BACKGROUND AND OBJECTIVE:Performing lipid testing after statin initiation is recommended to monitor response. Inadequate response may indicate non-adherence, which is associated with an increased risk of cardiovascular events and increased costs. Group-based trajectory modeling is an approach to establish probabilistic developmental trajectories of adherence, differentiating individuals by their distinct longitudinal medication-taking behaviors. We examined whether lipid testing is associated with distinct trajectories of statin adherence among individuals enrolled in a Medicare fee-for-service plan in the USA. METHODS:A retrospective cohort study was conducted using the Centers for Medicare & Medicaid Chronic Condition Warehouse 5% sample of Medicare fee-for-service data between 2006 and 2015. Statin use and lipid testing were identified using claims data. The proportion of days covered was calculated for each 30 days after the index date, which was used to estimate the probability of belonging to each potential adherence trajectory. RESULTS:In a cohort of 138,101 statin initiators, four statin adherence trajectory groups were identified. The four groups were differentiated as "rapid decline" (21.53%), "gradual decline" (10.25%), "decline first then improve later" (26.47%), and "high adherence" (41.75%). Compared with "high adherence," initiators who had lipid tests within 360 days after statin initiation were less likely to fall into "rapid decline" (adjusted odds ratio: 0.661; 95% confidence interval 0.641-0.683), "gradual decline" (adjusted odds ratio: 0.834; 95% confidence interval 0.801-0.868), and "decline first then improve later" groups (adjusted odds ratio: 0.936; 95% confidence interval 0.910-0.962). CONCLUSIONS:Lipid testing is positively associated with greater use of statin medication across different adherence trajectories in the present study.

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

Background: Sympathetic crashing acute pulmonary edema (SCAPE) is a medical emergency in which severe, acute elevation in blood pressure results in acute heart failure and fluid accumulation in the lungs. Without prompt recognition and treatment, the condition often progresses rapidly to respiratory failure necessitating in-tubation and intensive care unit (ICU) admission. In addition to non-invasive positive pressure ventilation (NIPPV), high-dose nitroglycerin (HDN) has become a mainstay of treatment; however, an optimal dosing strat-egy has not been established.Objective: The purpose of this study was to describe the characteristics and outcomes of patients who received an HDN infusion (>= 100 Ng/min) for the management of SCAPE in the Emergency Department (ED) of a large urban academic medical center. Outcomes were also analyzed to determine predictors of safety and efficacy including use of adjunct medication therapies. Results: There were 67 adult patients who received HDN infusion for SCAPE from January 1, 2018 to December 31, 2018. The median (IQR) systolic blood pressure (SBP) on initiation of HDN infusion was 211 (192-233) mmHg. Patients were 63% male, 84% black, 51% had a history of heart failure (HF), and 36% had end-stage renal disease (ESRD). IV nitroglycerin (NTG) was initiated at a median (IQR) dose of 100 (100-200) mcg/min with median (IQR) peak rate in the first hour of 200 (127.5-200) mcg/min and an absolute maximum observed rate of 400 Ng/min overall. 73% of patients received NIPPV, 48% sublingual (SL) or IV bolus nitroglycerin before HDN infusion, 58% loop diuretic, and 34% angiotensin-converting enzyme inhibitor (ACE\\I) or angiotensin II receptor blocker (ARB). Rates of ICU admission, intubation, acute kidney injury (AKI) at 48 h, and hypotension were 37%, 21%, 13%, and 4% respectively.Conclusion: This is the largest to date study describing the use of an HDN infusion (>= 100 Ng/min) strategy for the management of SCAPE. HDN infusion may be a safe alternative strategy to intermittent bolus HDN.(c) 2022 Elsevier Inc. All rights reserved.

Landolf, Kaitlin1; Noh, Judy2; Devabhakthuni, Sandeep3; Heavner, Mojdeh4 Author Information

