Recent guidelines for acute ischemic stroke (AIS) indicate administration of intravenous thrombolysis (IVT) in patients receiving direct oral anticoagulants (DOAC) is not firmly established and may be harmful unless certain potential parameters are met. This systematic review and meta-analysis explores safety outcomes and other clinical parameters from the growing number of publications describing patients taking a DOAC who experience an AIS that is treated acutely with IVT alone. Embase, International Pharmaceutical Abstracts, and PubMed were searched up to January 9, 2024 for studies including adult patients taking a DOAC who experienced an AIS treated with IVT and did not undergo endovascular therapy (EVT), regardless of the use of an anticoagulation reversal agent. Primary safety outcomes evaluated included symptomatic intracranial hemorrhage (sICH), any intracranial hemorrhage, and in-hospital mortality. A total of 873 patients from 78 studies, primarily case reports or case series of patients receiving dabigatran with or without idarucizumab reversal (n = 340), were included in the review. The rate of sICH during the index hospitalization was 3.3%. Seven high-quality studies with low risk of bias included outcomes for patients on DOAC and comparator groups of either patients not taking an oral anticoagulant (no OAC) or patients taking a vitamin K antagonist (VKA) with INR primarily <1.7 at the time of AIS. No significant difference was observed in the incidence of sICH among patients receiving DOAC vs. no OAC (odds ratio [OR] 0.8, 95% confidence interval [CI]: 0.48-1.33) or among patients receiving DOAC vs. VKA (OR 1.02, 95% CI 0.59-1.75). Similar findings of no difference were observed for other safety outcomes. Findings from this study suggest that utilization of IVT as sole recanalization therapy for AIS may be safe in patients taking a DOAC; however, further studies are needed to elucidate specific parameters that differentiate timepoints and variables to ensure safe, optimal treatment.

Objective: This study aimed to assess the impact of curricular content reduction in a 3-year integrated course sequence in a Doctor of Pharmacy curriculum on student-reported mental and physical health. Methods: A 3-hour, 5-days-a-week integrated course sequence spanning 3 years of a curriculum was transitioned to a 3-hour, 4-days-a-week course, representing 207 h of reduced in-class time. After implementation, first- through third-year student pharmacists were asked to complete a 23-item voluntary survey regarding the impact of the curricular change on their mental and physical health, how they spent time on the non-Integrated Learning Experience course day, and additional demographic and social characteristics. Respondents were asked to participate in follow-up focus group sessions to elucidate the findings of the survey. Results: A total of 197 students (50.3% response rate) representing the classes of 2024, 2025, and 2026 responded to the survey, and 15 students participated in 1 of 4 focus group sessions. Most students indicated a preference for the 4-days-a-week over the 5-days-a-week course and reported improvement in mental and physical health during the 4-days-a-week course. Most students used the additional time to study or complete assignments, while many third-year students used it to work, but many also used it to complete personal errands and activities, which led to a positive impact on their well-being. Conclusion: Student self-reported mental and physical health improved with a reduction in curricular content by 1 course session (3 h) per week.

ObjectiveTo evaluate the effect of curricular content reduction in an integrated course sequence spanning three years of a Doctor of Pharmacy curriculum on student exam scores and course grades.MethodsThis two-year, pre-post study compared student overall average and final exam scores and overall course grades after the transition from a 5-day to 4-day week of an integrated learning experience (ILE) course sequence. Additionally, an anonymous, optional 23-item survey was distributed to P1-P3 students asking about the 4-day week change, how they utilized the non-ILE day, and additional demographic and social characteristics to identify factors influencing success on exam and course performance during the 4-day week.ResultsThere were 533 students included in the overall analysis with no significant differences in overall course grades in the 5-day versus 4-day week. Exam scores were not significantly different after the transition except in two of twelve courses where scores were higher and final exams scores were not significantly different, except for higher final exam scores in one course during the 5-day week. Significant positive influencers of top quartile of exam performance included pre-pharmacy GPA ≥ 3.5, age 25-29, and pre-pharmacy coursework at the parent institution, whereas using the non-ILE day primarily to sleep negatively influenced outcomes.ConclusionCurricular density is a prevalent problem and addressing it at a program level is essential. Reducing curricular content and hours at our institution did not adversely impact student exam and course performance and slight improvement was noted in some areas.

