After adjusting for propensity to receive each of the treatment choices, no significant difference was found in the incidence of AKI development or other outcomes between the groups. The previously described finding that concomitant vancomycin and piperacillin-tazobactam increases AKI in non-critically ill patients may not be generalizable to the critically ill population. Prospective evaluation of this hypothesis is warranted.

OBJECTIVES To compare the predictive validity of the 2003 Beers, 2012 Beers, and STOPP Criteria. DESIGN Retrospective cohort. SETTING Managed care administrative claims data from 2006 to 2009 PARTICIPANTS 174,275 commercially insured persons 65 and older in the United States. MEASUREMENTS Association between adverse drug events, emergency department (ED) visits, and hospitalization outcomes and inappropriate medications using time-varying Cox proportional hazard models. Measures of model discrimination (c-index) and hazard ratios (HR) were calculated to compare unadjusted and adjusted models for associations. RESULTS The prevalence of inappropriate prescribing was 34.1%, 32.2%, and 27.6% for the 2012 Beers, 2003 Beers, and the STOPP Criteria. Each criteria modestly discriminated ADEs in unadjusted analyses: STOPP Criteria (HR=2.89 [2.68–3.12]; C-index=0.607), 2012 Beers Criteria (HR=2.51 [2.33–2.70]; C-index=0.603), 2003 Beers Criteria (HR=2.65 [2.46–2.85]; C-index=0.605). Similar results were observed for ED visits and hospitalizations. Adjusted analyses increased the c-indices to between 0.65 and 0.70. The kappa for agreement between criteria was 0.80 for the 2003 and 2012 Beers Criteria, 0.58 for the 2012 Beers and STOPP Criteria, and 0.59 for the 2003 Beers and STOPP Criteria. For the three outcomes, the 2012 Beers Criteria had the highest sensitivity (61.2%–71.2%) and the lowest specificity (41.2%–70.7%) while the STOPP Criteria had the lowest sensitivity (53.8%–64.7%) but the highest specificity (47.8%–78.1%). CONCLUSIONS All three criteria were modestly prognostic for ADEs, EDs, and hospitalizations with the STOPP Criteria slightly outperforming both Beers Criteria. With low sensitivity, low specificity, as well as low agreement between the criteria, these criteria can be used in a complementary fashion to enhance sensitivity of detecting ADEs.

Background:Acid suppression therapy (AST) is routinely used in critically ill patients to prevent stress-related mucosal bleeding (SRMB).Objective:Our objective was to determine the impact of a structured educational intervention on AST used for prevention of SRMB on appropriateness of AST.Methods:A single-center, retrospective, cohort study of appropriate use of AST in critically ill patients admitted to the medical intensive care unit (ICU) at an academic medical center between January to June of 2014 (no intervention) and January to June of 2015 (intervention) was conducted. The percentage of patients prescribed inappropriate AST, inappropriate AST at ICU transfer and hospital discharge, doses of inappropriate AST, and adverse effects associated with AST use were compared between periods using chi-square tests.Results:Patients in the intervention group (n=118) were 5 years older than patients in the no intervention group (n=101). AST was inappropriately initiated more frequently in the no intervention group (23% vs. 11%, p=0.012). Continuation of inappropriate AST at ICU transfer and hospital discharge was similar between groups (60% vs. 53%, p=0.277 and 18% vs. 14%, p=0.368, respectively).Conclusion:Patients had appropriate AST initiated and inappropriate AST withheld more frequently when formal education was provided. This low-cost intervention strategy can be implemented easily at institutions where pharmacists interact with physicians on rounding services and should be evaluated in institutions where interactions between pharmacists and physicians occur more frequently in non-rounding situations.

Adult patients receiving norepinephrine and vasopressin in the resolving phase of septic shock may be less likely to develop clinically significant hypotension if vasopressin is the final vasopressor discontinued.

Patients treated with early concomitant vasopressin and norepinephrine achieved and maintained MAP of 65 mm Hg faster than those receiving initial norepinephrine monotherapy, suggesting that overcoming vasopressin deficiency sooner may reduce the time patients spend in the early phase of septic shock.

Early initiation of vasopressin in patients with septic shock may achieve and maintain goal MAP sooner and resolve organ dysfunction at 72 hours more effectively than later or no initiation.

Immunohistochemistry (IHC) has been somewhat underutilized in the practice of toxicological pathology but can be a valuable tool for the evaluation of rodent neoplasms, both in a diagnostic and an investigational role. Determining an exact tumor type using standard hematoxylin and eosin (H&E) staining of formalin-fixed tissues can be challenging, especially with metastatic and/or poorly differentiated tumors. Successful IHC is dependent on many factors, including species and tissue type, type and duration of fixation, quality fresh or frozen sectioning, and antibody specificity. The initial approach of most tumor diagnosis IHC applications is distinguishing epithelial from mesenchymal differentiation using vimentin and cytokeratin markers, although false-negative and/or false-positive results may occur. Experimentally, IHC can be employed to investigate the earliest changes in transformed tissues, identifying cellular changes not normally visible with H&E. Individual markers for proliferation, apoptosis, and specific tumor proteins can be used to help distinguish hyperplasia from neoplasia and determine specific tumor origin/type. IHC provides a relatively rapid and simple method to better determine the origin of neoplastic tissue or investigate the behavior or progression of a given neoplasm. Several experimental and diagnostic examples will be presented to illustrate the utility of IHC as a supplement to standard staining techniques.

Pharmacists in hospitals and health systems can play a key role in recognizing the various forms of opioid toxicity and in preventing inappropriate prescribing and diversion of opioids.