval 1.22–9.93) but not with cADR. Excessive polypharmacy (ten or more medicines) (χ2 = 5.73, p = 0.02), but not polypharmacy, was associated with any ADR occurrence. One in five patients had an ADR and experienced short-term morbidity as a result. For 11 patients, the ADR was preventable. These findings illustrate that middle-aged patients are vulnerable to medicine-related harm. Additional research in larger studies is needed to more comprehensively describe the prevalence and risk factors for ADRs in middle-aged patients.

Objectives:To develop a pharmacokinetic model describing total and unbound teicoplanin concentrations in patients with haematological malignancy and to perform Monte Carlo simulations to evaluate target attainment of unbound trough concentrations with various dose regimens.Methods:This was a hospital-based clinical trial (EudraCT 2013-004535-72). The dosing regimen was 600/800 mg q12h for three doses then 600/800 mg daily. Serial total and unbound teicoplanin concentrations were collected. Maximum protein binding was estimated from serum albumin concentration. Population pharmacokinetic analyses and Monte Carlo simulations were conducted using Pmetrics®. Target total and unbound trough concentrations were ≥20 and ≥1.5 mg/L, respectively.Results:Thirty adult patients were recruited with a mean (SD) bodyweight of 69.1 (15.8) kg, a mean (SD) CLCR of 72 (41) mL/min and a median (IQR) serum albumin concentration of 29 (4) g/L. A three-compartment complex binding pharmacokinetic model best described the concentration-time data. Total and unbound teicoplanin concentrations were related by serum albumin concentration and a dissociation constant. CLCR and bodyweight were supported as covariates for CL and volume of the central compartment, respectively. Dosing simulations showed that high CLCR was associated with reduced probability of achieving target total and unbound trough concentrations. Low serum albumin concentration was associated with a reduced probability of attaining target total but not unbound trough concentrations. A method to estimate the unbound teicoplanin concentration from the measured total concentration at different serum albumin concentration was demonstrated.Conclusions:Standard teicoplanin dosing regimens should be used with caution in patients with haematological malignancy. Bodyweight, CLCR and serum albumin concentration are important considerations for appropriate dosing.

ABSTRACT The objective of this study was to explore the following aspects of teicoplanin use in patients with hematological malignancy: early attainment of target trough concentrations with current high-dose teicoplanin regimens, variability in unbound teicoplanin fractions, factors associated with observed total and unbound trough concentrations, efficacy and toxicity, and renal function estimation. This was a single-center, prospective study. Samples for determination of trough concentrations were taken on days 3, 4, 7, and 10. Total and unbound teicoplanin concentrations were determined using validated high-performance liquid chromatography methods. Regression analyses were used to identify the factors associated with the trough concentration. Thirty teicoplanin-treated adults with hematological malignancy were recruited. Despite the use of dosages higher than the conventional dosages, the proportions of patients with a trough concentration of ≥20 mg/liter at 48 h and at 72 h were 16.7% and 37.9%, respectively. Renal function was significantly negatively associated with total trough concentrations at 48 h and 72 h (P < 0.05). For an average hematological malignancy patient (creatinine clearance = 70 ml/min), sequential loading doses of at least 12 mg/kg of body weight may be needed to achieve early adequate exposure. In the absence of measured creatinine clearance, estimates obtained using the Cockcroft-Gault (total body weight) equation could prove to be an acceptable surrogate. The unbound fractions of teicoplanin were highly variable (3.4 to 18.8%). Higher unbound fractions were observed in patients with low serum albumin concentrations. Teicoplanin was well tolerated. Teicoplanin loading doses higher than those in current use appear to be necessary. Increased dosing is needed in patients with increased renal function. The high variability in protein binding supports the contention for therapeutic drug monitoring of unbound teicoplanin concentrations. (This study has been registered with EudraCT under registration no. 2013-004535-72.)

