2026 Southeastern Residency Conference

Background  -
Since 2018, calcitonin gene-related peptide (CGRP)–targeting therapies have expanded migraine prevention options. Inhibiting endogenous CGRP may pose risks, as recently noted by the US Food and Drug Administration (FDA) with new safety information and now requiring the risks of worsening hypertension and Raynaud’s phenomenon to be included in the labeling for all CGRP-targeting agents. This project aimed to assess the risk of clinically relevant blood pressure changes and other adverse outcomes associated with long-term CGRP-targeting therapy and to identify baseline risk factors that might guide safer use.

Methods -
This is a retrospective observational longitudinal cohort project for quality improvement. Eligible patients enrolled within the Ralph H. Johnson Veterans Affairs Healthcare System (RHJVAHS) who had an active diagnosis of migraine and a documented prescription for CGRP-targeting therapies for migraine prevention between May 17, 2018 and July 31, 2024 were included. Therapies examined were erenumab, fremanezumab, galcanezumab, atogepant, and rimegepant. A longitudinal logistic model was used to evaluate variables over time, from baseline within 1 year prior to starting to 1 year after initiation of CGRP-targeting treatment with quarterly follow-up.
The primary objective was to determine whether there is a clinically relevant change in median blood pressure, defined as an increase in stage of hypertension, increase in antihypertensive medication dose or additional antihypertensive medication added, or any episode of hypertensive crisis after use of a CGRP-targeting agent long-term for migraine prevention. The secondary objective was to determine whether there is an increased incidence of all cause hospitalizations, ER visits, or new Raynaud’s Syndrome diagnosis after use.

Results –
A total of 490 unique patients (5,188 encounters; mean follow-up 2.6 years) were included. The primary composite outcome was observed in 3,253 (64.7%) encounters. Adjusted mean probabilities for the composite outcome were similar across drug exposures. No agent was associated with significantly increased odds of composite outcome versus erenumab 70 mg. Atogepant showed a non-significant lower risk (OR 0.654, 95% CI 0.414–1.034; p=0.07) while a nonsignificant increased risk was observed for encounters with no CGRP-targeting agent refill, OR 1.33 (95% CI: 0.981-1.810]; p = 0.066.
After adjusting for baseline comorbidities, Black race was associated with significantly lower odds of the primary outcome as well as a history of coronary artery disease (CAD) and use of abortive CGRP-targeting therapy. There was no statistically significant association between the primary outcome and the presence of obstructive sleep apnea or chronic kidney disease, however an increasing number of baseline antihypertensive medications was significantly associated with higher odds of the composite outcome.
Secondary analyses revealed 2,728 (54.3%) encounters with hypertension stage progression, but no agent was associated with increased risk compared to erenumab 70 mg. Rimegepant 75 mg was associated with a higher odds ratio (OR 1.852, 95% CI 0.975–3.518; p = 0.06); however, this did not reach statistical significance. Among 564 (11.2%) encounters with escalation of antihypertensive therapy, dose decrease of CGRP therapy was linked to more than a two-fold higher risk of escalation (OR 2.277, 95% CI 1.027–5.046, p=0.043), likely reflecting blood pressure-related medication adjustments. Hypertensive crisis was very rare (n=1). Secondary outcomes occurred infrequently and are not reported here.

Conclusion:
Long-term use of CGRP-targeting therapies in this veteran population was associated with a significant incidence of clinically relevant worsening of hypertension, with nearly 65% of encounters experiencing the composite outcome, driven primarily by progression in hypertension staging. No statistically significant differences in risk were observed between individual CGRP agents and the erenumab 70 mg reference. Numerical higher risk with rimegepant and lower risk with atogepant warrant further study. Ongoing blood pressure monitoring in patients treated with CGRP-targeting drugs remains warranted.

Title: Acute Pain Management in Patients with Opioid Use Disorder: Evaluating Practice and Outcomes Within a Tertiary Care Facility

Authors: Breanna Wright, Mary Beth Brinkman, Justin Gruca
TriStar Centennial Medical Center – Nashville, TN

Background: Chronic pain is reported by 20.5% of Americans within the United States. Chronic pain is defined as pain that lasts beyond three months and extends past normal tissue healing time. Although hospitalized patients are treated for chronic pain, they may also require acute pain management in instances such as moderate to severe fractures or post-surgical pain. These instances may lead to undertreated pain by physicians due to fear of cognitive, respiratory, and psychomotor side effects which may be exaggerated with short-term opioid use. It is important to maintain adequate pain management, especially in patients with opioid use disorder (OUD) because undertreated pain has been shown to result in poor health outcomes, including early discharges, negative stigma, and overall mistrust of the healthcare system. Opioid use disorder is defined as a pattern of opioid use associated with a range of consequences, and with increased mortality leading to significant impairment or distress. The American Society of Addiction Medicine (ASAM) have published guidelines for the treatment of OUD, but there is still a lack of consensus among providers as it relates to acute pain management. In this study, we aimed to describe characteristics of acute pain management in patients on chronic opioid therapy within our institution.

