Houston Methodist Department of Pharmacy Annual Research Report 2018- 2019 by Houston Methodist Professional Publications

HOUSTON METHODIST DEPARTMENT OF PHARMACY Annual Research Report | 2018–2019

2018 – 2019 HOUSTON METHODIST POSTGRADUATE PHARMACY RESIDENCY & FELLOWSHIP CLASS Houston Methodist Department of Pharmacy The Department of Pharmacy collaborates with the health care team to provide innovative, personalized, cost-effective pharmaceutical care in a culture dedicated to quality and safety. Houston Methodist Department of Pharmacy’s vision is to be recognized as a global leader of pharmaceutical care in the healthcare setting. To that end, we strive to: • Continuously improve the quality and safety of patient care and the medication management process • Cultivate an environment of collaboration and teamwork • Provide high-quality training and education to our technicians, student interns, residents, and pharmacists • Maximize the use of automation and information technology • Maximize cost efficiencies and resource utilization

TABLE OF CONTENTS

2 | Letter from Daniel L. Metzen, PharmD, MBA

3 | Letter from Alex C. Varkey, PharmD, MS, FAPhA

System Director of Pharmacy Services, Houston Methodist Director of Pharmacy Services, Houston Methodist Hospital

4 | Pharmacy Research Committee Members

5 | Letter from Katherine K. Perez, PharmD

Chair of Pharmacy Research Committee

6 | Pharmacy Research Funding

8 | Pharmacy Awards & Recognitions

10–31 | 2018–2019 Houston Methodist Hospital Pharmacy Postgraduate Trainees 10 | PGY1 Pharmacy Residency Hayley Brazeale, PharmD Megan Cooper, PharmD Rodrigo De La Torre, PharmD Daniel Galipeau, PharmD Grace Hwang, PharmD Chelsea Lopez, PharmD

16 | PGY1 International Graduates

24 | PGY2 Infectious Diseases Pharmacy Residency

Ty Drake, PharmD, BCPS

25 | PGY2 Internal Medicine Pharmacy Residency teffany Nguyen, PharmD S

26 | PGY2 Oncology

Pharmacy Residency

Rana Aljadeed, PharmD Leroy Koh, PharmD Darin Yassine, PharmD

Lauren Bailey, PharmD Jade Hefler, PharmD

28 | PGY2 Solid Organ Transplant Pharmacy Residency

18 | PGY1/PGY2 Health-System Pharmacy Administration Residency

Niaz Deyhim, PharmD Akeem Bale, PharmD, MS, BCPS Stella Kim, PharmD, MS, BCPS

Erin Bilgili, PharmD Christine Pham, PharmD

28 | Clinical Pharmacy Fellowship

22 | PGY2 Critical Care Pharmacy Residency Jesse Harris, PharmD

Celia Morton, PharmD

32 | System Pharmacy Research Bibliography

in Outcomes Research Tomona Iso, PharmD Elsie Rizk, PharmD

LETTER FROM THE SYSTEM DIRECTOR OF PHARMACY SERVICES WITH THE 2018-2019 YEAR BEHIND US, THE ANNUAL RESEARCH REPORT highlights another year of the pharmacy teamâ&#x20AC;&#x2122;s dedication to excellence in patient care, a prominent characteristic spread throughout the pharmacy departments. Medication outcomes and economic research provide us knowledge and ultimately improve our ability to provide unparalleled quality care for the patients we serve. Thanks to the contributors of this report and thanks to the pharmacy teams for your innovation and commitment to our patients.

Daniel L. Metzen, PharmD, MBA System Director of Pharmacy Services

LETTER FROM THE DIRECTOR OF PHARMACY SERVICES ON BEHALF OF THE HOUSTON METHODIST HOSPITAL (HMH) PHARMACY MANAGEMENT TEAM, I want to extend my sincere appreciation to all of our graduating residents. Our residents and fellows fully invest in their respective opportunities to grow both personally and professionally, and in the process, make a lasting impact on HMH Pharmacy’s effort to optimize patient outcomes. For over three decades, Houston Methodist Hospital Pharmacy has made important advancements in pharmacy practice through the adoption of new technologies and through the interdisciplinary research efforts of many from the HMH Pharmacy Team. The crux of our research activity continues to reside in our pharmacy training programs, and we are indebted to the hard work and dedication of our pharmacy learners, preceptors/practitioners, and support staff. Among the highlights of accomplishments in the 2018-2019 Residency Year: • HMH pharmacy residency alumni and current HMH pharmacy administrators continue our tradition of attaining research grants, including the inaugural ASHP New Practitioner Leadership Research Grant to study the impact of a pharmacy technician career ladder in a multi-hospital system. • Antimicrobial Stewardship Center of Excellence designation by the Infectious Diseases Society of America (IDSA) at HMH; one of the highest recognitions nationally for Antimicrobial Stewardship Programs. • HMH PGY2 Critical Care Pharmacy Residency Program received the 2019 Residency Program Excellence Award from the Texas Society of Health-System Pharmacists. This is the third HMH Pharmacy Residency Program to receive this honor, following the PGY1 Pharmacy Residency (2013), and the PGY1/PGY2/MS Health-System Pharmacy Administration Residency (2018) At Houston Methodist, we take “Leading Medicine” seriously. I continue to be impressed with the quality of pharmacy’s efforts in growth and innovation, and I have our residents, fellows, and their preceptors to thank for much of that. We remain in position to develop and share innovative practices in part because of our Pharmacy Research Committee, a group dedicated to ensuring excellence in the quality and feasibility of research conducted by HMH pharmacy. As we move ahead to the 2019-2020 residency year, we will continue with laser focus on what we do each and every day. That includes enhancing our medication distribution, clinical services, and regulatory/quality compliance efforts to provide an environment of unparalleled safety, quality, service, and innovation for our patients. Our patients always deserve our best – and it is the reason we all work so hard to develop safe and effective processes and practices from which our patients will benefit. Thanks for all that you have done and continue to do for our patients.

Alex C. Varkey, PharmD, MS, FAPhA Director of Pharmacy Services

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PHARMACY RESEARCH COMMITTEE MEMBERS

Katherine K. Perez, PharmD, BCIDP Chair

Mobolaji Adeola, PharmD, BCPS Member

Engie Attia, PharmD, BCPS Project Development Lead

Amaris Fuentes, PharmD, BCPS, BCCCP Visibility Lead

Michael Johnson, PhD External Statistician Consultant

Jill C. Krisl, PharmD, BCPS Project Approval Lead

David R. Putney, PharmD, MPH, BCPS - AQ Cardiology Member

Elsie Rizk, PharmD Project Support Lead

Michael Sirimaturos, PharmD, BCNSP, BCCCP, FCCM Education Lead

Joshua T. Swan, PharmD, MPH, BCPS, FCCM Past Chair & Research Infrastructure Lead

Sara Varnado Balk, PharmD, BCPS Project Alignment Lead

LETTER FROM THE PHARMACY RESEARCH COMMITTEE CHAIR This report marks the fourth year of notable achievements the Houston Methodist Pharmacy Department’s research endeavors. As the new Chair for the Pharmacy Research Committee (PRC), I am honored to have this opportunity to celebrate the research success of the Houston Methodist Pharmacy Department over the last year. Our department consistently demonstrates a commitment and dedication to the success and advancement of pharmacy practice and patient care at HM. This report also marks the end of Joshua T. Swan’s PRC chairmanship. Since the Pharmacy Research Committee’s inaugural year, Joshua’s leadership has been characterized by innovative ideas, strategic thinking, and, most valuable, tireless efforts to increase the quality of research training provided by the Department of Pharmacy at Houston Methodist. On behalf of the PRC, we thank Joshua for his extraordinary work, energy, and devotion to the PRC and look forward to his ongoing involvement as Past Chair & Research Infrastructure Lead. The mission of the Pharmacy Research Committee is to ensure excellence in the quality and feasibility of research conducted, and the quality of research training provided by the Department of Pharmacy at Houston Methodist. During 2018-2019, the PRC continued to maintain and optimize existing project programs, including development, approval, alignment, support, education and visibility. Productive collaborations within and outside HM have been incorporated into existing program functions. Noteworthy committee developments over 2018-2019 include: • System Pharmacy Research Bibliography: clinicians surveyed to compile 2014–2019 publication catalog • Project approval support role: established to assist the project approval lead coordinate project review panels, process and maintain the final project approval list • Research infrastructure program: championed by the Past Chair and will focus on the Pharmacy Center for Outcomes Research and Economics expansion, grant applications, and project impact assessment As chair, my overall goal is to foster a shared commitment to helping all members of the department be successful and to solidify the framework our members have built for lasting research progress. I would like to extend my sincere gratitude and appreciation to previous and continuing members of the committee for all of their hard work, tenacity, dedication and productivity. Thank you for your unwavering support!

Katherine K. Perez, PharmD, BCIDP Chair, Pharmacy Research Committee

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PHARMACY RESEARCH FUNDING Veronica Ajewole, PharmD, BCOP, Clinical Pharmacy Specialist in Oncology and Assistant Professor of Pharmacy Practice at Texas Southern University College of Pharmacy and Health Sciences, received a $6,000 grant from Texas Southern University for the implementation of an oral chemotherapy medication therapy management clinic at the Houston Methodist Hospital Outpatient Cancer Center. The goal of the oral chemotherapy clinic is to increase patient adherence to oral chemotherapy and optimize clinical outcomes through patient education, adherence tracking, toxicity identification and management, and by decreasing polypharmacy and potential drug interactions.

Sunny B. Bhakta, PharmD, MS, BCPS, Operations Manager at Houston Methodist Hospital, received a $4,500 New Practitioner Leadership Research Grant from the American Society of Health-System Pharmacists for the project titled “Systemization and Evaluation of the Impact of a Pharmacy Technician Ladder in a Multi-Hospital System.” The grant will be used to evaluate the effect of a system pharmacy technician career ladder on employee satisfaction through assessment of Press Ganey employee opinion survey scores with correlation to theory of reasoned action questionnaire results. The research project will establish impact evidence to supplement prior recommendations from the American Society of Health-System Pharmacists. Research team co-investigators include Niaz Deyhim, PharmD; Alex Varkey, PharmD, MS, FAPhA; Kevin W. Garey, PharmD, MS, FASHP; Rene Martinez, CPhT; and Daniel Metzen, PharmD, MBA.

Samantha Kuten, PharmD, Clinical Pharmacy Specialist in Solid Organ Transplantation, received a $292,000 research grant for an investigator initiated trial from Veloxis Pharmaceuticals, Inc. for the “Evaluation of Early Dose Escalation using Extended-Release Tacrolimus to Reduce Acute Rejection and Donor Specific Antibodies in African American Renal Transplant Recipients.” The study is active and currently enrolling patients. She is a co-principal investigator on each of these trials with Dr. A. Osama Gaber, Director of the J.C Walter Jr. Transplant Center.