Background: Patients living with chronic obstructive pulmonary disease (COPD) are at risk for lower respiratory tract infections caused by respiratory syncytial virus (RSV). The first RSV vaccines were approved in 2023 for adults ages 60 years and older. The safety and efficacy of the RSV vaccines and their clinical implications in patients living with COPD, apart from composite comorbidity results, are under-reported. Methods: This rapid review aimed to collect and report data pertaining to RSV vaccine safety and efficacy in patients living with COPD. Resources searched included Ovid MEDLINE, EMBASE, International Pharmaceutical Abstracts, published peer-reviewed abstracts, ClinicalTrials.gov, and the United States Food and Drug Administration (FDA) website. Results: Seven records were included: five research manuscripts and two ongoing clinical trials. Patients living with COPD were included in RSV vaccine clinical trials, but outcomes of RSV vaccine safety and efficacy in patients living with COPD were grossly unreported. Conclusions: Future clinical trials of patients living with COPD and subgroup analyses of patients living with COPD within existing studies evaluating RSV vaccine safety and efficacy are necessary to substantiate outcomes in this population.

BackgroundSepsis fluid resuscitation is controversial, especially for patients with volume overload risk. The Surviving Sepsis Campaign recommends a 30 mL/kg crystalloid fluid bolus for patients with sepsis-induced hypoperfusion. Criticism of this approach includes excessive fluid resuscitation in certain patients.ObjectiveTo assess the efficacy and safety of guideline-concordant fluid resuscitation in patients with sepsis and heart failure (HF) or end-stage kidney disease (ESKD).MethodsA retrospective cohort study was conducted in patients with sepsis who qualified for guideline-directed fluid resuscitation and concomitant HF or ESKD. Those receiving crystalloid fluid boluses of at least 30 mL/kg within 3 hours of sepsis diagnosis were placed in the concordant group and all others in the non-concordant group. The primary outcome was in-hospital mortality. Secondary outcomes included intensive care unit (ICU) and hospital length of stay (LOS); vasoactive medications and net volume over 24 hours; new mechanical ventilation, new or increased volume removal, and acute kidney injury within 48 hours; and shock-free survival at 7 days.ResultsOne hundred twenty-five patients were included in each group. In-hospital mortality was 34.4% in the concordant group and 44.8% in the non-concordant group (p-value=0.1205). The concordant group had a shorter ICU LOS (7.6 versus 10.5 days, p-value=0.0214) and hospital LOS (12.9 versus 18.3 days, p-value=0.0163) but increased new mechanical ventilation (37.6 versus 20.8%, p-value=0.0052). No differences in other outcomes were observed.ConclusionReceipt of a 30 mL/kg fluid bolus did not affect outcomes in a cohort of patients with mixed types of HF and sepsis-induced hypoperfusion.

Background: Direct oral anticoagulants (DOACs) are known to have similar efficacy with a decreased risk of bleeding when compared to warfarin for the treatment of venous thromboembolism (VTE). In patients with obesity, there are limited data regarding the safety and efficacy of DOACs. Despite concerns for both under- and over-dosing patients with extremes of body weight, there are no dose adjustment recommendations in the package inserts for any of the DOACs. Objective: To evaluate the safety and efficacy of DOACs versus warfarin for the treatment of VTE in patients with obesity. Methods: This single-center, retrospective cohort study included obese patients initiated on DOAC or warfarin therapy for VTE from January 2015 to January 2022. Patients with cancer, hypercoagulable disorders, end-stage kidney disease, or pregnancy were excluded. The primary endpoint was VTE recurrence. Secondary endpoints included major and minor bleeding. Results: A total of 120 patients met criteria for inclusion. Ninety-two received DOAC therapy and 28 received warfarin. The primary endpoint occurred in 4 patients in the DOAC group and 3 patients in the warfarin group (P = 0.35). Major bleeding occurred in 2 patients. Minor bleeding events occurred in 10 (8.33%) patients. Of those, 6 (6.5%) events occurred in patients receiving a DOAC and 4 (14.3%) events occurred in patients receiving warfarin (P = 0.28). Limitations of this study include the retrospective single-center study design. Conclusions: There was a comparable risk of bleeding and recurrent VTE between DOACs and warfarin in patients initiated on therapy for VTE.