Methods: This is a single-center, retrospective cohort study conducted through chart review from January 1, 2025 through July 1, 2025. Patients were identified via a computerized report using a clinical surveillance platform, generated by searching for buprenorphine medication orders. Patients admitted to our facility with acute pain and identified as being on chronic opioid therapy or receiving buprenorphine for opioid use disorder were included. Exclusion criteria consisted of oncology patients, nonverbal patients, patients admitted to the intensive care unit (ICU), patients receiving methadone inpatient or outpatient, and patients undergoing surgery during their admission. The primary endpoint was the average number of as needed (PRN) pain medication orders. Secondary endpoints included pain scale reduction, psychiatric provider consultations, naloxone administrations, methylnaltrexone administrations, and number of unplanned readmissions or emergency department (ED) visits.

Results: A total of 65 patients were screened; 27 patients met inclusion criteria and 38 patients were excluded. Less than half of the patients included within the study were male, and 85% of patients had a prior history of substance use disorder. Twenty-two of 27 patients had a medication-assisted treatment (MAT) regimen prior to index admission to our facility. The average number of PRN pain medication orders was 1.9, with an average of 0.5 PRN opioid orders and 1.4 PRN non-opioid orders. On average, pain scores decreased from admission to discharge by 0.5. Naloxone and methylnaltrexone were not administered to patients included in this study during the index admissions. 4 patients (14.8%) were readmitted within 30 days, while 8 patients (29.6%) visited the emergency department following their index admission.

Conclusion: Pain is a complex condition that can be challenging to manage, both acutely and chronically. This study’s assessment of acute pain control in patients with chronic pain demonstrated outcomes comparable to those reported in prior studies and highlighted the importance of effective acute pain management within this population. Patients had a similar average of PRN analgesic orders to those in prior studies and experienced modest reductions in pain scores from admission to discharge. Increasing the availability of PRN pain medications may further improve pain control in patients with chronic pain.
This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare affiliated entity. The views expressed in this publication represent those of the author(s) and do not necessarily represent the official views of HCA Healthcare or any of its affiliated entities.

Comparing the efficacy and safety of sotalol and dofetilide for maintenance of normal sinus rhythm at a community health system Abigail Millsaps, Caitlin Casper, Dustin Bivins Northeast Georgia Medical Center – Gainesville, GA 
Background: Atrial fibrillation (AF) occurs when inappropriate electrical currents cause the atria to beat out of sync with the ventricles, creating the hallmark irregularly irregular heart rhythm. The risk of developing AF increases with age and structural heart damage, making AF a significant cause of morbidity and mortality worldwide. AF, if left untreated, can lead to cardiomyopathy, heart failure, and thromboembolism.  

Sotalol and dofetilide are class III antiarrhythmic drugs used for pharmacologic cardioversion to normal sinus rhythm (NSR) in patients who have atrial fibrillation (AF) or atrial flutter. These agents act on potassium-gated channels in myocardial cells to delay repolarization, prolong the action potential duration, and increase the effective refractory period (ERP). An increase in ERP extends the amount of time that the myocyte cannot be stimulated to fire another action potential, thus leading to a decrease in the incidence of arrhythmogenicity. However, this mechanism of action increases the risk of excessive QT (QTc) prolongation, which can result in torsades de pointes (TdP) or significant ventricular arrhythmias. Therefore, manufacturer labeling and treatment guidelines recommend initiating these medications in a hospital setting with continuous cardiac monitoring. 

There is only one randomized controlled trial directly comparing sotalol and dofetilide. The EMERALD trial, conducted in 1999, compared the safety and efficacy of dofetilide and sotalol to placebo for initial cardioversion from AF to NSR and found 29.5% of patients given dofetilide and 5.9% given sotalol converted into NSR without needing direct current cardioversion (DCCV). Researchers also found 71% of patients who converted to NSR and received dofetilide maintained NSR at 6 months compared to 59% who received sotalol. Researchers reported three cases of TdP, all in the dofetilide group. 

Purpose: The purpose of this study was to determine if sotalol or dofetilide is more efficacious at maintaining NSR at 6 months post-cardioversion in patients with AF/a-flutter. 

Methods: This was a retrospective chart review to determine the percentage of patients in NSR six months post-cardioversion either pharmacologically or via DCCV after being loaded inpatient with dofetilide or sotalol. The study population included adults ≥18 years old at Northeast Georgia Health System (NGHS) between to January 1, 2022 to August 31, 2025 who were hospitalized with AF or a-flutter, completed inpatient loading with sotalol or dofetilide, achieved NSR prior to discharge either pharmacologically or via DCCV, and were continued on the selected treatment at discharge. Patients were excluded if they had a historical use of dofetilide or sotalol, concurrent use of other antiarrhythmic medications, baseline contraindications, documented non-adherence to study medications, history of ventricular arrhythmias, or were part of a vulnerable population. Authors used chi-squared analysis to evaluate primary and secondary endpoints. 