PHARMACY RESEARCH FUNDING Joshua T. Swan, PharmD, MPH, BCPS, FCCM, Administrative Specialist in Drug Information, Formulary Management, was awarded a $18,276 sub-award from Vanderbilt University Medical Center to collaborate on the 6R01HL111111 grant from National Heart, Lung, and Blood Institute at the National Institutes of Health. This was the third year that Houston Methodist Hospital was an active enrollment site for the Maximizing the Efficacy of Sedation and Reducing Neurological Dysfunction and Mortality in Septic Patients With Acute Respiratory Failure (MENDS II) clinical trial. This multicenter, randomized clinical trial will compare dexmedetomidine versus propofol for the outcome of delirium-free, coma-free days among ventilated and critically ill adults with sepsis. In addition, Swan was awarded: • A $105,300 research grant for an investigator-initiated study from Grifols Shared Services North America, Inc., for a “Retrospective Evaluation of Adherance to Guideline Recommendations for Administration of Human Rabies Immune Globulin for Rabies Postexposure Prophylaxis at a Multi-Hospital Health System.” This study has been completed and accepted for publication. • A $96,000 research grant for an investigator-initiated study from Pacira Pharmaceuticals, Inc., for an “Evaluation of intraoperative liposomal bupivacaine and postoperative intravenous acetaminophen on postoperative opioid use within 24 hours of colorectal surgery.” • A $25,000 research grant for an investigator-initiated study from La Jolla Pharmaceutical Company for a “Retrospective Evaluation of the Incidence, Clinical Management, and Clinical Course of Vasooplegia Following Left Ventricular Assist Device Implantation.” • A $19,200 research grant for an investigator-initiated study from CSL Behring, LLC, for an “Evaluation of postoperative clinical outcomes among patients who refuse blood products (Jehovah’s Witnessess) who receive prothrombin complex concentrate during complex cardiac surgery.

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PHARMACY AWARDS & RECOGNITION The Houston Methodist Hospital Antimicrobial Stewardship Program received Antimicrobial Stewardship Centers of Excellence (CoE) designation from the Infectious Diseases Society of America (IDSA). Only a few hospitals in Texas have earned the designation, and it remains a very rare accomplishment nationwide. The IDSA launched the program in 2017 to recognize institutions that have created antimicrobial stewardship programs (ASP) led by infectious diseases physicians and infectious diseases-trained pharmacists that are of the highest quality and have achieved standards established by the Centers for Disease Control and Prevention (CDC). The IDSA CoE program places emphasis on an institution’s ability to implement stewardship protocols using its electronic health record system and providing ongoing education to its medical staff. The CoE designation means these institutions serve as the “gold” standard for executing novel antimicrobial stewardship principles and demonstrate commitment to decreasing antimicrobial resistance.

PHARMACY AWARDS & RECOGNITION The Houston Methodist Hospital PGY2 Critical Care Pharmacy Residency Program received the 2019 Texas Society of Health-System Pharmacists (TSHP) Residency Program Excellence Award at the TSHP Annual Seminar in Frisco, Texas. This award recognizes one out of approximately 140 pharmacy residency programs in Texas with a track record of excellence in the training of pharmacy residents. Awarded programs serve as role models across the state of Texas by employing unique and innovative methods for teaching and quality improvement, providing an excellent practice environment for residency training and learning, and having an organized process for the development of outstanding residency preceptors. The program has graduated 24 trained clinical pharmacists who practice in diverse settings including critical care, solid organ transplantation, emergency medicine, mechanical circulatory support, medication safety, formulary management, medical science liaisons in pharmacy industry, directors of pharmacy, and professors and associate deans of students at colleges of pharmacy. Many of the graduates maintain pharmacy board certification, with 79% of the graduates board certified in Critical Care (BCCCP), Pharmacotherapy (BCPS) or Nutrition Support (BCNSP); 17% of graduates are board certified in more than one specialty. All graduates have been members of critical care specialty organizations, with 71% maintaining active membership in the national Society of Critical Care Medicine (SCCM) organization or in state or regional chapters. The graduates maintain a longstanding history of leadership involvement within SCCM Texas Chapter, including two presidents among many other elected positions. At a national level, graduates have served various roles in SCCM, including committee leadership and Annual Congress moderators. The group also boasts a number of awards and recognitions, including: • 3 Fellows of Critical Care Medicine (FCCM) • 1 Institutional Review Board (IRB) Vice Chair • 4 Residency/Fellowship Program Directors • 6 Texas Chapter of SCCM Alan I. Fields Award winners since its inception in 2010 • ASHP Research and Education Foundation Excellence in Medication Safety Award • TSHP Innovative Collaborative Practice Award • TSHP Residency Program Excellence Award at their respective institutions • Over 90 publications and over 60 research presentations at local, regional, national, or international venues • Over 50 awards, including 10 Preceptors of the Year, 7 Teachers of the Year, 9 SCCM Presidential Citations, and 1 Young Pharmacist Investigator Award

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Evaluation of differences in bleeding rates among thromboprophylaxis strategies post bioprosthetic valve replacement Hayley S. Brazeale, PharmD; Allison D. Wilson, PharmD; Patrick Schmees, PharmD PURPOSE

RESULTS

Bioprosthetic valves are less thrombogenic than mechanical valves and therefore do not require lifelong anticoagulation. For this reason, bioprosthetic valves may be favorable in patients at a higher risk of bleeding. This study aimed to evaluate bleeding outcomes among thromboprophylaxis with aspirin, vitamin K antagonists (VKAs), and direct oral anticoagulants (DOACs) following bioprosthetic aortic and/ or mitral valve replacement.

Of the 423 patients identified to have received a bioprosthetic AVR and/or MVR during the specified time period, total of 274 patients were included. The proportion of patients that experienced bleeding was similar between the aspirin monotherapy and the VKA +/- aspirin groups: 19.7% (34 of 173 patients) and 23.3% (10 of 43 patients), respectively. Fewer incidences of bleeding were observed in the DOAC +/- aspirin group: 12.1 % (7 of 58 patients). Higher rates of thrombosis, hospital readmissions, early discontinuation of therapy, and longer length of hospital stay occurred in the VKA +/- aspirin group.

METHODS

This is a retrospective, observational, single-center study conducted at a large quaternary health system in the Texas Medical Center. Patients were included in the analysis if they were prescribed aspirin, VKA, or DOAC after surgical bioprosthetic aortic (AVR) and/or mitral valve replacement (MVR) from May 1, 2016 through April 30, 2018. The follow-up period evaluated was 90 days post indexed procedure date. Patients were allocated into one of three groups contingent upon thromboprophylaxis agent(s) prescribed: aspirin monotherapy, VKA +/- aspirin, or DOAC +/- aspirin. The primary outcome was a composite of major and minor bleeding events post bioprosthetic valve replacement. Secondary endpoints included re-operation for bleeding event, thrombosis complications, length of hospital stay, hospital readmissions or outpatient follow up due to adverse drug events (ADEs), early discontinuation of therapy, and mortality. Baseline demographics and clinical outcomes were evaluated and compared using descriptive statistics.

CONCLUSION

In our study, DOAC +/- aspirin therapy was associated with lower bleeding rates as compared to aspirin monotherapy and VKA +/- aspirin after bioprosthetic AVR and/or MVR. Utilization of VKA +/- aspirin correlated with higher incidence of complications. Further studies are warranted to determine optimal thromboprophylaxis strategy post bioprosthetic valve replacement.

PGY1 PHARMACY RESIDENCY

Hayley Brazeale, PharmD Hayley earned her PharmD from the Texas Tech University Health Sciences Center School of Pharmacy in 2018. Following the completion of her PGY1 residency, Hayley will continue her postgraduate training as a PGY2 Pharmacy Resident in internal medicine at Houston Methodist Hospital. Primary project preceptor: Allison Wilson, PharmD, BCPS Presented at 2018 VizientÂŽ Pharmacy Network, Anaheim, California; 2019 Midwest Pharmacy Residents Conference, Omaha, Nebraska

Impact of protease inhibitor-based anti-retroviral therapy on tacrolimus intrapatient variability in HIV+ kidney transplant recipients Megan Cooper, PharmD; Ian Dunne, PharmD; Samantha Kuten, PharmD; Anna Cantwell, PharmD; Edward A. Graviss, PhD, MPH; Duc Nguyen, MD, PhD; Mark Hobeika, MD; A. Osama Gaber, MD

PURPOSE

RESULTS

High tacrolimus (FK) intra-patient variability (IPV) has been associated with inferior outcomes in transplantation. Human immunodeficiency virus (HIV+) transplant recipients have been shown to experience higher acute rejection rates, possibly due to the drug-drug interactions between highly active anti-retroviral therapy (HAART) and immunosuppression regimens. In this study, we aim to determine the impact of protease inhibitor (PI)-based HAART regimens on FK variability and whether this affects immune outcomes.

Twenty-three HIV+ KTRs were included, of which 10 were receiving PI-based HAART. At 6 and 12 months, population median %CV were 35.8% and 41%, respectively. At 6 months, high IPV was experienced in 6/10 (60%) PI-based and 5/13 (38%) non-PI-based KTRs. At 12 months, high IPV was experienced in 7/10 (70%) PI-based and 4/13 (31%) non-PI-based KTRs. Median IPV was higher at 6 months (37.3% vs 26.8%, p=0.11) and significantly higher at 12 months (57.8% vs. 30.9%, p=0.01) in PI-based KTRs. No differences in immune outcomes were observed.

METHODS

CONCLUSION

We performed a single-center review of HIV+ kidney transplant recipients from 2007 to 2017. Patients were divided into high or low tacrolimus IPV cohorts based on median % coefficient of variation at 6 months post-transplant [%CV = (σ/μ) x 100]. Secondary endpoints included IPV at 12 months, biopsy-proven acute rejection, development of donor specific antibodies, graft function, patient and graft survival.

Our data suggests that PI-based regimens may be associated with a higher degree of FK variability. However, given the small sample size, we did not observe significant differences in immune outcomes. Further studies are warranted to determine the impact of PI-based HAART on FK IPV and subsequent graft outcomes in HIV+ transplant recipients.

PGY1 PHARMACY RESIDENCY

Megan Cooper, PharmD Megan earned her BS in Biochemistry from The University of Texas in 2013 and PharmD from the University of Houston College of Pharmacy in 2018. Following the completion of her PGY1 residency, Megan will continue her postgraduate training as a PGY2 Pharmacy Resident in solid organ transplantation at Houston Methodist Hospital. Primary project preceptor: Ian Dunne, PharmD, BCPS, AAHIVP Presented at 2018 Vizient® Pharmacy Network, Anaheim, California; 2019 Midwest Pharmacy Residents Conference, Omaha, Nebraska; 2019 American Transplant Congress, Boston, Massachusetts

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Prophylactic beta blocker use to prevent postoperative atrial arrhythmias after lung transplantation Rodrigo M. De La Torre, PharmD; Sara Varnado Balk, PharmD; Jill C. Krisl, PharmD; Brett Pierce, PharmD; Yixin Chen, PharmD PURPOSE

RESULTS

Postoperative atrial arrhythmias (POAA) are associated with increased morbidity, length of stay, readmission rates, and health care costs. The estimated incidence of POAA ranges between 19% and 46% in lung transplant patients, with a median onset of 2 to 7 days. POAA management in this population has been adapted from evidence in cardiac surgery patients. In our study, we described the incidence of postoperative atrial arrhythmias in our lung transplant population.