Objectives: To describe the population pharmacokinetics of teicoplanin in adult patients with haematological malignancies receiving higher than standard doses, and to perform Monte Carlo simulations to determine dosing regimens associated with optimal teicoplanin concentrations.Methods: This was a hospital-based clinical trial (EudraCT 2013-004535-72). Nine blood samples were collected on Day 3, plus single trough samples on Days 7 and 10, and 24 and 48 hours after the last dose. Teicoplanin minimum inhibitory concentrations were determined for Gram-positive isolates from study patients. Population pharmacokinetic analyses and Monte Carlo dosing simulations were undertaken using Pmetrics.Results: Thirty adult haematological malignancy patients were recruited with a mean (SD) loading dose, age, total body weight, and creatinine clearance of 9.5 (1.9) mg/kg, 63 (12) years, 69.1 (15.8) kg, and 72 (41) mL/min, respectively. A three-compartment linear pharmacokinetic model best described the teicoplanin concentration data. Covariates supported for inclusion in the final model were creatinine clearance for clearance and total body weight for volume of the central compartment. The median (IQR) area under the concentration-time curve from 48 to 72 hours (AUC(48-72h)) was 679 (319) mg.h/L. There was a strong correlation between the AUC(48-72h) and trough concentration at 72 hours (Pearson correlation coefficient 0.957, p < 0.001). Dosing simulations showed that administration of five loading doses at 12-hourly intervals, stratified by total body weight and creatinine clearance, increased the probability of achieving target concentrations within 72 hours.Conclusions: To increase the number of patients achieving optimal teicoplanin concentrations an individualized dosing approach, based on body weight and creatinine clearance, is recommended. (C) 2017 European Society of Clinical Microbiology and Infectious Diseases. Published by Elsevier Ltd. All rights reserved.

Journal of Clinical Pharmacy and TherapeuticsVolume 41, Issue 6 p. 739-740 Letter to the Editor Comment on: pharmacy-led medication reconciliation programmes at hospital transitions: a systematic review and meta-analysis T. C. Grimes PhD MPSI, T. C. Grimes PhD MPSI tagrimes@tcd.ie orcid.org/0000-0002-7154-3243 School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Dublin 2, Ireland Pharmacy Department, Tallaght Hospital, Dublin 24, IrelandSearch for more papers by this authorN. Breslin MD FRCPI, N. Breslin MD FRCPI Medical Directorate, Tallaght Hospital, Dublin 24, IrelandSearch for more papers by this authorE. Deasy MSc MPSI, E. Deasy MSc MPSI School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Dublin 2, Ireland Pharmacy Department, Tallaght Hospital, Dublin 24, IrelandSearch for more papers by this authorE. Moloney MD FRCPI FCCP, E. Moloney MD FRCPI FCCP Medical Directorate, Tallaght Hospital, Dublin 24, IrelandSearch for more papers by this authorJ. O'Byrne MSc MBA MPSI, J. O'Byrne MSc MBA MPSI School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Dublin 2, Ireland Pharmacy Department, Tallaght Hospital, Dublin 24, IrelandSearch for more papers by this authorC. Wall MB MSc FRCPI, C. Wall MB MSc FRCPI Medical Directorate, Tallaght Hospital, Dublin 24, IrelandSearch for more papers by this authorT. Delaney MSc FPSI, T. Delaney MSc FPSI School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Dublin 2, Ireland Pharmacy Department, Tallaght Hospital, Dublin 24, IrelandSearch for more papers by this author T. C. Grimes PhD MPSI, T. C. Grimes PhD MPSI tagrimes@tcd.ie orcid.org/0000-0002-7154-3243 School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Dublin 2, Ireland Pharmacy Department, Tallaght Hospital, Dublin 24, IrelandSearch for more papers by this authorN. Breslin MD FRCPI, N. Breslin MD FRCPI Medical Directorate, Tallaght Hospital, Dublin 24, IrelandSearch for more papers by this authorE. Deasy MSc MPSI, E. Deasy MSc MPSI School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Dublin 2, Ireland Pharmacy Department, Tallaght Hospital, Dublin 24, IrelandSearch for more papers by this authorE. Moloney MD FRCPI FCCP, E. Moloney MD FRCPI FCCP Medical Directorate, Tallaght Hospital, Dublin 24, IrelandSearch for more papers by this authorJ. O'Byrne MSc MBA MPSI, J. O'Byrne MSc MBA MPSI School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Dublin 2, Ireland Pharmacy Department, Tallaght Hospital, Dublin 24, IrelandSearch for more papers by this authorC. Wall MB MSc FRCPI, C. Wall MB MSc FRCPI Medical Directorate, Tallaght Hospital, Dublin 24, IrelandSearch for more papers by this authorT. Delaney MSc FPSI, T. Delaney MSc FPSI School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Dublin 2, Ireland Pharmacy Department, Tallaght Hospital, Dublin 24, IrelandSearch for more papers by this author First published: 06 October 2016 https://doi.org/10.1111/jcpt.12452Citations: 1Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article.Citing Literature Volume41, Issue6December 2016Pages 739-740 RelatedInformation