Results: Between January 1, 2022 and August 31, 2025, 57 of 335 patients on sotalol and 17 of 53 patients on dofetilide met inclusion criteria. Baseline characteristics were similar between groups. We found no statistically significant difference in normal sinus rhythm at 6-months between sotalol and dofetilide (84.2% vs 82.4%; p = 0.557). There were no statistically significant differences in incidence of TdP or the percentage of patients requiring DCCV prior to discharge (76.5% vs 91.2%; p = 0.116). 

Conclusion: Based on these findings, there is no difference between sotalol and dofetilide at maintaining NSR at 6 -months. Only one occurrence of TdP was detected in the sotalol group, and the dofetilide group had a lower percentage of patients requiring DCCV before discharge; however, these were not statistically significant. Limitations of this study included its retrospective nature, small sample size, and reliance on provider documentation. 

Title: Impact of a System-wide Pharmacy Clinical Decision Support Council on Pharmacist-Facing Medication Warning Alerts
Authors: Benny Zhang, PharmD; Craig MacDonald, PharmD

Background: Clinical decision support (CDS) is a powerful tool that provides clinicians with knowledge and patient-specific information, filtered or presented at appropriate times, to ensure safe and effective patient care. Medication warning alerts can support clinical decision-making, reduce medication errors and adverse drug events, and improve adherence to evidence-based practice. However, redundant or inappropriate medication warning alerts can lead to alert fatigue and result in unintended consequences that may compromise the safety and quality of patient care. In our system, medication warnings are supplied by a third-party vendor and can appear during order entry, verification, or medication administration and impact providers, pharmacists, and nurses. The formation of a system-wide pharmacy clinical decision support council aimed to optimize medication-related alerts to ensure front-end clinicians are seeing relevant and important warnings across a large health-system. The purpose of this study is to evaluate the impact of a system-wide pharmacy clinical decision support council on the volume of pharmacist-facing medication warning alerts.

Methods: This was a retrospective pre-post analysis conducted using EHR extracted data from 2023 to 2026 in a single health-system. Medication warning alerts presented to pharmacists were evaluated. Trends in alert volume (per 1,000 orders) were analyzed over time to assess changes following decisions made by the pharmacy clinical decision support council.

Results: In Progress

Conclusion: In Progress

Title: Impact of pre-transplant midodrine use on simultaneous liver-kidney transplant outcomes

Authors: Matthew Molk1, Mojibola Awe2, Teresa Gennaro1, Heather Snyder1, Farjad Siddiqui1; Emory University Hospital, Atlanta, GA1; The Johns Hopkins Hospital; Baltimore, MD2

Objective: Determine the impact of pre-transplant midodrine use on outcomes after SLK transplant related to delayed graft function.

Self Assessment Question: Does midodrine use prior to simultaneous liver-kidney transplant increase the incidence of specific kidney delayed graft function. 

Background: Midodrine is commonly used in patients with end-stage kidney and liver diseases for various indications. A previous study suggested that midodrine use prior to kidney transplant worsens post-transplant outcomes, including delayed graft function (DGF), graft failure, and death. Alternatively, another study among simultaneous liver-kidney (SLK) transplant recipients found no significant difference in hospitalization, graft failure, or death in patients treated with pre-transplant midodrine. Given the paucity of data, the purpose of this study was to determine the impact of pre-transplant midodrine use on outcomes after SLK transplant.

Methods: This was a single-center, retrospective chart review of adult patients who received a SLK transplant at Emory Transplant Center between February 2015 and June 2024. Patients who died within 7 days post-transplant were excluded. Patients were placed into 2 study arms determined by their pre-transplant midodrine use. Pre-transplant midodrine use was defined as treatment with midodrine for at least 3 months prior to transplant. The primary outcome was the incidence of kidney-specific DGF, defined as the requirement for dialysis within the first 7 days after transplant. Secondary outcomes included post-transplant hospital length of stay, midodrine use at discharge from index admission, estimated glomerular filtration rate (eGFR) at discharge and 1 year, readmission rates, and kidney allograft survival and patient survival at 1-year post-transplant. Primary and secondary outcomes were analyzed using descriptive statistics.

Results: Of the 104 patients screened, 94 patients met inclusion criteria with 13 patients in the midodrine group and 81 in the non-midodrine group. Median age was similar between groups (57 vs. 58 years) and a majority of patients in both arms were Caucasian and male. Patients in the midodrine had a higher median MELD score at the time of transplant compared to the non-midodrine group (34 vs. 31; p < 0.001). Kidney-specific DGF occurred more frequently in the midodrine group vs. the non-midodrine group, however this difference was not statistically significant (30.8% vs. 12.3%, p = 0.083). The midodrine group had a significantly longer median post-transplant length of stay (17 vs. 11 days, p < 0.001) and a higher incidence of midodrine use at discharge (15.4% vs. 2.5%, p = 0.032). While eGFR at discharge trended lower in the midodrine group (47 vs. 66 mL/min/1.73m², p = 0.075), eGFR at 1-year post-transplant was comparable between groups (53 vs. 56 mL/min/1.73m², p = 0.462). Readmission rates at 6-12 months post-transplant were greater in the midodrine group (54% vs. 17%; p = 0.003). Kidney allograft survival and patient survival at 1-year post-transplant were similar between groups.

