Objective. To compare pre-and post-intervention test scores assessing insulin injection technique and counseling skills among P1 students with (intervention) or without (control) simulated patients, and to compare counseling checklist and knowledge retention test scores between groups. Methods. This study utilized cluster randomization. In addition to traditional instruction, the intervention group counseled a simulated patient on the use of insulin using the teach-back method. Test score changes from baseline were analyzed via two-sample t-test.Results. The intervention group exhibited a significantly greater increase in knowledge test scores from baseline compared to the control group. Similar changes were seen in post-instruction counseling checklist scores and knowledge retention test scores from baseline. Conclusion. Simulated patient interactions, when added to traditional coursework within a P1 skills lab, improve student counseling aptitude and knowledge retention scores.

Background: Coronavirus disease 2019 (COVID-19) can cause serious complications such as multiorgan failure and death which are difficult to predict. We conducted this retrospective case-control observational study with the hypothesis that low serum albumin at presentation can predict serious outcomes in COVID-19 infection. Methods:We included severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) reverse transcriptase-polymerase chain reaction (RT-PCR) confirmed, hospitalized patients from March to July 2020 in a tertiary care hospital in the USA. Patients were followed for 21 days for the development of the primary endpoint defined as the composite outcome which included acute encephalopathy, acute kidney injury, the requirement of new renal replacement therapy, acute hypercoagulability, acute circulatory failure, new-onset heart failure, acute cardiac injury, acute arrhythmia, acute respiratory distress syndrome (ARDS), high flow oxygen support, intensive care unit (ICU) stay, mechanical ventilation or death; and the secondary endpoint of death only. Univariate and multivariate logistic regression analyses were performed to study the effect of albumin level and outcomes. Results:The mean age was 56.76 years vs. 55.67 years (P = 0.68) in the normal albumin vs. the low albumin group. We noticed an in-verse relationship between serum albumin at presentation and serious outcomes. The low albumin group had a higher composite outcome (93.88% vs. 6.12%, P < 0.05) and higher mortality (13.87% vs. 2.38%, P < 0.05) in comparison to the normal albumin group. The multivariate logistic regression analysis revealed higher odds of having composite outcomes with lower albumin group (odds ratio (OR) 10.88, 95% confidence interval (CI) 4.74 -24.97, P < 0.05). In the subgroup analysis, the multivariate logistic regression analysis revealed higher odds of having composite outcomes with the very low albumin group (OR 7.94, 95% CI 1.70 -37.14, P < 0.05).Conclusions: Low serum albumin on presentation in COVID-19 infection is associated with serious outcomes not limited to mortality. The therapeutic option of albumin infusion should be investigated.

Acute pancreatitis has numerous etiologies, with the most common including gallstones, alcohol abuse, and medications such as angiotensin-converting enzyme (ACE) inhibitors, statins, and diuretics. Mirtazapine has been associated with increased serum cholesterol and serum triglyceride levels. However, few studies have reported dangerously elevated triglyceride levels resulting in acute pancreatitis. This report discusses a case of mirtazapine-induced pancreatitis in a 46-year-old African American female. The patient presented to the emergency department with pancreatitis, presumably alcohol-induced as with a prior admission, but she denied any recent alcohol use. Mirtazapine then became the suspected cause of her hypertriglyceridemia-induced pancreatitis and was discontinued. After discontinuing mirtazapine, and utilizing an insulin infusion, her triglyceride levels normalized and symptoms of pancreatitis resolved. Using the Naranjo Adverse Drug Reaction Probability Scale, a total score of 5 was calculated indicating a probable adverse drug reaction of acute pancreatitis from mirtazapine.

Introduction: Decreased well-being in medical careers has resulted in increased burnout, errors, and patient mortality rates. However, while well-being and burnout of providers and medical residents has been studied previously, it is difficult to apply this information to pharmacy residents as the programs are different in time, focus, and requirements. In addition, differences in resident demographics and goals further elucidate difficulties in applying these findings to well-being of pharmacy residents.With residency program directors (RPDs) often having the first and most frequent contact with pharmacy residents, ensuring these individuals better understand resident well-being could facilitate increased well-being and satisfaction, as well as stronger connections to the program itself.Objective: The primary objective was to identify discrepancies between residents and RPDs in the perception of resident well-being. Methods: This was a pilot cohort study. Resident and RPD responses were solicited utilizing Listservs of RPDs in 15 states, as well as platforms such as the North Carolina Association of Pharmacist's Residency Community.Results: Residents reported a statistically significant lower overall well-being, with only 49.1% of respondents reporting a "good" or "great" level of well-being, as compared with 80.1% of RPDs reporting their residents' well-being as "good" or "great" (P < .001). Secondary end points, such as perception of communication, relationships, and emotional health, revealed similar significant results of RPDs' higher perception of resident well-being in comparison with resident responses. Of the 15 secondary end points evaluated, 13 showed residents reporting a lower well-being score compared with the RPDs' perception.Conclusion: There is a large disparity between residents' perception and RPDs' perception of well-being. This disparity should be viewed as an opportunity to foster conversation, improve well-being, and implement change in pharmacy residencies across the country. Further studies could be beneficial in understanding specific, successful initiatives that promote higher well-being scores among pharmacy residents.