Overall a total of 124 patients met our inclusion criteria. The majority of patients received a double lung transplant (n=84, 68%) with a transplant indication of obstructive lung disease (n=85, 69%). Our POAA incidence within 7 days was determined to be 19% (n=24), with a median onset of 5 days postoperatively. POAA was mostly managed by beta blocker monotherapy (n=10, 27%), while a large proportion (n=26, 70%) required a combination of agents to manage their POAA. Of note, our one-year post-transplant survival was 97%.

METHODS

This study is a descriptive, single-center, retrospective cohort of patients who received lung transplantation at the Houston Methodist Hospital during May 2016 to August 2018 who received a postoperative beta blocker within 72 hours postoperatively. Our primary endpoint was to describe the incidence of postoperative atrial arrhythmias within seven days of lung transplantation. Secondary endpoints included POAA incidence within 14 and 30 days of transplantation, POAA management, intensive care unit and overall length of stay, discharge disposition, stroke and transient ischemic attack incidence, and oneyear post-transplant survival. Baseline and demographic characteristics, as well as POAA incidence rates, were analyzed using descriptive statistics.

CONCLUSION

Our data suggests our POAA incidence within 7 days is consistent with and on the lower end of what is reported in the literature. Our POAA incidence could be related in part to beta blocker use but cannot be proven from our study.

PGY1 PHARMACY RESIDENCY

Rodrigo De La Torre, PharmD Rodrigo earned his BA in Biology from the University of St. Thomas in 2007 and PharmD from the University of Houston College of Pharmacy in 2018. Following completion of his PGY1, Rodrigo will continue his postgraduate training as a PGY2 Pharmacy Resident in oncology at Houston Methodist Hospital. Primary project preceptor: Sara Varnado Balk, PharmD, BCPS Presented at 2018 VizientÂŽ Pharmacy Network, Anaheim, California; 2019 Annual Midwest Pharmacy Residents Conference, Omaha, Nebraska

Incidence of Cardiovascular Toxicity among Patients Receiving Tyrosine Kinase Inhibitors: A Single-Institution Observational Study Daniel Galipeau, PharmD; Hanna Zaghloul, PharmD; Rosetta Lee, PharmD; Barry Trachtenberg, MD; Joe Ensor, PhD PURPOSE

RESULTS

Tyrosine kinase inhibitors (TKIs) have seen increased use for the treatment of various diseases, including certain malignancies, as they are targeted oral agents with favorable adverse effect profiles as compared to standard chemotherapy. Recent studies have begun to describe cardiotoxicity associated with TKI treatment. Trials to date have inconsistently reported outcomes related to cardiotoxicity and have focused on one or two TKIs as opposed to the class of TKIs. Therefore, the true incidence of TKI-associated cardiotoxicity in the general population is unknown. The primary objective of this study was to describe the incidence of cardiovascular toxicity among patients receiving TKIs..

Of the 76 patients identified, 8 (10.5%) had a cardiac event during TKI use. Median time to event was 79 days (IQR 60.5 â&#x20AC;&#x201C; 122). Cardiotoxicity in combination with cardiotoxic oncologic agents occurred in did not occur. CONCLUSION

Risk of cardiotoxicity may extend to all TKIs as a class. TKIs are associated with a variety of cardiac-related events. Future studies should be conducted to further characterize the cardiotoxic risk of TKIs in the general population.

METHODS

This retrospective, observational study included patients who received at least one dose of a TKI at a multihospital health system from May 2016 through August 2018. Patients without baseline electrocardiogram and echocardiogram were excluded. Events occurring during TKI use were identified from ICD-10 codes and confirmed through retrospective chart review. The primary endpoint was incidence of cardiotoxicity. Secondary endpoints included time to cardiac event and incidence of cardiotoxicity in combination with cardiotoxic oncologic agents.

PGY1 PHARMACY RESIDENCY

Daniel Galipeau, PharmD Dan earned his PharmD from the University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences in 2018. Following completion of his PGY1 residency, Dan will continue his postgraduate training as a PGY2 Pharmacy Resident in cardiology at The Ohio State University. Primary project preceptor: Hanna Zaghloul, PharmD, BCOP Presented at 2018 VizientÂŽ Pharmacy Network, Anaheim, California; 2019 Midwest Pharmacy Residents Conference, Omaha, Nebraska

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Adherence to guideline recommendations for human rabies immune globulin patient selection, dosing, timing, and anatomical site of administration in rabies post-exposure prophylaxis Grace S. Hwang, PharmD; Elsie Rizk, PharmD; Lan N. Bui, PharmD; Tomona Iso, PharmD; Emily I. Sartain; Anh Thu Tran; Joshua T. Swan, PharmD, MPH PURPOSE

RESULTS

Rabies is a fatal disease that mandates proper prophylaxis after a rabies virus exposure in order to prevent death. Rabies infection can occur in humans when key elements of the rabies post-exposure prophylaxis regimens are omitted or incorrectly administered. This study evaluated adherence to Centers of Disease Control and Prevention recommendations for rabies immune globulin (IG) patient selection, dosing, timing of administration, and site of administration.

This study included 246 patients met inclusion criteria. Rabies IG was administered to 91% (223 of 244) of patients with an indication. Of 223 patients who received rabies IG, 219 (98%) received doses within 10% of 20 IU/kg of body weight, and all 223 (100%) received rabies IG within 7 days of the first rabies vaccine administration. Only 56% (96 of 170) of patients with a wound that could be infiltrated with rabies IG actually received rabies IG via infiltration into and around the wound.

METHODS

CONCLUSION

This study is a retrospective, cross-sectional study at a multi-hospital health system including 1 academic medical center, 7 community hospital, and 8 freestanding emergency care centers. The study included patients who received at least one dose of rabies IG or rabies vaccine at any of the study sites within the system from January 2015 through June 2018. The study excluded patients whose date of the first rabies vaccination was unknown and patients who received rabies IG at an external facility prior to presenting to the study sites.

This study demonstrated high adherence to guideline recommendations for rabies IG for patient selection (91%), dosing (98%), and timing (100%). However, non-adherence was observed in rabies IG infiltration at wound sites as recommended by guidelines.

PGY1 PHARMACY RESIDENCY

Grace Hwang, PharmD Grace earned her PharmD from the University of Houston College of Pharmacy in 2018. Following the completion of her PGY1 residency, Grace will continue her postgraduate training as a PGY2 Pharmacy Resident in medication use safety in oncology at the Dana Farber Cancer Institute. Primary project preceptor: Joshua T. Swan, PharmD, MPH, BCPS, FCCM Presented at 2018 VizientÂŽ Pharmacy Network, Anaheim, California; 2019 Midwest Pharmacy Residents Conference, Omaha, Nebraska

Ramelteon for surgical intensive care unit delirium Chelsea N. Lopez, PharmD; Amaris Fuentes, PharmD; Jonathan Balk, PharmD

PURPOSE

In intensive care unit (ICU) patients, delirium contributes to increased mortality, prolonged hospitalization and long-term cognitive impairment. It is thought that exogenous melatonin may help mitigate delirium through a negative feedback mechanism that decreases the breakdown of melatonin and serotonin’s precursor tryptophan. Others have attributed sleep disturbances, a risk factor for delirium, to impaired melatonin secretion in critically ill patients. There currently remains a lack of robust evidence supporting the use of exogenous melatonin or melatonin receptor agonists in the prevention of delirium. The primary objective of this study was to describe the use of ramelteon and the incidence of delirium, as assessed by Confusion Assessment Method for the ICU (CAM-ICU) scores, in surgical ICU patients ≥ 18 years of age. METHODS

This is a single-center, retrospective, descriptive cohort study of surgical ICU patients who received ramelteon from May 22, 2016 to June 30, 2018. All adult patients admitted to the surgical-liver ICU (SLICU) or cardiovascular surgery ICU (CVICU) who received at least three doses of ramelteon 8 mg within a 7-day period were included. Patients with less than a 3-day ICU stay or who received ramelteon prior to ICU admission were excluded.

The primary endpoint was the percentage of deliriumfree days in the week prior to and post first ramelteon administration. Secondary endpoints included time to delirium onset, number of CAM-ICU positive days, mortality at discharge, number of ramelteon doses and ICU length of stay (LOS). RESULTS

Of the 231 patients identified, delirium developed in 201 patients at some point during their ICU stay and 151 patients had at least one day of delirium after ramelteon administration. The median percentage of CAM-ICU negative, delirium free days in the week prior to and including the first day of ramelteon was 4 days (out of 8 days; IQR 2-7 days), compared to 6 days (out of days 7 days; IQR 3-7 days) in the week after the first ramelteon dose. The median time to CAM-ICU positive from ICU admission and from the first dose of ramelteon was 2 days (IQR 1-5 days) and 3 days (IQR 1-7 days), respectively. The median number of ramelteon doses was 6 (IQR 4-13 doses) and median ICU LOS was 22 days (IQR 11-38 days). Mortality at hospital discharge was 8.2%. CONCLUSION

In surgical ICU patients, ramelteon administration was associated with a greater number of delirium-free days.

PGY1 PHARMACY RESIDENCY

Chelsea Lopez, PharmD Chelsea earned her BS in Neurobiology from The University of Texas at Austin in 2014 and her PharmD from the University of Illinois-Chicago College of Pharmacy in 2018. Following the completion of her PGY1 residency, Chelsea will continue her postgraduate training as a PGY2 Pharmacy Resident in critical care at Houston Methodist Hospital. Primary project preceptor: Jonathan Balk, PharmD, BCCCP Presented at 2018 Vizient® Pharmacy Network, Anaheim, California; 2019 Midwest Pharmacy Residents Conference, Omaha, NebraskaConference, Omaha, NE

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Characterization of benzodiazepine infusions as appropriate or inappropriate among mechanically ventilated patients at a community hospital Rana Aljadeed, PharmD; Ola Adejuwon, PharmD; Joshua T. Swan, PharmD, MPH PURPOSE

RESULTS

The Pain, Agitation and Delirium (PAD) guidelines have a conditional recommendation stating that “non-benzodiazepines sedatives may be preferred to sedation with benzodiazepines to improve clinical outcomes in mechanically ventilated patients.” We aim to evaluate the adherence to PAD guidelines regarding the choice of sedative agent in the patients who are mechanically ventilated in the intensive care units at a community hospital.

A total of 81 patients received orders for benzodiazepine infusions during the study period, with 15 patients randomly sampled for initial analysis. Of those evaluated, 53% were male with an average age of 52 ± 17.4 years. The benzodiazepine orders were active for 46.9 ± 42.2 hours. A benzodiazepine infusion was started in 14 (93%) of these patients with a duration of infusion of 41.9 ± 39.1 hours. Only five patients (33%) had a compelling indication for the benzodiazepine infusion order, which included treatment of seizure (n = 4) and alcohol withdrawal (n = 1).