Background:In select patients with minor ischemic stroke, dual antiplatelet therapy (DAPT) with aspirin plus clopidogrel is recommended if initiated early and continued for 21 to 90 days. Dual antiplatelet therapy use, in a broader population, has shown to increase the risk of bleeding without an increased antithrombotic benefit. An ongoing area of uncertainty is whether DAPT would benefit the nonminor stroke population when continued for 21 to 90 days.?s.Objective:To describe the effects of DAPT after a nonminor stroke.Methods:This single-center, retrospective cohort study included patients initiated on antiplatelet therapy started within 1 week of symptom onset for a nonminor ischemic stroke from January 2013 to January 2020. Patients with any bleeding disorder or National Institutes of Health Stroke Scale score <4 were excluded. The primary endpoint was major bleeding at 3 months. Secondary endpoints included recurrent stroke and minor bleeding.Results:A total of 158 patients met criteria for inclusion. Ninety (57%) received DAPT, and 68 (43%) received single antiplatelet therapy (SAPT). The primary endpoint occurred in 3 patients in the DAPT group and 1 patient in the SAPT group (P = 0.463). Minor bleeding occurred in 1 patient receiving DAPT and 2 patients receiving SAPT (P = 0.402). There were 10 patients in the DAPT group and 5 patients in the SAPT group who experienced recurrent stroke or transient ischemic attack (P = 0.429). Limitations of this study include the retrospective single-center study design.Conclusion:There was a comparable risk of bleeding and recurrent stroke between DAPT and SAPT in patients admitted with an acute nonminor stroke.

The Student Success Program at Auburn University Harrison College of Pharmacy is designed to support student success throughout all four years of our Practice Ready Curriculum, from the time of admission through graduation. The objective is to describe the formation and goals of student success program.

To assess the impact of de-densifying an integrated learning experience (ILE) course sequence spanning three years on pharmacy student wellbeing.

Objective To evaluate the role of sodium-glucose cotransporter-2 (SGLT2) inhibitors in patients with heart failure with preserved ejection fraction (HFpEF). Data sources A literature search of PubMed, the Cochrane Library, and Google Scholar databases (January 2015 to June 20, 2023) was performed with keywords: sodium-glucose co-transporter 2 inhibitors OR SGLT2 inhibitors OR bexagliflozin OR canagliflozin OR dapagliflozin OR empagliflozin OR ertugliflozin OR sotagliflozin AND heart failure OR heart failure with preserved ejection fraction, and terms related to CV outcomes including cardiovascular death, hospitalization, hospitalization for heart failure, mortality, death, and major adverse cardiovascular event (MACE). Study selection and data extraction The reference list from retrieved articles as well as relevant review articles was considered. Pivotal randomized controlled trials and meta-analyses with a primary or secondary end point of CV death or heart failure hospitalization were included. Studies conducted solely in a diabetic patient population were excluded. Data synthesis Dapagliflozin and empagliflozin, in a broad population of heart failure patients including, HFrEF, HFmrEF, HFpEF, and without diabetes, have shown consistent improvement in the combined outcome of CV death and hospitalization for heart failure (HR 0.80, 95% CI 0.73-0.87) and in the reduction of heart failure hospitalizations (HR 0.74, 95% CI 0.67-0.83). In patients with HFpEF, cardiovascular mortality was not demonstrated (HR 0.88, 95% CI 0.77-1.00). Rates of adverse events were low. Relevance to patient care and clinical practice Patients with HFpEF and NYHA class II-III with frequent symptoms or hospitalizations for heart failure derive the most benefit from SGLT2 inhibitors with an overall goal of a reduction in heart failure hospitalizations. Conclusions The treatment of HFpEF has made progress, but there is still work to be done. Now, SGLT2 inhibitor therapy can be used to further help with symptom control and reduce overall hospitalizations for heart failure.