Conclusion: Pre-transplant midodrine use in SLK recipients does not appear to affect short term outcomes after transplant; however larger studies need to be conducted.

Title: Incidence of Bleeding in Patients Receiving Parenteral Anticoagulation and Apixaban Therapy for VTE Treatment

Primary: Ashley Hannah, [email protected]
Secondary: Sara Anne Meyer, Lilia Macias, Evaline Inigo, Sarah Lopez

Background: The purpose of this study is to evaluate the association between apixaban dosing and inpatient bleeding in patients treated for venous thromboembolism following initial parenteral anticoagulation. In the inpatient setting, patients with venous thromboembolism are often initiated on parenteral anticoagulation before being transitioned to an oral anticoagulant such as apixaban. This study also aimed to evaluate whether the duration of parenteral anticoagulation was associated with initiation of reduced-dose apixaban. Understanding the factors associated with treatment decisions and clinical outcomes is critical, particularly as bleeding remains a significant complication of anticoagulant therapy.

Methods: A retrospective, randomized controlled trial was conducted involving 289 subjects at St. Joseph’s/Candler Health System from September 2024 to August 2025. Participants received parenteral anticoagulation with either standard heparin or enoxaparin, along with an oral agent. Participants received either 5 mg or 10 mg of apixaban directly following parenteral anticoagulation. This study included patients admitted for a hospital stay that were diagnosed with a venous thromboembolism within twenty-four hours of admission and received treatment with apixaban following parenteral anticoagulation. Participants with a prior history of venous thromboembolism, previous long-term therapeutic anticoagulation with apixaban for three months or severe renal dysfunction were not included. Participants were also excluded if they required anticoagulation therapy plus dual antiplatelet therapy for other indications, or thrombolytic therapy. However, participants on thrombolytic therapy undergoing catheter directed thrombolysis were not excluded.
The primary endpoint of the study was the number of bleeding events documented. Secondary endpoints included the number of patients presenting with first recurrent venous thromboembolism within six months of starting apixaban therapy, confirmed by physician documentation; assessment of severity of illness and its impact on treatment duration, evaluation of total duration of parenteral anticoagulation and its association with initiation of full versus reduced doses of apixaban therapy and lastly, identifying prescriber characteristics and practice settings associated with each treatment approach.

Conclusion: In summary, in this study no statistically significant differences were observed in bleeding events, hemoglobin decline or recurrence rates within six months of therapy between patients initiated on apixaban 5 mg in comparison to 10 mg. Prescribing patterns favored the initiation dose of 10 mg following parenteral anticoagulation for venous thromboembolism. The full dose of 10 mg appeared to be favored among the nine prescriber groups evaluated. Among patients that experienced a bleeding event, hemoglobin decrease greater than 3g/dL or recurrence within six months, apixaban 10 mg was most commonly prescribed.
  

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Abstract
Purpose/Background: Effective lipid management is a cornerstone of secondary prevention in patients with Acute Coronary Syndromes (ACS). The 2025 Guideline for the Management of Patients with ACS emphasizes obtaining a baseline lipid profile on admission, initiating or continuing high-intensity statin therapy during hospitalization, and considering early initiation of non-statin therapies for high-risk patients. Despite these recommendations, adherence to guideline-directed lipid management remains variable. Previous studies suggest baseline lipid panels are not consistently obtained, statins may be underutilized or prescribed at suboptimal intensities, and follow-up lipid testing is often missed. These gaps may delay achievement of lipid targets and increase the risk of recurrent cardiovascular events. This pharmacy project assessed lipid management practices for ACS patients at Huntsville Hospital and guided development of targeted pharmacy interventions to enhance adherence and optimize inpatient lipid care.

Methodology: A single-center, institutional review committee–approved pre-post analysis was conducted in patients hospitalized with acute coronary syndromes (ACS). A random sample of patients admitted between January 2025 and September 2025 with a documented ACS diagnosis was included in the pre-intervention cohort. Patients were excluded if they had a prior history of ACS or incomplete data. A pharmacy-driven intervention was implemented, consisting of targeted education for transitions of care (TOC) pharmacists and promotion of pharmacist-led discharge optimization. A post-intervention cohort was identified using the same inclusion and exclusion criteria, with the additional requirement of a documented TOC discharge note. The primary endpoints were (1) the proportion of patients with a baseline lipid panel obtained within 48 hours of admission and (2) the proportion of patients discharged on optimized guideline-directed lipid-lowering therapy. Baseline demographics and lipid management variables were collected from the electronic medical record. Descriptive statistics were used for analysis.