METHODS

In this retrospective single-center cohort study, we included patients who were mechanically ventilated and initiated on benzodiazepine infusion from January 2018 to December 2018. This analysis randomly sampled 15 patients for pilot data collection. The primary endpoint was appropriateness (appropriate or inappropriate) of the benzodiazepine infusion based on the presence of a compelling indication for therapy as recommended by PAD guidelines. Appropriate indications for benzodiazepine infusion included active management of alcohol withdrawal, benzodiazepine withdrawal, status epilepticus, agitation that refractory to propofol, or concurrent administration of a neuromuscular blocking agent.

CONCLUSION

Benzodiazepine-based sedation has been associated with poor clinical outcomes in multiple published randomized trials and is not recommended by current guidelines unless the patient has a compelling indication. During this pilot analysis, the majority (67%) of patients who received orders for a benzodiazepine infusion did not have a compelling indication for that choice of sedative. Additional data will be collected on a larger sample of patients to further describe this potential medication safety issue by further describing provider practices at this community hospital.

PGY1 PHARMACY RESIDENCY - INTERNATIONAL GRADUATES

Rana Aljadeed, PharmD Rana earned her BS in Pharmaceutical Sciences from King Saud University in Saudi Arabia and her PharmD from the University of Illinois-Chicago College of Pharmacy in 2017. Following completion of her PGY1, Rana plans to pursue a PGY2 pharmacy residency in critical care. Primary project preceptor: Ola Adejuwon, PharmD, BCCCP, BCNSP, BCPS Presented at 2019 Midwest Pharmacy Residents Conference, Omaha, Nebraska; 2019 American Society of Health-System Pharmacists Summer Meeting, Boston, Massachusetts.

Will the incorporation of rapid diagnostic tests with pharmacist involvement improve time to antimicrobial therapy for gram positive bacteremia and candidemia in two community hospitals? Leroy Koh, PharmD, MPH; Punit Shah, PharmD; Aileen Korulla, PharmD; Charles Janak, PharmD; Katherine K. Perez, PharmD PURPOSE

RESULTS

The increasing use of technology to rapidly identify an infectious organism can assist clinicians in providing faster and effective therapy for bloodstream infections. However, even with rapid testing tools, prompt clinical response is needed to translate the results into appropriate actions. The purpose of this study was to determine if the introduction of real time pharmacists’ response to positive rapid diagnostic tests would lead to a decrease in time to antimicrobial therapy for gram positive bacteremia and candidemia in a community hospital setting.

A total of 140 patients were included into the preintervention group and 124 patients in the intervention group. Baseline demographics were well matched between the groups. The mean time to effective therapy decreased from 13.9±21.6 hours in the pre-intervention group to 8.6±12.5 hours in the intervention group (HR=1.15, 95%CI 0.89-1.48, p=0.29). The mean time to optimal therapy significantly decreased from 53.7±57.7 hours in the pre-intervention group to 38.4±31.5 hours in the intervention group (HR=1.73, 95%CI 1.33-2.26, p<0.001). Clinical pharmacist made a total of 26 (18.6%) recommendations in the pre-intervention group, compared to 63 (50.8%) recommendations in the intervention group (OR=4.53, 95%CI 2.61-7.87, p<0.001).

METHODS

This was a quasi-experimental study conducted in two community hospitals. The study was comprised of two cohorts of patients who tested positive for gram positive bacteremia with Staphylococcus aureus, Enterococcus faecalis, Enterococcus faecium or Candida species. The pre-intervention cohort was admitted from November 2017 through May 2018. The intervention cohort was admitted from July 2018 through January 2019 after the intervention of real-time pharmacist interventions went live. Patients were excluded if they had mixed positive blood cultures within the same admission, died or transferred out prior to cultures becoming positive, or had received antibiotics before blood samples were taken. Cox regression was used to investigate the time to effective or optimal therapy.

CONCLUSION

The introduction of real-time pharmacists’ response to positive rapid diagnostic tests led to a significant decrease in time to initiation of optimal antimicrobial therapy. The results showed that the allocation of limited manpower resources of a community hospital to such a stewardship program is justifiable.

PGY1 PHARMACY RESIDENCY - INTERNATIONAL GRADUATES

Leroy Koh, PharmD, MPH Leroy earned his BS in Pharmacy from National University of Singapore in 2014, his PharmD from Nova Southeastern University in 2017 and his MPH from University of Southern California in 2017. Following the completion of his PGY1 residency, Leroy aims to be a certified diabetes educator and return to Singapore to further the practice there. Primary project preceptor: Punit Shah, PharmD, BCPS Presented at 2019 ASHP Summer Conference, Boston, Massachusetts; 2019 Midwest Pharmacy Residents Conference, Omaha, Nebraska.

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Evaluation of the efficacy and safety of apixaban and rivaroxaban in cancer patients receiving concomitant active anti-neoplastic therapy at an outpatient cancer setting Darin Yassine, PharmD; Erika N. Brown, PharmD, MS; David Putney, PharmD, MPH; Oyejoke Fasoranti, PharmD PURPOSE

Venous thromboembolism (VTE) is a common complication among cancer patients with an estimated risk of 20%. Causes are multifactorial and include prothrombogenic antineoplastic medications. The purpose of this study is to describe the impact of the drug interactions between direct oral anticoagulants (DOACs) and antineoplastic therapies on the safety and efficacy of DOACs. METHODS

We retrospectively reviewed charts of cancer patients receiving active antineoplastic therapies and concomitant VTE treatment (apixaban or rivaroxaban) at five Houston Methodist Hospital outpatient oncology clinics between September 2017 and August 2018. Drug interactions were identified and classified as either strong, moderate, or mild based on the study by Nicholas and colleagues which reviewed commonly used antineoplastic medications and their effects on CYP3A4 and P-glycoprotein derived from FDA-approved package inserts and large drug databases. Lexicomp and Micromedex were also checked for DDIs. The primary endpoint was a composite of VTE recurrences and major or minor bleeding events. RESULTS

Forty-nine patients met study inclusion criteria and were further categorized into patients with drug interactions (N=23) and patients with no drug interactions (N=26).

Primary composite endpoint occurred in 15 patients (65.2%) in the drug interaction (DDI) group compared to 16 patients (61.5%) in the no drug interaction (NonDDI) group (P=1). For secondary endpoints, there was no statistically significant difference in VTE recurrence, major, and minor bleeding events between patients with strong and moderate vs. mild DDIs in the DDI group. The most common DDI among these patients was CYP3A4 inhibition. Anti-Mitotic Microtubule Inhibitors (37.5%) In DDI group had the highest incidence of the primary endpoint. Breast cancer (27.3%), lung cancer (18.2%), ovarian cancer (15.2%), and gastrointestinal cancers (15.2%) among both patient groups had the highest incidence of adverse events. Based on our results, strong and moderate DDIs may be associated with higher incidence of major bleeding compared to mild DDIs. CONCLUSION

There was no statistically significant difference in the composite endpoint of VTE recurrence, major and minor bleeding events between patients who have a drug interaction between DOACs and antineoplastic therapies and those who do not have a drug interaction. Utilization of literature resources other than standard pharmacy database are needed to identify potential DDIs with apixaban and rivaroxaban. Further prospective study with a larger sample size is warranted.

PGY1 PHARMACY RESIDENCY - INTERNATIONAL GRADUATES

Darin Yassine, PharmD Darya earned her BS in Pharmacy and PharmD from the Lebanese American University College of Pharmacy. Following completion of her PGY1 residency, Darya plans to pursue a PGY2 pharmacy residency in critical care. Primary project preceptor: Erika N. Brown, MS, PharmD, BCOP Presented at 2019 Midwest Pharmacy Residents Conference, Omaha, Nebraska; 2019 American Society of Health-System Pharmacists Summer Meeting, Boston, Massachusetts.

Impact of sugammadex versus neostigmine/glycopyrrolate on perioperative efficiency Niaz Deyhim, PharmD; Amanda Beck, PharmD, MS; Jonathan Balk, PharmD; Michael Liebl, PharmD PURPOSE

Neuromuscular blockade necessitates the utilization of reversal agents to accelerate the postoperative recovery period and sustain operating room patient throughput. Sugammadex, a synthetic gamma-cyclodextrin, was introduced to the market with evidence of more rapid and predictable reversal of neuromuscular blockade compared to alternatives, such as neostigmine/glycopyrrolate. Higher medication acquisition costs have limited more extensive use of sugammadex compared to that of neostigmine/glycopyrrolate. However, the enhanced onset of neuromuscular blockade reversal may reduce comprehensive costs through the reduction of patient encounter time in the operating room (OR) and length of stay in the post-anesthesia care unit (PACU). The purpose of this study was to examine the impact of sugammadex versus neostigmine/glycopyrrolate on perioperative efficiency to validate medication acquisition cost value.

and PACU costs per minute at Houston Methodist Hospital. Statistical analyses were conducted with Wilcoxon rank sum test, Fisherâ&#x20AC;&#x2122;s exact test, chi-squared test, and multiple linear regression, as appropriate. RESULTS

There were a total of 640 surgical cases at Houston Methodist Hospital eligible for inclusion into the research study. The time from medication administration to OR exit exhibited statistical significance for sugammadex compared to neostigmine/glycopyrrolate (P<0.001). Linear regression, however, invalidated predictive outcome from reversal agent selection to the primary endpoint (P=0.122; r2 = 0.004). Medication acquisition cost review highlighted a difference of $186.12 upon selection of reversal agent. Temporal benefits with sugammadex correlated to an investment return of $56.84 and $2.18 in the OR and PACU, respectively. CONCLUSION

METHODS

A retrospective investigation was performed of patients with a surgical procedure at Houston Methodist Hospital from July 31, 2017 through August 1, 2018. The primary endpoint was time from reversal medication administration to OR exit. Secondary endpoints include reversal agent administration to anesthesia end timeframe, reversal agent administration to extubation timeframe, and PACU length of stay. Patient-specific doses were assessed to calculate medication acquisition costs. The economic benefits of sugammadex were measured through review of average OR

While sugammadex is associated with more rapid reversal of neuromuscular paralysis, its utilization does not correlate to consequential time saved in the OR, as postulated by prior analyses, or extrapolation to workflow capacity for increased surgical case volume. The time from reversal agent administration to OR exit is comparable with that of neostigmine/glycopyrrolate and establishes economic insignificance. Consideration of the sugammadex acquisition cost further limits the financial benefit of its purchase, and therefore, promotes more restrictive use of sugammadex to indications with clinical relevance.