PURPOSE:The purpose of this study was to gauge postgraduate year 1 (PGY1) pharmacy residency candidates' reactions to supplemental applications, as well as aspects specific to our process, including a personality test and situational judgment test (SJT).METHODS:After rank lists were submitted, applicants to our program were invited to complete an online survey. Outcomes of interest included candidates' perceptions of relevance and fairness. Whether candidates' attitudes differed based on the receipt of an interview offer was also assessed.RESULTS:Of 199 applicants to our program for the 2021-2022 training year, 48 applicants (24.1%) completed the survey, 15 of whom had received an interview offer. Most (64.6%) agreed that supplemental applications were useful, and nearly all (95.8%) indicated that they were willing to submit one for programs in which they were most interested. The process was seen as being fair, although ratings were higher among those who received interview offers. Most respondents believed that the personality test and SJT were relevant to the role of a resident, but attitudes towards the SJT were generally more favorable and less likely to vary according to whether candidates received an interview offer. Candidates believed that the personality test and SJT were not as representative of them as letters of reference or their curriculum vitae, but perceptions of academic performance varied.CONCLUSION:Applicants responded positively to our supplemental application and indicated that they would be willing to complete one for programs of interest. These findings should help assuage concerns about the use of supplemental applications, particularly when short-answer or essay formats are avoided.

Purpose To help ensure that we were accurately and consistently evaluating applicants to our postgraduate year 1 (PGY1) pharmacy residency program, we performed a job analysis to inform a redesign of our selection process. A diverse panel of subject matter experts from our program was convened to develop a task inventory; a list of knowledge, skills, abilities, and other characteristics necessary for success in our program; and behavioral snapshots representing especially strong or weak resident performance (ie, critical incidents). After achieving a priori thresholds of consensus, these items were used to augment our application screening instrument (eg, development of anchored rating scales), build an online supplemental application consisting of a personality test and situational judgment test, develop a work sample consisting of a patient case presentation, and enhance the structure of our interviews (eg, by asking a consistent pattern of questions for all candidates). Preceptors reported that the redesigned process was more organized, easier to complete, and facilitated greater rating consistency. Conclusion Job analysis represents an approach to designing selection processes that are more valid, reliable, transparent, and fair. Based on our experiences, recommendations for those who are considering changes to their selection process are provided.

Journal Article Corrected proof A comprehensive approach to an effective training program for new pharmacy residency preceptors Get access Sandeep Devabhakthuni, PharmD, BCCP, Sandeep Devabhakthuni, PharmD, BCCP University of Maryland School of Pharmacy, Baltimore, MD, USA Address correspondence to Dr. Devabhakthuni (sdevabha@rx.umaryland.edu). Twitter: @deepdev511 Search for other works by this author on: Oxford Academic Google Scholar Carley Castelein, PharmD, BCPS, CPPS, Carley Castelein, PharmD, BCPS, CPPS Medication Safety and Systems Innovation, HCA Healthcare, Nashville, TN, USA Search for other works by this author on: Oxford Academic Google Scholar C Whitney White, PharmD, BCPS, FASHP, FALSHP C Whitney White, PharmD, BCPS, FASHP, FALSHP Samford University, McWhorter School of Pharmacy, Homewood, AL, USA Search for other works by this author on: Oxford Academic Google Scholar American Journal of Health-System Pharmacy, zxac374, https://doi.org/10.1093/ajhp/zxac374 Published: 16 December 2022 Article history Published: 16 December 2022 Corrected and typeset: 11 January 2023

Background: Congestion predominates in exacerbations of heart failure with reduced ejection fraction (HFrEF) or preserved ejection fraction (HFpEF), but evidence suggests that excess volume may be distributed differently in these 2 subgroups. Methods and Results: In this retrospective study, diuretic efficiency (DE, or net urine output per 40-mg of intravenous furosemide equivalent) during the first 72 hours was compared between patients hospitalized with HFrEF (n = 121) versus HFpEF (n = 120). Multivariate analysis was used to compare the 2 groups based on expected baseline differences (e.g., demographics, heart failure etiology, concomitant therapy). During the first 72 hours, mean daily diuretic doses were higher in patients with HFpEF versus HFrEF (172.0 vs. 159.9 mg, respectively, P = 0.026) but urine output was not significantly different (2603.3 mL vs. 2667.5 mL, respectively, adjusted P = 0.100). Similarly, mean cumulative DE did not differ (−673.5 vs. −637.8 mL/40-mg in the HFrEF and HFpEF groups, respectively, adjusted P = 0.884). An exploratory analysis of propensity-matched cohorts yielded similar findings. Correlations between the components of DE varied considerably and only became weak to moderately correlated toward the end of the observation period. Conclusions: Although cumulative DE did not differ between patients with HFrEF and HFpEF, variable correlations in the components of DE suggest there may be differences in diuretic response that warrant future analysis.