Aim: To describe the development, implementation, and structure of an innovative evidence based medicine (EBM) advanced pharmacy practice experience (APPE) rotation and evaluate student pharmacists' perceptions of the course. Methods: A five-week, EBM APPE rotation was designed by seven faculty. Students worked remotely in teams and individually to complete pre and post-assessments, journal clubs, journal scans, drug information questions, and clinical debates, as well as self- and peer-assessments. Students were asked to rate their perceptions of the course on a 5-point Likert scale. Results: A total of eighteen students, precepted by seven faculty members, completed the rotation. Students completed three group journal clubs, three individual journal scans, one individual journal club, one drug information question, and one clinical debate. Students survey data indicated that confidence in EBM skills was high following the rotation. Conclusion: This EBM APPE rotation was successful. The structure of this rotation may be transferable to a variety of settings.

Objective: To evaluate the role of oral anticoagulation in patients with stage 5 chronic kidney disease (CKD-5) or end-stage kidney disease (ESKD). Data Sources: A literature search of PubMed (January 2000 to July 1, 2021), the Cochrane Library, and Google Scholar databases (through April 1, 2021) was performed with keywords DOAC (direct-acting oral anticoagulant) OR NOAC or dabigatran OR rivaroxaban OR apixaban OR edoxaban AND end-stage kidney disease combined with atrial fibrillation (AF) or venous thromboembolism (VTE) OR pulmonary embolism OR deep-vein thrombosis. Study Selection and Data Extraction: Case-control, cohort, and randomized controlled trials comparing DOACs to an active control for AF or VTE in patients with CKD-5 or ESKD and reporting outcomes of stroke, recurrent thromboembolism, or major bleeding were included. Data Synthesis: Nine studies were included. Efficacy data supporting routine use of warfarin or DOACs in CKD-5 or ESKD are limited. Rivaroxaban and apixaban may provide enhanced safety compared to warfarin in patients with AF. Data for VTE are limited to 1 retrospective study. Relevance to Patient Care and Clinical Practice: Because of the paucity of rigorous, prospective studies in CKD-5 or ESKD, OACs should not be broadly used in this population. It is clear that data regarding efficacy of DOACs cannot be reliably and safely extrapolated from the non-ESKD population. Therefore, use of OACs in this population should be individualized. Conclusions: If OACs for stroke prevention with AF are deemed necessary, apixaban or rivaroxaban can be considered. DOACs cannot currently be recommended over warfarin in patients with CKD-5 or ESKD and VTE.

OBJECTIVES:This study evaluated the occurrence of major bleeding following the initiation of oral anticoagulation therapy in patients with end-stage kidney disease (ESKD) in a community teaching hospital. METHODS:This was a single-center retrospective study that enrolled patients admitted to the study hospital with ESKD and who received oral anticoagulation (warfarin or nonvitamin K oral antagonists [NOACs]). The primary endpoint was the occurrence of major bleeding at any time while taking oral anticoagulation. Key secondary endpoints included occurrence of minor bleeding, thrombotic events, and hospitalizations because of bleeding or thrombosis. RESULTS:There were 36 patients who received warfarin and 32 patients who received a NOAC. A major bleeding event occurred in 15 of 36 patients (42%) in the warfarin group and in 5 of 32 patients (16%) in the NOAC group (P = 0.032). Hospitalizations as a result of either a bleeding event or a thrombosis occurred in 19 of 36 patients (53%) in the warfarin group and in 8 of 32 patients (25%) in the NOAC group (P = 0.026). The majority of patients in the NOAC group (69%) received a reduced dose for the indication. CONCLUSIONS:Warfarin increased the risk of major bleeding in patients with ESKD compared with NOACs and did not reduce the risk of thrombotic events.