PGY1 -PGY1/PGY2 HEALTH-SYSTEM PHARMACY ADMINISTRATION RESIDENCY

Niaz Deyhim, PharmD Niaz earned her PharmD from the Texas A&M University College of Pharmacy in 2018. Niaz will continue postgraduate training at Houston Methodist Hospital as a PGY2 Health-System Pharmacy Administration Resident. Primary project preceptor: Amanda Beck, PharmD, MS Presented at 2018 VizientÂŽ Pharmacy Network, Anaheim, California; 2019 Midwest Pharmacy Residents Conference, Omaha, Nebraska.

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Impact of In-Hospital Clinical Pharmacists’ Activities on 30-day Readmissions among High Risk Medicare Shared Savings Program (MSSP) Patients Akeem Bale, PharmD, MS; Kim Birtcher, PharmD, MS; David Putney, PharmD, MPH; Divya Varkey, PharmD, MS; Alex Varkey, PharmD, MS PURPOSE

RESULTS

Hospital readmissions reduction continues to be a major goal for health care institutions. It costs the Centers for Medicare and Medicaid Services (CMS) more than $26 billion annual and hospitals are penalized financially by CMS for not meeting readmissions goal. This study aimed to evaluate the impact of in-hospital pharmacists’ activities on readmissions among high-risk patients.

A total of 333 patients (53.8% female, median age, 72 years) were included in the primary analysis, including 235 patients in the intervention group and 98 in the control group. There was a nonsignificant reduction in 30-day readmission rate between the intervention and control group 38.3% vs. 42.9% [RR 0.89 (95% CI, 0.68-1.18)]. Median time to 30-day readmission was 13 days (4-23) and 12 days (3-19) for the pharmacist activity and control groups respectively. The risk of readmissions within 30 days after discharge was lower in the subset of patients who received medication history and discharge support provided by a pharmacist (HR, 0.68; 95% CI, 0.46-0.98).

METHODS

This multicenter retrospective cohort study was completed at Houston Methodist Health System. Patients admitted between June 2018 to December 2018 were included if they were ≥18 years, designated as high-risk MSSP patient, and received a pharmacist consult. Patients who received a consult-related pharmacist activity (intervention) were compared to patients who did not receive a consult-related pharmacist activity (control). The primary endpoint was 30-day readmission rate between the groups. Secondary endpoint included the effect of each pharmacy activity or combination of activities on readmission rates.

CONCLUSION

In-hospital pharmacists’ activities may reduce 30-day readmission among high-risk MSSP patients.

PGY2 -PGY1/PGY2 HEALTH-SYSTEM PHARMACY ADMINISTRATION RESIDENCY

Akeem Bale, PharmD, MS, BCPS Akeem earned his PharmD degree from the University of Toledo in 2017 and MS in Pharmacy Administration and Leadership at the University of Houston College Of Pharmacy in 2019. Following completion of his PGY2 residency, Akeem will assume the role of pharmacy manager at the Cleveland Clinic. Primary project preceptor: David R. Putney, PharmD, MPH, BCPS Presented at 2018 Vizient® Pharmacy Network, Anaheim, California; 2019 Alcaldé Southwest Leadership Conference, Frisco, Texas.

Evaluating the impact of drug-disease alerts on health outcomes in a health system Stella Kim, PharmD, MS; David Putney, PharmD, MPH; Sunny Bhakta, PharmD, MS; Kevin W. Garey, PharmD, MS PURPOSE

RESULTS

Medication errors and adverse drug events are common and can cause substantial harm. Many errors that result in injury can be potentially prevented by the use of appropriately designed computerized clinical decision support (CDS) alerts. Electronic health record (EHR) systems that embed CDS can reduce medication errors by alerting to drug-disease interactions. Previous studies have identified up to 44% of the general population are estimated to have drug-disease interactions; however, the clinical relevance of these alerts is inconclusive.

A total of 41,470 patient encounters were reviewed. 39 patient encounters (21.0%) among the case group that were administered the drug experienced QTc prolongation. Univariate analysis for comparison of case group vs. controls revealed that length of stay and the composite endpoint were significantly associated with the case group. After adjustment for age, ethnicity, and length of stay, being in the case group caused a significantly higher likelihood of having the composite endpoint (OR, 4.9; 95%, 3.4 to 7.1). CONCLUSION

METHODS

This 16-week multicenter, case-control study integrated EHR technology with a commercial drug-disease interaction alert database to evaluate the clinical significance of drug-disease interaction alerts. This study specifically focused on agents that exacerbate QTc prolongation. The primary objective of this study was to assess the incidence of QTc prolongation in patients identified with a QTc drug-disease interaction alert compared to similar patients in which a QTc drug-disease alert did not occur. Indirect effects of QTc prolongation including cardiopulmonary arrest requiring resuscitative efforts and inpatient mortality were also assessed.

A systematic assessment of harmful outcomes associated with drug-disease interaction alerts may provide opportunities to identify clinically impactful alerts vs. nonclinically significant alerts. Further studies are still warranted to evaluate a larger subset of drug-disease interaction alerts to determine the long-term impact on patient outcomes.

PGY2 -PGY1/PGY2 HEALTH-SYSTEM PHARMACY ADMINISTRATION RESIDENCY

Stella Kim, PharmD, MS, BCPS Stella Kim earned her PharmD degree from the University of Houston in 2017 and MS in Pharmacy Administration and Leadership at the University of Houston College of Pharmacy in 2019. Following completion of her PGY2 residency, Stella will assume the role of pharmacy operations manager at Houston Methodist Baytown. Primary project preceptor: David R. Putney, PharmD, MPH, BCPS Presented at 2018 VizientÂŽ Pharmacy Network, Anaheim, California; 2019 AlcaldĂŠ Southwest Leadership Conference, Frisco, Texas.

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Comparison of the effects of Smoflipid® vs. Intralipid® on liver enzymes among patients with chronic liver disease Jesse E. Harris, PharmD; Jonathan L. Balk, PharmD; Michael Sirimaturos, PharmD PURPOSE

RESULTS

Intravenous lipid emulsions (ILE) play an integral role in parenteral nutrition (PN) by providing a balanced source of calories as well as providing essential fatty acids. Existing literature has shown that composition of ILE may have immunomodulatory effects which can negatively impact liver function. Soy-based ILE, such as Intralipid®, are comprised of omega-6 fatty acids which are pro-inflammatory compared to other types of fatty acids. Combination lipids, such as Smoflipid®, contain less soybean oil and include other oils which are less proinflammatory and have shown to have a more favorable impact on liver enzymes when compared to soy-based ILE in patients with intact hepatic function. The purpose of this study was to compare the median change in liver enzymes (AST and ALT) in patients with chronic liver disease who receive PN with Smoflipid® vs. Intralipid® from initiation of ILE to day seven.

Ninety-nine patients with chronic liver disease met inclusion criteria and received ILE therapy while on PN. Of these, 54 received Smoflipid® and 45 received Intralipid®. The median (interquartile range) MELD-Na score at initiation of ILE therapy was 29.3 (17.7 – 35.9) vs. 21.7 (15.4 – 34.9); p= 0.44 in the Smoflipid® and Intralipid® arms, respectively. There was no statistical median difference in AST [12 units/L (-16 – 38) vs. 6 units/L (-7 – 25); p= 0.87] or ALT [5 units/L (-2 – 17) vs. 2 units/L (-7 – 16); p= 0.40] from start of ILE therapy out to day seven. In regards to secondary endpoints, there were no statistically significant differences identified.

METHODS

This was a retrospective, single-center, cohort study of patients with chronic liver disease who received ILE therapy in conjunction with PN from May 2016 – October 2018. A bivariate analysis was performed to evaluate the primary endpoint of median change in ALT and AST from start of ILE out to day seven. Secondary endpoints included change in total bilirubin, newly diagnosed infections out to 14 days post initiation of ILE therapy, change in Model for Endstage Liver Disease (MELD-Na) scores during the study timeframe, and hospital length of stay.

CONCLUSION

In patients with chronic liver disease who received PN therapy with Smoflipid® vs. Intralipid®, there was no observed statistical or clinical difference in the change in liver enzymes from the start of ILE therapy out to day seven. Further, long-term studies are needed to elucidate the impact of prolonged ILE therapy on liver enzymes in chronic liver disease.

PGY2 CRITICAL CARE PHARMACY RESIDENCY

Jesse E. Harris, PharmD Jesse earned his PharmD from Texas Southern University in 2017. He completed his PGY1 residency at Houston Methodist Hospital. Following the completion of his PGY2 residency, Jesse will remain at Houston Methodist Hospital as a clinical pharmacy specialist in cardiology. Primary project preceptor: Michael Sirimaturos, PharmD, BCNSP, BCCCP, FCCM Presented at 2018 Vizient Pharmacy Network, Anaheim, California; 2019 Texas Medication Center Critical Care Research Forum, Houston.

Outcomes Associated with Utilization of a Pharmacy-Managed Impella® Anticoagulation Protocol Celia A. Morton, PharmD; Luma Succar, PharmD; Sara Varnado Balk, PharmD; Luke Merten, PharmD; Kevin R. Donahue, PharmD PURPOSE

RESULTS

The Impella is a temporary, percutaneous ventricular assist device that provides cardiac support in the setting of cardiogenic shock as well as during high-risk percutaneous coronary intervention. Anticoagulation is necessary while on Impella® support to prevent thrombotic complications. At Houston Methodist Hospital, clinical pharmacists utilize a pharmacy-managed heparin protocol to adjust heparin purge solution concentrations and titrate supplemental heparin to achieve a partial thromboplastin time (PTT) of 60 to 80 seconds. The purpose of this study was to evaluate the outcomes associated with utilization of a pharmacy-managed Impella® heparin protocol at a large academic medical center. ®

METHODS

This was a retrospective, single-center, descriptive, observational, cohort study of patients with Impella® left ventricular assist devices whose anticoagulation was managed with a pharmacy heparin anticoagulation protocol. Each device implanted was considered a separate event managed via the pharmacy protocol. Impella® events were excluded if devices were placed greater than 24 hours prior to admission, if biventricular Impella® devices were placed at initial implant, if bivalirudin was initiated at time of device placement, or if a modified anticoagulation protocol was initiated. The primary outcomes were incidence of bleeding and suspected Impella® pump thrombosis during heparin management via the pharmacy protocol.

Seventy-five Impella® devices, implanted in 66 unique patients were included in the study. Median duration of pharmacy heparin management per protocol was 4.4 days [IQR 1.8, 7.9] and median duration of Impella® support was 6.9 days [IQR 4.1, 17.1]. During active pharmacy titration, 29 bleeding events (38.7%) and 8 (10.7%) suspected Impella® pump thrombosis events occurred. The majority of bleeding events occurred in the setting of therapeutic and subtherapeutic PTT, 13 (44.8%) and 12 (41.4%), respectively. Half of the thrombosis events occurred in the presence of a subtherapeutic PTT. Overall, 51.3% of PTT levels drawn during the study period were within the therapeutic range of 60 to 80 seconds. Time to pharmacy titration was 7.9 hours [IQR 4.6, 18.8] and median time to therapeutic PTT following initiation of active pharmacy titration was 16.9 hours [IQR 8.4, 26.3]. CONCLUSION

Use of a pharmacy managed heparin anticoagulation protocol during Impella® support prevented device thrombosis in a majority of patients, with an acceptable incidence of bleeding events. The majority of bleeding events occurred in the setting of subtherapeutic and therapeutic PTT levels; therefore, it is likely that bleeding events were not related to over-anticoagulation from the protocol. Overall, this study suggests that utilization of a pharmacy-managed heparin protocol is safe and effective in this patient population.

