Clinicians should continue to weigh the risk of stroke versus bleeding before prescribing DOACs in the CKD and dialysis population.

BackgroundPatients undergoing hemodialysis frequently report pain with multifactorial causes, not limited to that experienced directly from hemodialysis treatment. Their pain may be nociceptive, neuropathic, somatic or visceral in nature. Despite this, pain in this population remains under-recognized and under-treated. Although several tools have been used to measure pain in patients undergoing hemodialysis as reported in the literature, none of them have been validated specifically in this population. The objective for this review was to compare and contrast these pain assessment tools and discuss their clinical utility in this patient population.MethodsTo identify pain assessment tools studied in patients undergoing hemodialysis, a literature search was performed in PubMed and Medline. An expert panel of dialysis and pain clinicians reviewed each tool. Each pain assessment tool was assessed on how it is administered and scored, its psychometric properties such as reliability, validity and responsiveness to change, and its clinical utility in a hemodialysis population. Brief Pain Inventory, McGill Pain Questionnaire, Pain Management Index, Edmonton Symptom Assessment System, Visual Analogue Scale and Faces Pain Scale were evaluated and compared.ResultsThis assessment will help clinicians practicing in nephrology to determine which of these pain assessment tools is best suited for use in their individual clinical practice.

Warfarin is frequently used in the hemodialysis (HD) population for atrial fibrillation (AF) and venous thromboembolism (VTE); however, there is insufficient evidence to support this practice. Given that HD patients have 3 - 10 times the risk for both stroke and bleeding than the general population, anticoagulation in these patients is controversial. Time in therapeutic range (TTR) is accepted as a surrogate outcome of clinical effectiveness and safety of warfarin. The primary objective of this study was to evaluate TTR in an HD population. A 6-year retrospective chart review was performed in 46 HD patients on warfarin (target international normaized ratio (INR)=2-3). One year of patient data was collected, which included weekly INRs, demographics and clinical outcomes. TTR was calculated using the Rosendaal and fraction of INRs in range methods. The mean TTR using the Rosendaal and fraction of INRs in range method was 49.2±14.6% and 44.2±13.5%, respectively. Patients were 3 times more likely to be below target than above it, suggesting they were more often at risk of inadequate efficacy rather than toxicity. There were 9 serious bleeding and 9 thrombotic events; these occurred in patients with a TTR<60%. For the 9 serious bleeding events, the median INR on the day of the event was 2.1 (IQR 1.81-2.75). In conclusion, this HD unit is not meeting the TTR goal established in the literature and patients are often subtherapeutic. Further studies to investigate ways to improve TTR are warranted. Ultimately, a prospective study evaluating the safety and efficacy of warfarin in HD patients is needed.

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Background: People transitioning from hospital-to community-based care are at increased risk of experiencing medication problems that can lead to adverse drug events and poor health outcomes. Community pharmacists provide medication expertise and support during care transitions yet are not routinely included in communications between hospitals and other primary health care providers. The PhaRmacy COMmunication ParTnership (PROMPT) intervention facilitates medication management by optimizing information sharing between pharmacists across care settings. This developmental evaluation sought to assess the feasibility and acceptability of implementing the PROMPT intervention, and to explore how contextual factors influenced its implementation. Methods: PROMPT was implemented for 14 weeks (January-April, 2018) in the general internal medicine units at two teaching hospitals in Toronto, Canada. PROMPT featured two contact points between hospital and community pharmacists around patient discharge: (1) faxing an enhanced discharge prescription and discharge summary to a patient's community pharmacy and (2) a follow-up phone call from the hospital pharmacist to the community pharmacist. Our mixed-method evaluation involved electronic patient records, process measures using tracking forms, telephone surveys and semi-structured interviews with participating community and hospital pharmacists. Results: The intervention involved 45 patients with communication between 12 hospital and 45 community pharmacists. Overall, the intervention had challenges with feasibility. Issues with fidelity included challenges with the medical discharge summary being available at the time of faxing and hospital pharmacists' difficulties with incorporating novel elements of the program into their existing practices. However, both community and hospital pharmacists recognized the potential benefits to patient care that PROMPT offered, and both groups proposed recommendations for further improvements. Suggestions included enhancing hospital staffing and resources.

Objective. To describe students' experiences and perceptions of non-traditional student-preceptor learning models and evaluate the effectiveness of these models on students' learning experience. Methods. Pharmacy students who had completed at least one experiential rotation with a nontraditional learning model participated in semi-structured interviews. Models included peer-assisted learning (PAL; two or more students of same educational level), near-peer teaching (NPT; one or more junior students with one or more senior students), and co-preceptorship (CoP; two or more preceptors). Interviews were transcribed, coded, and analyzed for themes. Themes were mapped according to the Kirkpatrick model for evaluating educational training. Results. Twenty semi-structured interviews were conducted. Forty-three experiences (19 CoP, 14 PAL, 10 NPT) from 14 institutions were described. Many themes overlapped between the three models. In CoP, learners described increased preceptor availability and exposure to different patient care approaches. Challenges arose when preceptors had different expectations. Students overwhelmingly endorsed a multi-learner environment. Both PAL and NPT learners felt supported as collaboration with other learners was readily fostered. Potential challenges in PAL and NPT were difficulties when personalities conflicted and when there was a significant knowledge gap between the learners. All three models allowed for the development of skills, including communication and collaboration. Learners reported an enhanced approach to patient care and professional practice, including approaches to teaching as new preceptors. Conclusion. Pharmacy students and graduates valued their experiences in non-traditional studentpreceptor models. Institutions may find support for using these precepting models to increase placement capacity.

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Objective. To assess students' impressions on whether Virtual Interactive Cases (VIC) contribute to their learning experience. Methods. Ten 4th year pharmacy students each independently completed the same four VIC cases followed by a semi-structured interview conducted by VIC project team members. The interviews were audio-recorded, transcribed, and coded for themes using qualitative research methods.Results. All participating students completed all of the cases. Overall, students' feedback on VIC was positive. Five main themes emerged from the transcripts: 1) VIC facilitated their skills in information gathering; 2) they learned from the built-in, real-time, formative feedback; 3) they had a fun and positive learning experience; 4) VIC cases were realistic; and 5) VIC system was user- PAP Manuscript A J P EA c c e p t e d D r a f t friendly. Students also recommended that VIC be incorporated into classroom learning. Some students required additional explanation on the concept of time and costs associated with each action they selected, and the associated performance score. Conclusion.Pharmacy students' positive experiences with VIC cases support its use to bridge classroom learning with clinical practice.