Background Unexplained changes to medication are common at hospital discharge and underscore the need to standardise patient discharge clinical documentation. In 2013, the Health Information and Quality Authority in Ireland published a Standard on the structure and content of discharge summaries. The intention was to ensure that all necessary information was complete and communicated to the next care provider. Objectives This study investigated one Hospital's compliance with the Standard, and appraised two methods of electronic discharge communication (Symphony or Tallaght Education and Audit Management System (TEAMS)). Method A retrospective survey of 198 randomly selected discharge summaries was conducted at the study hospital, a 600 bed academic teaching hospital located in Dublin, Ireland. Results Of the 198 evaluated summaries, mean total compliance was 77%±4.2 (95% CI 76.3 to 77.5). Most (84.7%, n=173) summaries were completed using one of the systems (TEAMS). Absence of communication about alteration of preadmission medication was frequent (107 out of 130 patients (82.3%, CI 76.2 to 89.2)). Higher compliance rates were observed however, when information was interfaced or where there were dedicated fields to be completed. Conclusions Efforts to improve compliance with the National Standard for Patient Discharge Summary Information should focus on reporting changes made to medication during hospitalisation.

In 2010, our hospital introduced a higher target teicoplanin trough concentration of ≥20mg/L by Day 3 for haematological malignancy patients. This study aimed to explore whether target trough concentrations were achieved, to identify factors associated with trough concentrations attained, and to assess clinical efficacy with teicoplanin treatments and nephrotoxicity. This was a retrospective, single-centre, cohort study of 172 teicoplanin treatments in 104 adults with haematological malignancy. Mixed-effects regression was used to evaluate factors affecting trough concentrations, and logistic regression was used to assess the relationship between trough concentrations and treatment outcomes. Nephrotoxicity was assessed using the RIFLE criteria. Considerable variability in trough concentrations was observed, with trough concentrations ≥20mg/L rarely achieved early in therapy. A mixed-effects regression model explaining 52% of the variation in trough concentrations was developed. Dose and day of therapy were positively associated with trough concentration, whilst estimated renal function and, interestingly, acute myeloid leukaemia diagnosis were negatively associated (P<0.05). Results suggested a positive relationship between trough concentration and the likelihood of a favourable outcome for coagulase-negative staphylococcal central line-associated bloodstream infections. Elucidation of a specific target concentration requires further investigation. Teicoplanin was well tolerated renally. Findings suggest a risk of underexposure if conventional teicoplanin doses are used in haematological malignancy patients. Given the variability in trough concentrations observed, the identified factors affecting trough concentrations attained and the suggested link with clinical outcome, individualised initial dosing followed by therapeutic drug monitoring is recommended to ensure early adequate exposure in this vulnerable patient group.

Background The objectives of the current study were to determine amikacin pharmacokinetics in patients undergoing treatment with continuous venovenous haemodiafiltration (CVVHDF) in an Intensive Care Unit (ICU), and to determine whether peak and trough concentration data could be used to predict pharmacokinetic parameters. An open prospective study was undertaken, comprising five critically ill patients with sepsis requiring CVVHDF. Methods Peak and trough plasma concentrations and multiple serum levels in a dosage interval were measured and the latter fitted to both a one- and two-compartment model. Blood and ultrafiltrate samples were collected and assayed for amikacin to calculate the pharmacokinetic parameters; total body clearance (TBC), elimination rate constant (k) and volume of distribution (V d ). The concentration of amikacin in ultrafiltrate was used to determine the clearance via CVVHDF. CVVHDF was performed at prescribed dialysate rates of 1-2l h -1 and ultrafiltration rate of 2l h -1 . Blood was pumped at 200ml/min using a Gambro blood pump and Hospal AN69HF haemofilter. Amikacin dosing was according to routine clinical practice in the Intensive Care Unit. Results The multi serum level study indicated that the one compartment model was adequate to characterize the pharmacokinetics in these patients suggesting that peak and trough plasma level data may be used to estimate individual patient pharmacokinetic parameters and to optimise individual patient dosing during treatment with CVVHDF. CVVHDF resulted in an amikacin k of 0.109+/−0.025 h, t 1/2 of 6.74 +/− 1.69h, TBC of 3.39+/−0.817 h -1 , and V d of 31.4 +/− 3.27. The mean clearance due to CVVHDF of 2.86 l h -1 is similar to the creatinine clearance of 2.74 +/−0.4 lh -1 . Amikacin was significantly cleared by CVVHDF, and its half life in patients on CVVHDF was approximately 2–3 times that reported in subjects without renal impairment and not undergoing haemodiafiltration for any reason. Conclusions CVVHDF contributes significantly to total clearance of amikacin. The use of pharmacokinetic parameter estimates obtained from two steady state serum-drug concentrations (peak and trough) can be used to guide individualised dosing of critically ill patients treated with CVVHDF. This is considered a useful strategy in this patient cohort, particularly in avoiding the risk of underdosing.