Results: A total of 250 patients were included in the pre-intervention cohort and 47 patients in the post-intervention cohort. A baseline lipid panel was obtained in 93.6% of patients pre- and post-intervention. Guideline-directed lipid-lowering therapy at discharge improved from 79.2% to 87.2% post-intervention (absolute increase 8.0%), while non-adherence decreased from 20.8% to 12.8%. Pharmacist interventions were documented in 19.6% of post-intervention cases and included contacting providers to recommend addition of non-statin therapy for patients on high-intensity statins with LDL-C >70 mg/dL.

Conclusion: A pharmacy-driven intervention was associated with improved adherence to guideline-directed lipid management in patients hospitalized with ACS. While baseline lipid panel acquisition was high, improvements in discharge therapy optimization were observed. These findings support the role of pharmacist involvement and targeted interventions in improving lipid management in this high-risk population.

Title: Evaluation of intraoperative intravenous methadone administration for cardiothoracic surgery analgesia 
Author(s): Anna Carlson, Nevena Mihalovich, Ethan Gerrald, Zachary Klick, Paige Behr, Madison Fielding, Akshara Patel; Atrium Health Wake Forest Baptist, Winston Salem, NC 

Objective: To evaluate the efficacy and safety of intravenous (IV) methadone as adjunctive analgesia in cardiothoracic surgery (CTS)
  
Background:  Post-operative opioid stewardship has been a focus of national and state level initiatives to curtail the prescribing of excessive opioid analgesics. The use of multimodal analgesics is recommended by the Society of Thoracic Surgery (STS) to reduce morphine milligram equivalents (MME). Pain following CTS is typically most severe within the first 24 hours postoperatively but may persist for several days. To effectively manage postoperative pain, methadone has been used intraoperatively due to its favorable pharmacokinetic profile, including its long half-life of 24-36 hours. Previous studies comparing methadone with shorter-acting opioids suggest reductions in pain scores and MME requirements in patients receiving intraoperative IV methadone. However, studies vary among types of surgery performed, reported opioid-related adverse events, and postoperative day (POD) study follow-up duration. Additional research is warranted to quantify the impact of intraoperative IV methadone and support practice optimization. 

Methods: This was a retrospective, single-center, cohort study utilizing electronic health record (EHR) data of patients undergoing CTS, including coronary artery bypass graft (CABG), aortic valve repair (AVR), isolated mitral valve repair or replacement (MVR/MVr), aortic root repair or replacement, or other combinations thereof. Data was collected utilizing an EHR report to identify CTS performed from March 2024 – August 2025. Patients were categorized into two groups: intraoperative IV methadone administration for adjunctive analgesia or standard of care. Key exclusion criteria are preoperative gastrointestinal obstruction (including ileus), mechanical circulatory support after index surgery, continuous infusion opioids within 48 hours prior to CTS, or active or prior opioid use disorder. The primary endpoint was average cumulative MME requirements through POD four or discharge, whichever comes first. Secondary endpoints include difference in daily MME requirements, incidence of naloxone rescue administration, intraoperative MME requirements, percentage of patients extubated within 6 and 24 hours, incidence of postoperative ileus, incidence of opioid-related adverse effects, and opioids prescribed at discharge in MME.  
Baseline characteristics assessed were age, sex, comorbidities, and type of CTS performed, as well as use of antiarrhythmic medications, glucagon-like-peptide-1 receptor agonists, and opioid, including methadone, use within 30 days. Results were analyzed utilizing descriptive statistics, with means or medians reported for continuous variables as appropriate. Categorical endpoints were analyzed using Fisher’s exact or chi-square test for normally distributed data.  
 
Results: 200 patients in total were included (IV methadone n=100; standard of care n=100). Baseline characteristics were similar between the two groups aside from a statistically significant difference in incidence of depression. There were no significant differences in type of CTS or number of adjunctive analgesic agents used postoperatively. Cumulative POD 0-4 MME were significantly lower in the methadone group compared with standard of care (167 vs 209; mean difference 42; p=0.046). Reductions in MME requirements were most notable on POD 0 and POD 1 (mean difference 16 and 19, respectively; p=0.006). There were no observed differences in incidence of naloxone administration, extubation within 6 and 24 hours, postoperative delirium, or ICU length of stay. Mean MME prescribed at discharge was significantly lower in the methadone group (126 vs 135 MME; p=0.0047).  
 
Conclusions: Administration of intraoperative IV methadone significantly reduces postoperative MME requirements when compared to standard of care. 

Evaluation of Chromium Picolinate for Blood Glucose Control in Critically Ill Patients
Christopher Stone, Richard Lane, Jared Briones 
AdventHealth Apopka

Background: Glycemic control is a cornerstone in the management of critically ill patients in the intensive care unit (ICU), as both hyper- and hypo-glycemia are associated with increased morbidity and mortality. Dysglycemia in critical illness is multifactorial, resulting from stress‑mediated neuroendocrine activation, inflammatory cytokine release, multiorgan dysfunction, and rapidly changing nutrition requirements. In recognition of adverse outcomes associated with dysglycemia, current ADA guidelines recommend targeting blood glucose levels between 140-180 mg/dL in critical illness. Chromium is a trace mineral involved in macronutrient metabolism, with studies in the outpatient setting indicating potential benefits for insulin sensitivity and glycemic control. Despite these findings, evidence supporting chromium supplementation in critically ill populations remains absent. This study aims to evaluate the effects of chromium picolinate on blood glucose management of critically ill subjects.