Introduction: Evidenced-based clinical reasoning and literature evaluation skills are essential aspects of pharmacy education and a variety of methods to incorporate these skills into the pharmacy curriculum exist. The authors sought to determine whether an evidence-based pharmacotherapy (EBP) elective course that focused on journal club presentations improved performance during Advanced Pharmacy Practice Experiences (APPEs). Methods: Students enrolled in the EBP course were compared to peers not enrolled in the course during the 2009-2011 academic years. Student performance in patient care, clinical reasoning, and literature evaluation domains was assessed. These domains included scores on APPEs, pharmaceutical care ability profile (PCAP), journal clubs, patient presentations, and seminars. Results: This analysis included 368 APPEs completed by EBP students and 2922 APPEs completed by non-EBP students. Mean scores on APPEs were 90.36% and 89.75% for the EBP and non-EBP groups (p=0.218). Performance on other measures of clinical reasoning and literature evaluation were also comparable. Conclusion: The analysis of this study found that enrollment in an elective course focused on intensive literature evaluation, presentations, and clinical application did not result in measurable differences in existing performance metrics during APPEs.

Abstract Background Altered pharmacokinetics in obese patients raise concerns over worse clinical outcomes. This study assessed whether obese patients receiving a β-lactam have worse clinical outcomes compared to nonobese patients and to identify if therapeutic drug monitoring may be beneficial. Methods This multicenter, retrospective cohort included hospitalized adults admitted from July 2015 to July 2017 treated with a β-lactam as definitive monotherapy against a gram-negative bacilli for ≥72 hours. Patients were excluded if there was lack of source control or if polymicrobial infections required >1 antibiotic for definitive therapy. Patients were classified based on body mass index (BMI): nonobese (BMI ≤29.9 kg/m2) and obese (BMI ≥30.0 kg/m2). The primary outcome was clinical treatment failure, and secondary outcomes were hospital length of stay, inpatient all-cause mortality, and 30-day all-cause readmission. Results There were 257 (43.6%) obese patients and 332 (56.4%) nonobese patients included. The most common infections were urinary (50.9%) and respiratory (31.4%). Definitive treatment was driven by third-generation cephalosporins (46.9%) and cefepime (44.7%). Treatment failure occurred in 131 (51%) obese patients and 109 (32.8%) nonobese patients (P < .001). Obesity and respiratory source were independently associated with increased likelihood of treatment failure. Obese patients were hospitalized longer than nonobese patients (P = .002), but no differences were found for all-cause mortality (P = .117) or infection-related readmission (0 = 0.112). Conclusions Obese patients treated with β-lactams have higher rates of treatment failure and longer hospitalization periods than nonobese patients. Future studies are needed to assess the impact of therapeutic drug monitoring and specific dosing recommendations for targeted infection types.

BACKGROUND:Anticoagulation is the mainstay of secondary stroke prevention in patients with atrial fibrillation; however, few studies have assessed the optimal timing for initiation of anticoagulation post cardioembolic stroke. In the 2 weeks following an acute cardioembolic stroke, the risk of recurrent stroke is as high as 8%, but this risk must be balanced against the risk of hemorrhagic transformation with early initiation of anticoagulation.PURPOSE:This study described the time to initiation of anticoagulation and evaluated the in-hospital incidence of hemorrhagic and ischemic complications in 106 patients with atrial fibrillation post an acute cardioembolic stroke.METHODS:A single-center retrospective cohort study was conducted to describe the time to initiation of therapeutic anticoagulation in patients with atrial fibrillation admitted to the hospital for an acute cardioembolic stroke. The primary outcome was the time to initiation of anticoagulation from the time of stroke onset. Secondary outcomes included the incidence of in-hospital hemorrhagic and ischemic complications.RESULTS:The median time to initiation of anticoagulation was 59.5 hours after stroke onset for those who did not receive thrombolytic therapy and 82.6 hours for those who did received thrombolytic therapy. Out of 100 patients initiated on anticoagulation, no ischemic complications were observed. Four patients experienced a hemorrhagic conversion following initiation of anticoagulation. In 3 of these patients, anticoagulation was initiated within 48 hours of stroke onset.CONCLUSION:A small percentage of patients experienced an in-house hemorrhagic conversion when anticoagulation was initiated between 48 hours and 7 days.