Introduction: The American Society of Health-System Pharmacists (ASHP) accreditation standards for postgraduate training programs require a continuous improvement plan as a method of quality improvement (QI). The University of Maryland (UM) Residency and Fellowship Program offers several residency and fellowship programs. The primary objective of this QI project was to assess the perceived effectiveness of the UM's training program in preparing trainees for their desired career goals. A secondary objective was to acquire suggestions from graduates to assist in QI. Methods: A 12-question electronic survey was sent to UM residents and fellows who graduated between 2012 and 2016. Survey questions addressed the graduate's perception of their training experience. Graduates were also asked how well certain skills were taught based on core ASHP requirements. Participation was voluntary and responses were anonymous. Results: Seventy-five graduates were identified for potential inclusion, and 43 (57%) completed the survey. Findings revealed 88% of graduates were practicing in a position that matched their training and 95% indicated that their program prepared them adequately for their current job. Conclusions: The ASHP accreditation standards for pharmacy residency programs require an ongoing process of QI. This study provides support for use of an electronic survey as a helpful tool to assess effectiveness of a residency program.

Patients living with HIV (PLWH) are predisposed to atherosclerotic cardiovascular disease (ASCVD), resulting in concomitant antiretroviral and statin use. A statin prescribing gap for PLWH has been reported, but appropriateness of statin selection and dosing (ASD) has not been described.

Gout is the most common inflammatory arthritis and is often comorbid with cardiovascular disease (CVD). Hyperuricemia and gout are also independent risk factors for cardiovascular events, worsening heart failure (HF), and death. The recommended treatment modalities for gout have important implications for patients with CVD because of varying degrees of cardiovascular and HF benefit and risk. Therefore, it is critical to both manage hyperuricemia with urate-lowering therapy (ULT) and treat acute gout flares while minimizing the risk of adverse cardiovascular events. In this review, the evidence for the safety of pharmacologic treatment of acute and chronic gout in patients with CVD and/or HF is reviewed. In patients with CVD or HF who present with an acute gout flare, colchicine is considered safe and potentially reduces the risk of myocardial infarction. If patients cannot tolerate colchicine, short durations of low-dose glucocorticoids are efficacious and may be safe. Nonsteroidal anti-inflammatory drugs should be avoided in patients with CVD or HF. The use of canakinumab and anakinra for acute gout flares is limited by the high cost, risk of serious infection, and relatively modest clinical benefit. For long-term ULT, allopurinol, and alternatively probenecid, should be considered first-line treatments in patients with CVD or HF given their safety and potential for reducing cardiovascular outcomes. An increased risk of cardiovascular death and HF hospitalization limit the use of febuxostat and pegloticase as ULT in this population. Ultimately, the selection of agents used for acute gout management and long-term ULT should be individualized according to patient and agent cardiovascular risk factors.

Introduction: Cardiovascular disease remains a leading cause of morbidity and mortality. Since the description of its therapeutic potential, aspirin has been a cornerstone of therapy following vascular events. However, aspirin in the primary prevention setting is controversial and major guideline groups provide inconsistent recommendations. Thus, there is variability in practice as providers are faced with a balance of therapeutic benefit and drug-induced harm. Areas covered: This article provides a critical appraisal of both past and present data for aspirin in the primary prevention setting. PubMed and Cochrane Central Register databases were searched from inception to May 1st, 2019. Expert opinion: The decision to initiate or withdraw aspirin for primary prevention requires an understanding of the equilibrium between efficacy and safety. In adults greater than 70 years of age, low to moderate cardiovascular risk, controlled diabetes, or at high risk of bleeding, initiation of aspirin for primary prevention should generally be avoided. Instead, risk factor modification should be prioritized. The net benefit of aspirin in those at high risk for cardiovascular disease and in those with uncontrolled diabetes is largely unknown. Ultimately, initiation or withdrawal of aspirin therapy must involve discussion of the patient's wishes and treatment expectations.