Methods: This was a retrospective chart review conducted within the AdventHealth Central Florida Division hospital system. Subjects were included if they were admitted from January 1st, 2022, to December 31st, 2025, age greater than 18 years, admitted to the ICU, diagnosed with type 2 diabetes mellitus or had an A1c of 6.5% or greater, and received continuous infusion insulin. Subjects were excluded if they were diagnosed with type 1 diabetes mellitus, received renal replacement therapy, or had documented chromium use prior to admission. The primary outcome was improved glycemic control, defined as a reduction in total daily insulin requirements of at least 15 units. Secondary outcomes included 30-day all-cause mortality, time to target glucose range (<180 mg/dL), hospital length of stay, ICU length of stay, and rate of adverse drug events.

Results: A total of 90 subjects were included, 45 in each group. Improved glycemic control occurred in 31% (14/45) of the chromium group compared to 13% (6/45) in the control (p-value=0.043). Analyzing the secondary outcomes, hours to target blood glucose range (<180 mg/dL) was 14 and 4 (p-value= 0.035) for the chromium and non-chromium groups respectively. There were no differences between additional outcomes including 30-day mortality, 30-day all cause readmission, hospital length of stay, ICU length of stay, and adverse drug events. Chromium was associated with decreased insulin utilization of 17.8 units compared to an increase of 22.4 units in the non-chromium group by day 3 of treatment (p-value< 0.001).

Conclusion: In critically ill patients with hyperglycemia, chromium picolinate supplementation was associated with a significant reduction in insulin utilization. No differences in adverse event rate were observed between the intervention and control group. These results indicate that chromium supplementation in critically ill patients may improve glycemic control. Limitations include the retrospective study design, lack of chromium level evaluation and the ability to identify an appropriate comparator. Further prospective studies are recommended to further explore the potential benefits of chromium on glycemic control in the critically ill.
 
Email [email protected]

Authors: Dalia Chamma, Colin Busbee, Holly Mclean, Desmond Durham 

Purpose/Background: The initial recommendation for empiric anaerobic coverage in aspiration pneumonia was made in the 1970s, following the identification of anaerobic isolates in multiple studies. This was likely due to poor isolation techniques and the collection of microbiologic specimens later in the course of disease, including after abscesses, necrotizing pneumonia, or empyema had developed. The purpose of this study is to evaluate whether a guideline-based educational intervention directed at prescribers reduces empiric anaerobic coverage in adults hospitalized with community-acquired pneumonia (CAP) or aspiration pneumonia without abscess or empyema, and to assess clinical outcomes, including C. difficile infections, days of therapy with empiric anaerobic coverage, and hospital length of stay.  
 
Methodology: This study will employ a retrospective chart review of patients to evaluate provider prescribing practices pre- and post-education. The educational intervention material is a guideline-based, one-page summary of the American Thoracic Society and Infectious Diseases Society of America (ATS/IDSA) 2019 CAP recommendations regarding the appropriate use of empiric anaerobic coverage in aspiration pneumonia. The educational material will highlight the indications for which anaerobic coverage is appropriate, emphasize that the management of aspiration pneumonia follows standard CAP treatment, and summarize the literature that the guidelines are based upon. Educational materials will be presented to the Antimicrobial Stewardship (AMS) Committee and to appropriate service-line leadership committees for review and approval prior to electronic distribution to clinicians. Data will be collected and evaluated from Slicer Dicer reports and the hospital’s electronic records for retrospective reviews of pre- and post-intervention. The primary objective is to compare the proportion of patients with community-acquired or aspiration pneumonia who receive empiric anaerobic coverage before versus after implementation of guideline-based provider education. Secondary objectives include comparing anaerobic antibiotic days of therapy, length of stay, time to clinical stability, and C. difficile infection 30-day readmission rates in patients with aspiration or community-acquired pneumonia in the pre- and post-intervention arms. 

Results: In progress. 

Conclusions: In progress. 