OBJECTIVE To assess the current use of β-blockers in patients with compelling indications for use, following the acute exacerbation of chronic obstructive pulmonary disease (COPD). METHODS We performed a multicenter retrospective observational study using data from all of the patients admitted to five institutions for an acute exacerbation of COPD. Patients were included if they were admitted for an acute exacerbation of COPD and had a compelling indication for the use of a β-blocker, defined as previous myocardial infarction or heart failure with left ventricular ejection fraction ≤40%. RESULTS There were 396 patients meeting the criteria for inclusion in the study. The population was predominantly white men with myocardial infarction as the most prevalent compelling indication. On admission, 267 (67.4%) patients were receiving β-blockers, which increased to 278 (70.2%) at discharge. There were 118 (29.8%) patients discharged without β-blockers. Of the predictors tested, none were significantly predictive of a patient not receiving β-blockers upon discharge; however, home and in-hospital β-blockers reduced the likelihood of being discharged without a β-blocker. Of the 129 patients not receiving β-blockers prehospitalization, 23 (17.8%) were discharged with a new prescription for a β-blocker. CONCLUSIONS Nearly one-third of patients with compelling indications for β-blockers were not prescribed the therapy at discharge.

BACKGROUND AND PURPOSE:The Society of Teachers of Family Medicine Group on Pharmacotherapy recommends a formal curriculum during family medicine residency training and describes benefits of utilizing pharmacists. Limited literature exists on how programs have incorporated questions from family medicine board preparation sources into pharmacotherapy academic education. The primary objective was to assess the impact on family medicine residents' perceived knowledge after incorporation of board review items into pharmacotherapy sessions.EDUCATIONAL ACTIVITY AND SETTING:Pharmacists affiliated with the University of Alabama Family Medicine Residency program incorporated questions from board preparation sources into monthly interactive pharmacotherapy sessions as part of a didactic curriculum between 2014 and 2016. An anonymous survey was administered for two consecutive years in 2015 and 2016 to assess residents' perceptions of the sessions and utilization of board-type questions as an active learning component. The change in residents' perception of knowledge was quantitatively analyzed and written comments were evaluated for recurring themes.FINDINGS:The cumulative survey response was 78% (68/87). Over 80% of residents reported that pharmacotherapy sessions and the use of board-type questions was quite or very helpful. The percent of residents that rated their knowledge as good or excellent significantly increased after every session compared to baseline. Residents noted the sessions' information, applicability, interactive nature, and relevance as strengths.SUMMARY:Incorporation of board preparation questions into interactive pharmacotherapy sessions was well received and improved residents' perception of pharmacotherapy knowledge. Utilizing this model in a formal pharmacotherapy curriculum taught by pharmacists is beneficial for family medicine resident learners.

Background Pharmacist interventions have been shown to have an impact on reducing readmission rates, however further research is necessary to target resources to high-risk populations and determine the most effective bundle of interventions. Objective To evaluate the effect of a pharmacist-bundled intervention on 30-day readmission rates for high-risk patients with pneumonia. Methods A pilot study with a historical control conducted at a community, teaching-affiliated medical center. Up to 65 selected subjects were included if they had pneumonia and any of the following high-risk criteria: admission within 6 months, at least 5 scheduled home medications, chronic obstructive pulmonary disease (COPD), or heart failure. A retrospective chart review was conducted to compile the historical control group that received usual care between June and November 2013. Patients admitted from December 2013 through March 2014 were reviewed to receive a bundled intervention. The primary outcome was 30-day readmission rates. Risk factors and reasons for readmission, pharmacist clinical interventions, and the time interval between discharge and readmission were also evaluated. Results A trend toward a reduced 30-day readmission rate was observed in the intervention group ( n = 43) compared to those who received usual care ( n = 65) (27.9% vs 40.0%; relative risk [RR], 0.6977; 95% CI, 0.3965–1.2278; P = .2119). The most commonly identified high-risk inclusion criteria were having at least 5 scheduled home medications and COPD. The time interval between discharge and readmission did not considerably differ between groups (10.8 vs 10.6 days). Conclusions The pharmacist-bundled intervention was associated with a reduced 30-day readmission rate for high-risk patients with pneumonia.