PGY2 CRITICAL CARE PHARMACY RESIDENCY

Celia A. Morton, PharmD Celia earned her PharmD at Drake University in Des Moines, IA. She completed her PGY1 Pharmacy Residency at New Hanover Regional Medical Center. Following her PGY2 Critical Care Pharmacy residency she will remain at Houston Methodist Hospital as a clinical specialist in critical care. Primary project preceptor: Kevin Donahue, PharmD, BCPS Presented at 2018 Vizient® Pharmacy Network, Anaheim, California; 2019 Texas Medical Center Critical Care Research Forum, Houston.

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Impact of an electronic antibiotic timeout on the utilization of frequently prescribed antibiotics in hospitalized patients Ty C. Drake, PharmD; Chase E. Janak, PharmD; Kevin W. Garey, PharmD, MS; Travis J. Carlson, PharmD; William Musick, PharmD; Clare Gentry, MD; Katherine K. Perez, PharmD PURPOSE

RESULTS

Methods to operationalize antibiotic timeouts (ATO) among hospitalized patients are often constrained by the high volume of antibiotic orders that surpass the capabilities of the antimicrobial stewardship program (ASP) to intervene. Houston Methodist Hospital implemented a streamlined electronic ATO process that alerted providers to evaluate the need for continued antibiotics on day 4 of predefined antiinfective therapy. Unresolved alerts were reviewed by clinical pharmacists the following day. The objective of this study was to determine the impact of this electronic ATO on frequently prescribed antibiotics.

A total of 8,458 patients met ATO alert criteria for inclusion in the pre-ATO timeframe and 6,901 patients with an ATO alert in the post-ATO group; 2,642 (38%) prompted a pharmacists’ review. The average composite DOT was 11. 5 per admission in the pre-ATO cohort, compared with 11. 1 in the post-ATO cohort (p=0.02). After multivariate linear regression, the ATO was significantly associated with a decrease of 0.5 DOT per patient admission (p < 0.001). Other factors associated with a reduction in DOT included age (p < 0.001), service line (p=0.003), and admission source (p=0.031). Mean hospital costs per admission were significantly reduced in the post-ATO group: $56,039 vs $53,321 (p=0.009). There was no difference in rates of CDI and MDRO.

METHODS

This was a quasi-experimental study in a 924-bed quaternary care hospital comparing days of therapy (DOT) in patients admitted prior to (February 2017 – January 2018) and after implementing an ATO process (March 2018 – February 2019). Antibiotics evaluated included vancomycin, cefepime, piperacillin/tazobactam, and meropenem. ATO alert logic was simulated retrospectively to capture the pre-ATO cohort. The primary outcome was mean composite DOT per patient admission. Secondary outcomes included total hospitalization cost, Clostridioides difficile infection (CDI) and multidrug resistant organism (MDRO) rates.

CONCLUSION

Implementation of our electronic ATO process demonstrated significant reductions in overall DOT for frequently prescribed antibiotics and decreased total hospital costs across a diverse patient population. This process provides a real-world strategy to operationalize a large scale ATO as an adjunct to an ASP.

PGY2 INFECTIOUS DISEASES PHARMACY RESIDENCY

Ty Drake, PharmD Ty earned his PharmD at Drake University in Des Moines, Iowa. He completed his PGY1 Pharmacy Residency at UnityPoint Health – Des Moines. Following completion of his PGY2 Infectious Diseases Pharmacy residency, Ty will assume the role of infectious diseases pharmacist at Houston Methodist Willowbrook. Primary project preceptor: Katherine Perez, PharmD, BCIDP Presented at 2018 Vizient® Pharmacy Network, Anaheim, California; 2019 Midwest Pharmacy Residents Conference, Omaha, Nebraska.

Evaluation of apixaban and rivaroxaban anti-Xa levels in relation to clinical outcomes Steffany Nguyen, PharmD; Melanie Ruegger, PharmD; Diane Dreucean, PharmD; Eric Salazar, MD, PhD; Kevin Donahue, PharmD PURPOSE

RESULTS

Since their emergence, factor Xa inhibitors have been increasingly used due to many favorable drug properties. Although not routinely recommended, anti-Xa levels calibrated to the specific factor Xa inhibitor may be useful in certain clinical scenarios, however, there are currently no laboratory standards that have established therapeutic ranges and no proven correlation between anti-Xa levels and clinical outcomes. The purpose of this study was to describe the utilization, application, and correlation of antiXa levels to safety outcomes in patients receiving apixaban or rivaroxaban.

A total of 336 qualifying anti-Xa levels were included for data analysis. At least 14 unique reasons for obtaining anti-Xa levels were identified, some of which were used to guide clinical decision-making. Of all anti-Xa levels obtained, 48 were associated with major bleeding events. The majority of anti-Xa levels were not drawn as peak levels, which are recommended to be drawn 2 to 4 hours from the last dose; despite this finding, many anti-Xa levels remained elevated above typical levels that would be otherwise observed within this time window, at further time intervals post-dose. More than 75% of patients were of elderly age and approximately 25% had multiple anti-Xa levels drawn during admission. Patients of body weight extremities and renal replacement therapy were represented in the major bleeding subgroup. Anticoagulation dosage regimens were either appropriate or inappropriately low as per therapeutic indication, however none were inappropriately high.

METHODS

This multicenter, retrospective, descriptive cohort study included adult patients at Houston Methodist receiving apixaban or rivaroxaban and had at least one anti-Xa level during admission from May 2016 through September 2018. Anti-Xa levels obtained within 24 hours of heparin or low-molecular weight heparin exposure were excluded. The primary endpoint was major bleeding events, defined in accordance with the International Society on Thrombosis and Haemostasis (ISTH). Secondary endpoints included anti-Xa levels for different doses, anti-Xa levels at different time intervals post-dose, thrombotic events, and reasons for checking levels. A pre-specified subgroup analysis was performed to further evaluate the primary endpoint.

CONCLUSION

Utilization of anti-Xa levels may be useful to assist in determining immediate appropriateness of anticoagulation therapy. The presence of elevated anti-Xa levels above typical observed ranges may be useful to guide clinical assessment of drug concentration present in systemic circulation, but must be carefully interpreted in conjunction with the clinical context for which they are obtained. Dose titration and use of reversal therapies based on anti-Xa level results in patients with major bleeding remain areas for further research.

PGY2 INTERNAL MEDICINE PHARMACY RESIDENCY

Steffany Nguyen, PharmD Steffany earned her PharmD from St. Louis College of Pharmacy in 2017. She completed her PGY1 residency at Memorial Hermann – Texas Medical Center in Houston. Following completion of her PGY2 in Internal Medicine, Steffany will remain at Houston Methodist Hospital as a clinical pharmacy specialist. Primary Project Preceptor: Melanie Ruegger, PharmD, BCPS Presented at 2018 Vizient® Pharmacy Network, Orlando, Florida; 2019 Midwest Pharmacy Residents Conference, Omaha, Nebraska.

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Effect of appetite stimulants on weight management in patients with cancer-associated anorexia Lauren Bailey, PharmD; Cynthia El Rahi, PharmD; Renee Stubbins, PhD; Jade Hefler, PharmD; Rosetta Lee, PharmD; Eric Bernicker, MD PURPOSE

RESULTS

Cancer-associated anorexia is associated with a poor prognosis, reduced survival, and poor quality of life. Use of appetite stimulants in patients with cancerassociated anorexia has been shown to increase appetite and weight while improving survival and quality of life. The purpose of this project is to evaluate the effect of appetite stimulants versus no appetite stimulants on weight management in cancer patients.

Of the 24 patients who met inclusion criteria for cancerassociated anorexia, 13 patients received an appetite stimulant, while 11 patients did not receive an appetite stimulant. The percentage of patients who maintained/ gained weight at 2 to 6 weeks in patients who received an appetite stimulant versus those who did not receive an appetite stimulant was 38% and 36%, respectively. The percentage of patients who reported a good/improved appetite in those who received an appetite stimulant versus those who did not receive an appetite stimulant was 62% and 27%, respectively.

METHODS

A retrospective chart review was conducted on oncology outpatients pre-identified by the registered dietitian as having cancer-associated anorexia from April 1, 2018 to May 1, 2019. The primary endpoint of this project was to assess the percentage of weight maintained/gained at 2 to 6 weeks from the time the patient was determined to meet criteria for cancer-associated anorexia in patients who received and did not receive an appetite stimulant. Secondary endpoints include change in albumin levels at 2 to 6 weeks, patient reported appetite, occurrence of medication side effects, barriers to treatment, and medication adherence.â&#x20AC;&#x192;

CONCLUSION

The use of appetite stimulants in patients with cancerassociated anorexia was associated with a comparable percentage of weight increase and an improved appetite when compared to no appetite stimulants.

PGY2 ONCOLOGY PHARMACY RESIDENCY

Lauren Bailey, PharmD Lauren earned her PharmD from the University of New Mexico in 2017. She completed her PGY1 residency at Harris Health System in Houston, TX. Following completion of her PGY oncology residency, Lauren will assume the role of outpatient oncology clinical pharmacist at Smith Clinic with Harris Health System. Primary project preceptor: Cynthia El Rahi, PharmD, BCOP Presented at 2018 VizientÂŽ Pharmacy Network, Anaheim, CA; 2019 Hematology/Oncology Pharmacy Association, Fort Worth, Texas; 2019 Midwest Pharmacy Residents Conference, Omaha, Nebraska.