Purpose: 
Type 2 diabetes mellitus (T2DM) is a global health issue with substantial costs. To improve care, Ralph H. Johnson VA Health Care System (RHJ VAHCS) adopted the “Potential SGLT2 Candidate by Appointment Dashboard”, a population management tool (PMT). This tool helps providers identify scheduled T2DM patients who are ideal candidates for SGLT2 inhibitors, specifically those with additional risks like kidney or heart disease. The PMT aims to increase prescriptions of SGLT2 inhibitors by proactively alerting providers to upcoming patient appointments. The purpose of this project is to increase appropriate prescribing of SGLT2 inhibitors in the primary care setting.  
Methods:
The pre-PMT implementation period is 10/1/2023 - 12/31/2024 followed by the PMT implementation period of 1/1/2025 - 3/31/2026. All primary care providers (PCPs) at RHJ VAHCS were formally introduced to the PMT in August of 2025. Through the months of August-November, hands-on experience was gained through pulling patients with upcoming appointments from a community-based outpatient clinic (CBOC). 51 patients that populated on the PMT were reviewed and those that were determined to be candidates were contacted to initiate SGLT2 inhibitors. Once hands-on experience was complete, smaller meetings were conducted individually at 5 outpatient clinics through November and January to further educate about the PMT. Survey questions were provided to assess providers’ overall comfortability with utilizing the PMT and to determine how many providers planned to implement this PMT in practice. During February and March, weekly meetings were held individually with 8 providers. The Plan-Do-Study-Act model was implemented through the meetings to establish overall facilitators and barriers to utilization of the PMT with the overarching goal to increase utilization for all providers. The primary endpoint of the study is to evaluate the impact of implementation of a PMT on the number of new SGLT2 inhibitor prescriptions initiated by PCPs. Subgroup analysis were included to assess how providers’ subscription to PMT, patients physically viewed on the PMT, and PharmD education on the PMT impacted the rate of new SGLT2 inhibitor prescriptions. The secondary endpoint is to determine the facilitators and barriers to implementation of the PMT.
Results 
During the pre-PMT implementation period, there was a total of 2,950 new start SGLT2 inhibitor prescriptions at the RHJ facility compared to the PMT implementation period with a total of 2,881 new starts. Of the 2,881 prescriptions, 448 new starts are specific to an associated visit on the PMT which was defined as prescriptions issued within three days of an appointment flagged on the tool. A total of 43,399 total candidates populated on the tool with 448 resulting in new start prescriptions making the overall rate of new starts with PMT utilization 1.03%. The rate of new starts increases up to 2.47% when compared to providers subscriptions to the PMT and increases to 4.51% when compared to patients reviewed on the PMT. When comparing any type PMT interaction including both subscriptions and views, that rate of new starts with subscriptions and views is 3.88%, subscription with no views is 1.89%, and no subscription with views 7.02%. When looking at pre/post PharmD education on the PMT, the rate of new starts decreased from 3.53% to 2.44% with a p-value of 0.0194 (significance ≤ 0.01). For the secondary endpoint, common facilitators to use include sustainability (6%, n=1), ease of use (17%, n=3), data accuracy (18%, n=3), timeliness (18%, n=3), and clinical relevance (41%, n=7). The common barriers to use include change fatigue (13%, n=5), information overload (15%, n=6), perceived lack of value (13%, n=5), usability (8%,  n=3), lack of training or technical support (2%, n=1), workflow disruption (23%, n=9), data quality concerns (8%, n=3), and time constraints (18%, n=7).
Conclusion:
In conclusion, most providers feel that it is a priority to initiate SGLT2 inhibitor prescriptions for the cardiorenal protective properties. While the overall number of new start SGLT2 inhibitors remains relatively the same after the PMT was implemented, the PMT demonstrated having a positive impact on the rate of new start SGLT2 inhibitor prescriptions through subscribing and viewing patients with the tool.  Time constraints, workflow disruption, and alert fatigue were common barriers to utilization of the PMT. While the “Potential SGLT2 Candidate by Appointment Dashboard” is a population management tool that aims to increase appropriate prescribing of SGLT2 inhibitors, updates that incorporate changes recommended by providers may lead to an uptake of utilization in the future.  

Evaluation of Initial Dose of Nitroglycerin for Acute Heart Failure Exacerbation
Authors: Amaury Santiago Malave, Christopher Lloyd, Lena Tran 
Background Nitroglycerin, a vasodilator, administered as an intravenous (IV) bolus at doses between 400 to 800 mcg and infusions of 100-200 mcg/min have shown to rapidly decrease preload, afterload, and improve myocardial oxygen supply in patients with pulmonary edema and acute decompensated heart failure. Literature suggests these higher IV doses of nitroglycerin have led to reduced intensive care unit (ICU) admissions and intubations; however, there is currently limited guidance for an initial nitroglycerin bolus dose or infusion rate, leading to frequent underdosing.  The objective of this study is to evaluate the use of nitroglycerin for acute heart failure exacerbations and to assess the significance of nitroglycerin doses on ICU admission and need for mechanical ventilation.