PurposeTo determine the type and frequency of formalized (structured education developed to meet a set of predefined goals and provide educational content and learning materials) and nonformalized physical examination (PE) training offered to pharmacy residents in adult patient care-focused residency programs in the United States and Puerto Rico. MethodsA survey was distributed to a random sample of 1000 postgraduate year one and two adult patient care residency program directors. Participants were queried to determine if they offered PE training and the types of training offered. Barriers to and reasons for not providing PE training were assessed. Descriptive statistics were performed. ResultsThere were 122 respondents. Thirteen (10.7%) programs provide formalized PE training and six of these were postgraduate year 1 residencies (46.2%). Informal PE training resources were provided in 97/117 (82.9%) programs. The duration and scope of training programs varied. Forty-four of 116 (37.9%) responding programs required components of the PE in one or more rotations. The most commonly cited reasons for those who have not considered a formalized training program (n = 94) were that performing a PE is not part of the residency program (56.4%), lack of perceived value (45.7%), that PE is not part of the practice of the organization (43.6%), lack of trained clinicians (35.1%), lack of awareness that this type of training is available (35.1%), and lack of time in the schedule (31.9%) (respondents were able to select more than one). ConclusionMany pharmacy organizations endorse PE, yet formalized PE training does not appear to be routinely offered in adult patient care-focused residency programs. Reasons for not offering a formalized training program suggest that raising awareness of the benefits of pharmacists learning PE is warranted. As pharmacists seek provider status, the need to increase PE training in pharmacy residency programs may be necessary.

PURPOSE The primary objective was to evaluate the impact of an analgosedation protocol in a cardiac intensive care unit (CICU) on daily doses and costs of analgesic, sedative, and antipsychotic medications. METHODS We conducted a single-center quasi-experimental study in 363 mechanically ventilated patients admitted to our CICU from March 1, 2011, to April 13, 2013. On March 1, 2012, an analgosedation protocol was implemented. Patients in the pre-implementation group were managed at the cardiologist's discretion, which consisted of a continuous sedative-hypnotic approach and opioids as needed. Patients in the implementation group were managed using this protocol. RESULTS The mean ± S.D. per-patient doses (mg/day) of propofol, lorazepam, and clonazepam decreased with the use of an analgosedation protocol (propofol 132,265.7 ± 12,951 versus 87,980.5 ± 10,564 [p = 0.03]; lorazepam 10.5 ± 7.3 versus 3.3 ± 4.0 [p < 0.001]; clonazepam 9.9 ± 8.3 versus 1.1 ± 0.5 [p = 0.03]). The mean daily cost of propofol and lorazepam also significantly decreased (33.5% reduction in propofol cost [p = 0.03]; 69.0% reduction in lorazepam cost [p < 0.001]). The per-patient dose and cost of fentanyl (mcg/day) declined with analgosedation protocol use (fentanyl 2,274.2 ± 2317.4 versus 1,026.7 ± 981.4 [p < 0.001]; 54.8% decrease in fentanyl cost [p < 0.001]). CONCLUSION The implementation of an analgosedation protocol significantly decreased both the use and cost of propofol, lorazepam, and fentanyl. Further investigation of the clinical impact and cost-effectiveness of a critical care consultation service with implementation of an analgosedation protocol is warranted in the CICU.

We set out to synthesize available data on antithrombotic strategies for patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI), with a focus on triple antithrombotic therapy (triple therapy [TT]; dual antiplatelet therapy plus an anticoagulant) versus dual therapy (DT; one antiplatelet agent and an anticoagulant). We searched OVID MEDLINE and PubMed from January 2005 to September 2017 using the search terms oral anticoagulant, triple therapy, dual therapy, acute coronary syndrome, percutaneous coronary intervention, and atrial fibrillation (limited to randomized controlled trials, observational studies, English language, minimum 6–12 months of follow-up, minimum 100 human patients). We excluded surveys, literature reviews, articles not directly related to TT versus DT, incomplete studies, and short-term in-hospital studies. All eligible studies were reviewed to evaluate possible antithrombotic management strategies for patients with AF undergoing PCI. Extracted studies were categorized according to the specific anticoagulant (vitamin K antagonist vs. direct-acting oral anticoagulant) and P2Y12 inhibitor used. Each category review was followed by a discussion providing insight into the quality of evidence and implications for practice. We found that the risk of bleeding with TT was higher than with DT, without demonstrated added benefit of reducing major adverse cardiovascular events. TT use should be minimized in patients with high bleeding risk, and patient-specific factors should be critically analyzed to select appropriate antiplatelet and anticoagulant agents.

Hypertensive emergency is defined as a systolic blood pressure > 180 mmHg or a diastolic blood pressure > 120 mmHg with evidence of new or progressive end-organ damage. The purpose of this paper is to review advances in the treatment of hypertensive emergencies within the last 5 years.

Balancing the competing risks of thrombosis and bleeding among left ventricular assist device (LVAD) recipients remains a challenge, and no consensus exists regarding an optimal antithrombotic regimen. Additionally, whether adjusting therapy according to thromboelastography (TEG) or platelet