Olanzapine for chemotherapy-induced nausea and vomiting (CINV) prophylaxis in patients receiving high-dose chemotherapy for autologous hematopoietic stem cell transplantation (ASCT) Jade L. Hefler, PharmD; Ekim Ekinci, PharmD, MS; James Cox, PharmD; Joe E. Ensor, PhD; Edward T. McLean, PharmD; Carlos A. Ramos, MD; Premal Lulla, MD; Rammurti T. Kamble, MD; George Carrum, MD PURPOSE

Olanzapine has demonstrated clinical efficacy for chemotherapy-induced nausea and vomiting (CINV) prophylaxis in patients receiving highly or moderately emetogenic intravenous chemotherapy. Olanzapine for CINV prophylaxis in patients receiving high-dose (HD) chemotherapy as conditioning for hematopoietic stem cell transplantation (HSCT) is not well established. The purpose of this review was to determine if an olanzapine-based CINV prophylaxis regimen is safe and effective for patients receiving HD chemotherapy for autologous HSCT (ASCT). METHODS

A single-center, retrospective analysis evaluated patients who received HD melphalan or BEAM (carmustine, etoposide, cytarabine, melphalan) for ASCT from June 2016 to September 2018. Before April 2017, a fosaprepitantbased CINV regimen was utilized for HD melphalan and BEAM as conditioning for ASCT. An olanzapine-based CINV regimen was adopted for HD melphalan in April 2017 and for BEAM in August 2018. Outcomes of olanzapine combined with ondansetron and dexamethasone (OOD) were compared with fosaprepitant combined with ondansetron and dexamethasone (FOD). Assessment period for CINV was defined as acute phase (chemotherapy days) and delayed phase (within 5 days of chemotherapy completion). Primary endpoint was proportion of days â&#x20AC;&#x192;

requiring rescue CINV medications during the assessment period. Secondary endpoints included number of rescue CINV medication doses, time to neutrophil engraftment (TTNE), and length of stay (LOS). RESULTS

In the acute phase, 10% of FOD patients required rescue CINV medications on at least 50% of days while approximately 3% of OOD patients required rescue medications on any day (p=0.006). In the delayed phase, the median proportion of days requiring rescue CINV medications was significantly lower with OOD (60% vs. 20%; p<0.0001). OOD had a significantly lower proportion of patients requiring rescue CINV medication doses during the acute phase (17% vs. 3%; p=0.004). In the delayed phase, the median number of CINV medication doses was significantly lower with OOD (7 vs. 2; p<0.0001). Median TTNE was 13 days in both cohorts. LOS was significantly shorter for OOD (mean 19.3 vs. 17.5 days; p<0.0001). The side effect profile was favorable for both cohorts. CONCLUSION

Proportion of days requiring rescue CINV medications was significantly reduced with an olanzapine-based CINV prophylaxis regimen, compared to a fosaprepitant-based regimen. Olanzapine appears to be safe and effective for CINV prophylaxis in patients receiving HD chemotherapy for ASCT.

PGY2 ONCOLOGY PHARMACY RESIDENCY

Jade L. Hefler, PharmD Jade earned her BS in Food Science and Human Nutrition from the University of Florida in 2014 and her PharmD degree from the University of Florida College of Pharmacy in 2017. She completed her PGY1 residency at Houston Methodist Hospital in Houston, TX. Following completion of her PGY2 oncology residency, Jade will assume the role of medical oncology clinical pharmacist at the University of Kansas Health System. Primary project preceptor: James Cox, PharmD, BCOP Presented at 2018 VizientÂŽ Pharmacy Network, Anaheim,CA; 2019 Transplantation & Cellular Therapy Meetings of ASBMT and CIBMTR, Houston, TX; 2019 Hematology/Oncology Pharmacy Association, Fort Worth, Texas; 2019 Midwest Pharmacy Residents Conference, Omaha, Nebraska

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Single-center experience describing the intra-patient variability in tacrolimus exposure in adult heart transplant recipients Erin P. Bilgili, PharmD; Jill C. Krisl, PharmD; Sara Varnado Balk, PharmD PURPOSE

RESULTS

Tacrolimus pharmacokinetics displays intra-patient variability (IPV), or fluctuations in troughs (C0) within an individual during a timeframe in which the dose is unchanged. High IPV in kidney and liver transplant recipients is associated with graft loss and rejection, however, this relationship has been variable in available literature in heart transplant (HT) recipients.

All patients were maintained on a triple drug immunosuppression regimen per protocol with mycophenolate at a median mycophenolate mofetil equivalent dose of 3000 mg/day and an institutional steroid taper to a median dose of prednisone 5 mg/day. The only identified drug class with CYP3A4 interactions during the study period was prophylactic antifungals. Voriconazole, a strong CYP3A4 inhibitor, was the most common antifungal used for prophylaxis at a median dose of 400 mg/day. The mean (±SD) and median (min-max) tacrolimus C0 IPV for the entire study period were 23.26% (+10.8) and 26.04% (8.3 – 57.5), respectively. Using the median of 26.04% as the cutoff, patients were divided into high (N=63) and low (N=63) IPV groups. Among the high and low IPV groups, the mean (±SD) and median (min-max) IPV were 37.6% (+8.6) vs 19.38% (+4.3), and 34.7% (26.07 – 57.5) vs 19.5% (8.3 – 26.01), respectively. During the entire study period, the occurrence of >1 and >3 rejection episodes was similar between patients with high and low IPV (63.5% vs. 61.9% and 11.1% vs. 9.5%). Patient and graft survival at 6 months was 95%.

METHODS

We aimed to describe tacrolimus IPV in our HT recipient population through a single-center chart review. Of 173 adult HT performed between January 1, 2013 and January 30, 2018, 126 recipients were included. Exclusion criteria included multi-organ transplants, not initiated on tacrolimus or converted to cyclosporine, graft loss, death, or lost to follow-up (<6 months data) during the data collection period. The primary endpoint was tacrolimus C0 IPV (%), collected during protocol follow-up time points. Secondary endpoints included immunosuppressant doses, concomitant medications with clinically significant effect on tacrolimus exposure (CYP3A4 inducers/inhibitors), route of tacrolimus administration, and biopsy results up to 6 months post-transplant.

CONCLUSION

Of the 126 included HT recipients, there was no clinical difference in rejection among patients with high and low tacrolimus C0 %IPV. The paucity of literature reporting the relationship between tacrolimus C0 %IPV and incidence of rejection in HT recipients have yielded contradictory results.

PGY2 SOLID ORGAN TRANSPLANTATION PHARMACY RESIDENCY

Erin Bilgili, PharmD Erin earned her BS in Biomedical Sciences from Auburn University in 2013 and her PharmD from Auburn University Harrison School of Pharmacy in 2017. She completed her PGY1 residency at Ascension Sacred Heart Health System in Pensacola, Florida. Following completion of her PGY2, Erin will assume the role of clinical pharmacy specialist in transplantation at the University of Alabama-Birmingham. Primary project preceptor: Jill C. Krisl, PharmD, BCPS Presented at 2018 Vizient Pharmacy Network, Anaheim, CA.

Evaluation of induction immunosuppression in elderly kidney transplant recipients Christine Pham, PharmD; Samantha Kuten, PharmD; Alex Rogers, PharmD; Richard Knight, MD; Duc T Nguyen, MD; Edward Graviss; A Osama Gaber, MD PURPOSE

RESULTS

It is well recognized that elderly transplant recipients experience lower rates of acute rejection along with higher rates of infectious death compared to their younger counterparts. While less intensive immunosuppression may be preferable, currently there are no recommendations for depleting versus non-depleting induction strategies. We sought to compare infectious and immunologic outcomes between anti-thymocyte globulin (ATG) and basiliximab (IL2RA) induction in elderly kidney transplant recipients (KTRs).

There were significantly more AA, deceased donors, and sensitized KTRs in the ATG group, reflecting the different criteria for induction agent. Consequently, development of dnDSAs (17% vs 7%, p=0.08) and rejection (11% vs 1%, p=0.03) occurred more frequently in the ATG group. ATG KTRs experienced higher rates of overall infectious complications (77% vs 56%, p=0.01), owing predominately to increased rates of bacterial (54% vs 39%, p=0.08) and viral infections (51% vs 35%, p=0.05). Urinary tract infections and CMV in particular occurred at high rates among ATG patients (46% and 32%, respectively).

METHODS

We performed a review of 146 KTRs greater than 65 years receiving ATG or IL2RA induction. Per institution protocol, depleting induction was administered to patients with the following characteristics, irrespective of age: African American (AA), PRA ≥20%, and/or re-transplantation. Infectious complications (bacterial, viral, and invasive fungal) and graft outcomes at 1 year were compared.

CONCLUSION

Elderly KTRs receiving ATG are at an increased risk for infectious complications, which was largely attributable to high rates of urinary tract infections and CMV. Additional strategies aimed at mitigating these complications in elderly patients requiring ATG may be beneficial.

PGY2 SOLID ORGAN TRANSPLANTATION PHARMACY RESIDENCY

Christine Pham, PharmD Christine earned her PharmD from St. Louis College of Pharmacy in 2016. She completed her PGY1 residency at Houston Methodist Hospital in Houston, Texas. Following completion of her PGY2 in solid organ transplantation, Christine will assume the role of clinical pharmacy specialist in thoracic transplantation at Houston Methodist Hospital. Primary project preceptor: Samantha Kuten, PharmD Presented at 2018 Vizient® Pharmacy Network, Orlando, Florida; 2019 Midwest Pharmacy Residents Conference, Omaha, NE; 2019 American Transplant Congress, Boston, MA.

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Defining vasoplegia following durable, continuous flow left ventricular assist device (CF-LVAD) implantation Joshua T. Swan, PharmD, MPH; Tomona Iso, PharmD; Elsie Rizk, PharmD; Barry H. Trachtenberg, MD; Jill Krisl, PharmD; Sara Varnado Balk, PharmD; Wadi N. Suki, MD; Adaani E. Frost, MD; Erik Suarez, MD; Faisal S Uddin, MD; Mahwash Kassi, MD; Noel Martin Giesecke, MD; Arvind Bhimaraj, MD, MPH; Faisal N. Masud, MD PURPOSE

Early identification and treatment of vasoplegia following CF-LVAD implantation is imperative for post-surgery recovery. In the absence of a consensus definition of vasoplegia following CF-LVAD, interventions and outcomes cannot be reliably assessed. This study aimed to construct criteria that would be reproducible, standardized, and associated with clinical outcomes. This study reports incidences and associations with non-favorable discharge (death, hospice, long term acute care, and rehab). METHODS

This retrospective, cohort study included patients who underwent initial CF-LVAD implantation on cardiopulmonary bypass from August 2016 through August 2018. Investigators identified 6 considerations for constructing vasoplegia criteria: (1) Period of observation: 72 hours post CPB termination. (2) Unit of time for measurement: Analysis was conducted at each 15-minute interval. (3) Clinical constructs: Version 1 (V1) used mean arterial pressure (MAP; mmHg) <60 or systemic vascular resistance (SVR; dynes·sec·cm-5) <800 combined with normal cardiac index (CI; L/min/m2) >2.2 and norepinephrine equivalents (NEE; mcg/kg/min) ≥0.1. Version 2 (V2) used MAP <60 or SVR <700 combined with CI >2.5 and NEE ≥0.2.

(4) Threshold logic strategies: Multiple hemodynamic measurements documented within an interval were categorized as having “ever” or “always” crossed the threshold. (5) Duration: The number of consecutive intervals where criteria were sustained. (6) Missing data: The last documented MAP and SVR were carried forward for 3 intervals, and CI for 288 intervals. RESULTS

This study included 98 CF-LVAD recipients. The incidence of vasoplegia for ≥1 interval was 61% for V1 ever, 32% for V1 always, 28% for V2 ever, and 14% for V2 always. The incidence of vasoplegia for ≥2 consecutive interval was 40% for V1 ever, 20% for V1 always, 15% for V2 ever, and 8% for V2 always. Absolute risk difference for non-favorable discharge when vasoplegia occurred for ≥1 interval was 16% for V1 ever, 27% for V1 always, 1% for V2 ever, and 23% for V2 always; for ≥2 consecutive intervals, 19% for V1 ever, 32% for V1 always, 8% for V2 ever, 25% for V2 always. CONCLUSION

Version 1 always for ≥1 interval and version 1 ever for ≥2 consecutive intervals occurred frequently and increased risk for non-favorable discharge by 19% to 27%.