Background:There remains variability in both practice and evidence related to optimal initial empiric dosing strategies for vancomycin.Objective:Our primary objective was to describe the percentage of obese patients receiving vancomycin doses consistent with nomogram recommendations achieving targeted initial steady-state serum vancomycin concentrations. Secondary objectives were to describe the primary endpoint in subgroups based on patient weight and estimated creatinine clearance, to describe the rate of supratherapeutic vancomycin accumulation following an initial therapeutic trough concentration, and to describe the rate of vancomycin-related adverse events.Methods:This single-center, IRB-approved, retrospective cohort included adult patients ≥ 100 kilograms total body weight with a body mass index (BMI) >30 kilograms/m2 who received a stable nomogram-based vancomycin regimen and had at least one steady-state vancomycin trough concentration. Data collected included vancomycin regimens and concentrations, vancomycin indication, serum creatinine, and vancomycin-related adverse events. Patients were divided into two cohorts by goal trough concentration: 10-15 mcg/mL and 15-20 mcg/mL.Results:Of 325 patients screened, 85 were included. Goal steady-state concentrations were reached in 42/85 (49.4%) of total patients.Conclusions:Achievement of initial steady-state vancomycin serum concentrations in the present study (approximately 50%) was consistent with the use of published vancomycin dosing nomograms.

Interprofessional team-based care has become the standard for practicing clinical pharmacists. However, it is difficult to simulate every aspect of this environment in the didactic curriculum. The purpose of this study was to determine if the addition of standardized patients (SP) or interprofessional student teams with SPs, to the use of a simulated electronic health record (EHR) improved student knowledge retention and perceptions. Methods. This was a prospective cohort study assessing three cohorts of first-year student pharmacists in pharmacy skills laboratory activities that occurred in 2018, 2019, and 2021. The primary objective of the study was to compare knowledge retention at 1-month related to the case material between groups. Each year an element of simulated experience was added onto the previous year's case. In 2018, students completed the case using the EHR web application only. In 2019, an objective structured clinical examination (OSCE) with SPs was combined with the previous year's experience. In 2021, student physician assistants were added to the 2019 experience. Case scores and student perceptions were also compared between groups.Results. Of the 260 potential participants, 238 students were included in the primary analysis. Significant improvement was demonstrated in one-month knowledge retention assessments with the addition of interprofessional team-based care and SPs. Mean knowledge retention assessment scores were 63.8%, 71.7%, and 76.1% respectively. There was also significant improvement in student perceptions. Conclusion. The addition of SPs and interprofessional team-based care to a pharmacy skills laboratory that utilizes a simulated EHR significantly improved student knowledge retention and perceptions.

Background: Area under the curve to minimum inhibitory concentration (AUC/MIC) has been recommended by the 2020 updated vancomycin guidelines for dosing vancomycin for both efficacy and safety. Previously, AUC/MIC has been cumbersome to calculate so surrogate trough concentrations of 15-20 mg/dL were utilized. However, trough-based dosing is not a sufficient surrogate as AUC/MIC targets of 400-600 can usually be reached without achieving troughs of 15-20 mg/dL. Targeting higher trough levels may also lead to adverse events including acute kidney injury (AKI) and nephrotoxicity. Objective: To compare the mean total first day vancomycin dose in traditional trough-based dosing versus dosing recommended by an AUC/MIC dosing program. Methods: Adult inpatients who received at least 24 hours of IV vancomycin treatment were included in this single-center, retrospective cohort study. The primary endpoint was difference in mean total first day vancomycin dose in milligrams (mg) received between patients’ traditional trough-based dosing and recommended dose via AUC/MIC electronic dosing calculator. Patients served as their own control by analyzing both actual dose received and dose recommended by the electronic AUC/MIC program. Rates of vancomycin induced adverse events, including acute kidney injury, elevated steady-state trough concentrations, and Red Man’s syndrome were also compared between patients who received doses consistent with the AUC/MIC dosing recommendation versus those who did not. Results: 264 patients were included in this study. Initial 24-hour vancomycin exposure was significantly lower with the recommended AUC/MIC dose versus the dose received (2380.7; SD 966.6 mg vs 2649.6; SD 831.8 mg, [95% CI 114.7:423.1] p=0.0007). Conclusions: Utilizing an electronic AUC/MIC vancomycin dosing calculator would result in lower total first day vancomycin doses.

The Impella devices are percutaneous intravascular ventricular assist devices indicated for use in patients with cardiogenic shock that occurs following acute myocardial infarction (MI) or open heart surgery. These devices must be used with a purge solution that contains heparin per manufacturer recommendation, which will prevent blood from reaching the motor causing pump thrombosis and mechanical failure. We describe the utilization of a dextrose-only purge solution plus systemic argatroban in 2 patients with suspected heparin-induced thrombocytopenia (HIT). Each case describes a patient with suspected HIT following Impella placement for cardiogenic shock post-MI that had an increased bleeding risk. In each case, pharmacy monitored and adjusted the patients’ argatroban, resulting in therapeutic anticoagulation without major bleeding or thrombotic events. These case reports demonstrate that use of a dextrose-only purge solution in the Impella device may be a safe and effective option when combined with systemic argatroban in patients with suspected or confirmed HIT who exhibit increased bleeding risk. Further research is needed to determine the optimal concentrations and duration of anticoagulation-free purge solution in these patients.