FELLOW – CLINICAL PHARMACY FELLOWSHIP IN OUTCOMES RESEARCH

Tomona Iso, PharmD Tomona earned her PharmD degree from Nova Southeastern University College of Pharmacy in 2018. Tomona will continue postgraduate training at Houston Methodist Hospital for as a second year clinical pharmacy fellow. Primary project preceptor: Joshua T. Swan, PharmD, MPH, BCPS, FCCM

Effect of intraoperative liposomal bupivacaine and postoperative intravenous acetaminophen on postoperative opioid use within 24 hours of colorectal surgery: a single-center, retrospective, factorial cohort study Elsie Rizk, PharmD; Joshua T. Swan, PharmD, MPH; Eric M. Haas, MD PURPOSE

The objective of this study was to evaluate the effect of 2 non-opioid analgesics, liposomal bupivacaine (LB) and intravenous (IV) acetaminophen, on opioid utilization after colorectal surgery. METHODS

This retrospective, 2x2 factorial cohort study evaluated 2 independent variables: 1) intraoperative LB and 2) IV acetaminophen administration within 18 hours after surgery. Patients undergoing an open or endoscopic colorectal resection or excision surgery at Houston Methodist Hospital from May 2016 until February 2018 were included. Exclusion criteria were age<18 years, colorectal surgery performed after one day of hospital admission, creation of colostomies or ileostomies, and documented allergy to acetaminophen, opioid, or bupivacaine. The primary outcome was the total IV morphine milligram equivalents (MME) administered within 24 hours after surgery. The postoperative observation period started at the time of patient transfer from the procedural area to the postsurgical care unit and ended at 24 hours after transfer, subsequent surgery, hospital discharge, or death, whichever occurred first. A multivariable linear regression model adjusted for American Society of Anesthesiologists (ASA) score,

management via the Enhanced Recovery after Surgery (ERAS) pathway, type of surgery (open vs percutaneous endoscopic), opioid use within 1 week prior to admission, and height was used for the primary outcome analysis. RESULTS

Among 564 patients who were included in the analysis, 209 patients received both LB and IV acetaminophen, 107 patients received LB only, 129 patients received IV acetaminophen only, and 119 patients did not receive any of the 2 studied analgesics. The mean IV MME used within 24 hours after surgery was 11.6 (SD=21.7) with LB vs 37.2 (SD=37.2) without LB. The mean IV MME used within 24 hours after surgery was 19.7 (SD=28.7) with IV acetaminophen vs 27.5 (SD=36.2) without IV acetaminophen. The linear regression analysis showed an IV MME difference of -16.7 (95% CI –21.8 to –11.6) for LB administration and 3.3 (95% CI –2.9 to 9.6) for IV acetaminophen administration after adjusting for covariates. CONCLUSION

After adjusting for meaningful covariates, LB was associated with a significant reduction of opioid use within 24 hours after colorectal surgery, but IV acetaminophen was not.

FELLOW – CLINICAL PHARMACY FELLOWSHIP IN OUTCOMES RESEARCH

Elsie Rizk, PharmD Elsie earned her PharmD degree from the Lebanese American University in 2016. She completed her PGY1 residency at Houston Methodist Hospital in 2017. Elsie will complete her fellowship training in December 2019. Primary project preceptor: Joshua T. Swan, PharmD, MPH, BCPS, FCCM

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SYSTEM PHARMACY RESEARCH BIBLIOGRAPHY 2014 TO 2019 Krisl J. Potential Benefit or Risk of Harm?: Use of Herbal Supplements in Patients with Heart Failure, Texas Chapter of American College of Cardiology Heart Failure Blog. Oct 2018 Krisl JC, Alloway RR, Shields AR, et al. Acute Rejection Clinically-Defined Phenotypes Correlates with Long-Term Renal Allograft Survival. Transplantation 2015 April; 99(10):2167-73 Krisl JC, Alloway RR, Shields AR, et al. Bortezomib-Based Antibody-Mediated Rejection Therapy and Simultaneous Conversion to Belatacept. Transplantation 2014; 97(4). Krisl JC, Alloway RR, Woodle ES. Off-Label Drug Use of Immunosuppressive Agents in Solid Organ Transplantation [Book chapter]. Textbook of Organ Transplantation. June 2014. Editors: Allan D. Kirk, Stuart J. Knechtle, Christian P. Larsen, Joren C. Madsen, Thomas C. Pearson. Publisher Wiley-Blackwell

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Pham VP, Luce AM, Ruppelt SC, et al. Age-Stratified Treatment Response Rates in Hospitalized Patients with Clostridium difficile Infection Treated with Metronidazole. Antimicrob Agents Chemother. 2015 Oct;59(10):6113-6.

Shah PJ, Koshy J, Everett N, Attia E. Severe Plasmodium falciparum Malaria Treated With Investigational Artesunate in the United States. J Pharm Pract. 2018 Jan 1:897190018782367. Epub ahead of print.

Phe K, Cadle RM, Guervil DJ, et al. Significant publications on infectious diseases pharmacotherapy in 2014. Am J Health Syst Pharm. 2015;72(16):1380-92.

Shank B, Nguyen P, Pherson E. Transitions of Care in Patients With Cancer. Am J Manag Care. 2017;23(7 Spec No.):SP280-SP284.

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SYSTEM PHARMACY RESEARCH BIBLIOGRAPHY 2014 TO 2019 Solomon JM, Ajewole VB, Schneider AM, et al. Evaluation of the prescribing patterns, adverse effects, and drug interactions of oral chemotherapy agents in an outpatient cancer center. J Oncol Pharm Pract. 2018. Epub ahead of print. Sparrow HG, Swan JT(co-primary), Moore LW, et al. Disparate outcomes observed within Kidney Disease: Improving Global Outcomes (KDIGO) acute kidney injury stage 1. Kidney Int. 2019;95(4):905-13. Succar L, Sulaica EM, Donahue KR, Wanat MA. Management of Anticoagulation with Impella Percutaneous Ventricular Assist Devices and Review of New Literature. J Thromb Thrombolysis. 2019. Epub ahead of print. Swan JT, Ashton CM, Bui LN, et al. Effect of chlorhexidine bathing every other day on prevention of hospital-acquired infections in the surgical ICU: a single-center, randomized controlled trial. Crit Care Med. 2016;44(10):1822-32. Swan JT, Giouroukakis M, Shank BR, et al. The value of pharmacy residency training for health-systems: an annotated bibliography. J Pharm Pract. 2014; 27(4):399-411. Swan JT, Zaghloul H, Cox JE, Murillo JR. Use of a pharmacy protocol to convert standard rituximab infusions to rapid infusion shortens the duration of outpatient infusion clinic visits. Pharmacotherapy. 2014 Jul;34(7):686-94. Swan JT. Agitation in mechanically ventilated ICU patients. In B. Boucher, & C. Haas (Eds.), Critical Care Self-Assessment Program, 2016 Book 3: Pain and Sedation/Support and Prevention. (pp. 27 - 56). Lenexa, KS: American College of Clinical Pharmacy. Swan JT. Decreasing inappropriate unable-to-assess ratings for the Confusion Assessment Method for the Intensive Care Unit. Am J Crit Care. 2014;23(1):60-9. Tatara AW, Ruegger M, Adeola M, Putney D. Time to Occurrence Based on Risk Stratification of Hospital-Acquired Venous Thromboembolism: A Retrospective Observational Cohort Study. J Pharm Pract. 2017. Epub ahead of print. Thomas J, Coralic A, Ruegger M, Thompson-Moore N. Descriptive Analysis of Patient Readmissions Within 60 Days Due to Medication-Related Events. Hosp Pharm. 2015 Jul;50(7):595-602. Thomas T, Fuentes A, Xu Q, Donahue K. Evaluation of heparin induced thrombocytopenia using probability scores in a mechanical circulatory support population. J Thromb Thrombolysis. 2019. Epub ahead of print.

Thompson-Moore NR, Wanat MA, Putney DR, Liebl PH, et al. Evaluation and Pharmacokinetics of Treatment Dose Enoxaparin in Hospitalized Patients With Morbid Obesity. Clin Appl Thromb Hemost. 2015;21(6):513-20. Umoru GO, Shah PJ, Tariq F. A Case Report of Neurotoxicity After Prolonged Doses of Acyclovir in a Patient With Renal Dysfunction. J Pharm Pract. 2019; Epub ahead of print. Varnado S, Peled-Potashnik Y, Huntsberry A, et al. Effect of diltiazem on exercise capacity after heart transplantation. Clin Transplant 2017; 31 (8): e12997. Wanat M, Fitousis K, Boston F, Masud F. Comparison of dexmedetomidine versus propofol for sedation in mechanically ventilated patients after cardiovascular surgery. Methodist Debakey Cardiovasc J. 2014;10(2):111-7. Wanat MA, Fitousis K. Comment: Critical Care Pharmacists and Medication Management in an ICU Recovery Center. Ann Pharmacother. 2019;53(1):105. Wanat MA, Swan JT. “Critical Care Pharmacotherapeutics [book review]” Journal of Pharmaceutical Care and Health Systems. 2014; S1:007. Whiddon AR, Dawson KL, Fuentes A, et al. Postoperative antimicrobials after lung transplantation and the development of multidrug-resistant bacterial and Clostridium difficile infections: an analysis of 500 non-cystic fibrosis lung transplant patients. Clin Transplant. 2016;30(7):767-73 Xia R, Kachru N, Tuazon, DM, et al. Evaluation of Neuromuscular Blockade Reversal on Postoperative Mechanical Ventilation Time in a Cardiovascular Surgery Population. J Cardiothorac Vasc Anesth. Article in Press Yang T, Cutshall BT, Tatara A, Ruegger M. Combined Insulin and GLP-1 Receptor Agonists: Simplifying Treatment or Adding Obstacles? J Pharm Pract. 2018. Epub ahead of print. Yang T, Murillo M, Vadharyia A, et al. Direct oral anticoagulants versus aspirin for venous thromboembolism after orthopedic surgery. Am J Health-Syst Pharm. 2019; Epub ahead of print.

QUICK FACTS HOUSTON METHODIST SYSTEM

8 2,312 915,81 1.2

Hospitals Operating beds Patient encounters Million outpatient visits

114,586

Admissions

23,669

Employees

6,000+

Aﬃliated physicians

HOUSTON METHODIST RESEARCH INSTITUTE

1,960 681

Credentialed researchers Faculty

584

Active clinical trials

1,261

Ongoing clinical protocols

1,29

Peer-reviewed publications

5,218

Collaborations around the world

$55.3

Million total extramural research funding

HOUSTON METHODIST houstonmethodist.org/pharmacy

092019