Methods This study was reviewed by the local investigational review board and deemed a quality improvement project. A retrospective data analysis was conducted on adult patients presenting to AdventHealth Central Florida hospitals between August 6, 2023 and August 29, 2025 with acute heart failure exacerbation requiring intravenous nitroglycerin and non-invasive positive airway pressure (NIPAP).  
Patients were stratified according to nitroglycerin initiation strategy: 1) higher-intensity nitroglycerin (HIN) which included receiving an IV nitroglycerin bolus and/or initiation of continuous infusion at ≥ 100 mcg/min. 2) lower-intensity nitroglycerin (LIN) which consisted of starting a continuous infusion at < 100 mcg/min with no bolus.  
Data was collected from the electronic health record and included baseline demographics, nitroglycerin bolus dose (if administered), initial infusion rate, and maximum infusion rate. Safety data included baseline and repeated measurements of systolic blood pressure, heart rate, respiratory rate, and oxygen saturation. The primary outcome was ICU admission. Secondary outcomes included hospital length of stay, endotracheal intubation, incidence of hypotension, infusion duration, time to NIPAP discontinuation, and change in vital signs two hours after infusion initiation. Continuous variables were analyzed using means with standard deviations and medians with interquartile ranges, as appropriate, and compared using Student’s t-test or the Mann-Whitney U test.  

Results A total of 181 patients met inclusion criteria, with 99 managed using HIN and 82 managed using a LIN. ICU admission occurred in 59.6% of patients in the higher-intensity group compared to 68.2% in the lower-intensity group, though this difference did not reach statistical significance (p = 0.226). Rates of endotracheal intubation (2.02% vs 4.88%, p = 0.285) and hypotension (4.04% vs 3.66%, p = 0.894) were similar between groups. Hospital length of stay and time to NIPAP discontinuation were not significantly different. The HIN group received significantly greater initial and maximum infusion rates (p < 0.001 for both comparisons). Median infusion duration was significantly shorter in the higher-intensity group (3 vs 4 hours, p=0.033). Changes in systolic blood pressure, respiratory rate, heart rate, and oxygen saturation were comparable between groups. 

Conclusion In this retrospective analysis of patients with acute heart failure exacerbations requiring NIPAP, a higher-intensity nitroglycerin initiation strategy was associated with lower ICU admission and intubation rates compared to a lower-intensity approach, although these differences did not reach statistical significance. Of note, this higher-intensity strategy was not associated with increased hypotension or adverse effects and resulted in a shorter median infusion duration. 
While the study was not powered to detect small differences in clinical outcomes, the observed trends suggest that more aggressive upfront nitroglycerin dosing may be both feasible and well tolerated in appropriately selected patients. These findings support the need for prospective, adequately powered studies to further evaluate dose thresholds for nitroglycerin strategies that can meaningfully reduce ICU admission and respiratory deterioration in acute heart failure exacerbations.

Background: Ectopic pregnancy is a potentially life-threatening condition commonly managed with methotrexate in hemodynamically stable patients without absolute contraindications. Although methotrexate dosing is calculated using body surface area, the optimal weight-based strategy in obese patients remains uncertain. Historically, Northside Hospital Atlanta, Cherokee, and Forsyth utilized adjusted body weight for dosing due to concerns about toxicity. However, questions regarding potential underdosing and reduced efficacy prompted a transition to total body weight–based dosing on May 6, 2025. This study compares treatment success and adverse drug reactions between adjusted body weight and total body weight methotrexate dosing strategies in hemodynamically stable obese patients with tubal ectopic pregnancy.

Methods: This retrospective cohort study evaluated the safety and efficacy of single-dose intramuscular methotrexate dosed at 50 mg/m2 in obese patients diagnosed with tubal ectopic pregnancy before and after implementation of total body weight–based dosing. Obesity was defined as a total body weight greater than 130% of ideal body weight. The primary outcome was treatment success, defined as resolution of ectopic pregnancy without additional methotrexate doses or surgical intervention. Secondary outcomes included adverse drug reactions. Eligible patients were ≥18 years old and received methotrexate for tubal ectopic pregnancy. Patients with relative contraindications to methotrexate such as, β-hCG >5,000 mIU/mL, ectopic mass >4 cm, or fetal cardiac activity, were included. Data collected from electronic medical records included demographics, baseline labs, initial β-hCG levels, ultrasound findings, need for additional methotrexate dosing, surgical intervention, and documented adverse events. Comparative analyses were performed within and between adjusted and total body weight dosing groups.

Results: A total of 120 women were included in the study, with 60 patients in both the pre-implementation and post-implementation cohorts. In the pre-implementation cohort, 32 patients were obese and 28 were non-obese. Treatment resolution occurred in 81.3% (26/32) of obese patients and 64.3% (18/28) of non-obese patients. Among non-obese patients, 17.9% (5/28) had pre-methotrexate β-hCG levels >5,000 mIU/mL, 7.1% (2/28) had ectopic masses >4 cm, and 0% had cardiac embryonic activity. In contrast, 0% of obese patients had β-hCG levels >5,000 mIU/mL, and none had ectopic masses >4 cm or embryonic cardiac activity. The post-implementation cohort included 37 obese and 23 non-obese patients. Treatment resolution occurred in 59.5% (22/37) of obese patients and 56.5% (13/23) of non-obese patients. Among non-obese patients, 4.3% (1/23) had pre-methotrexate β-hCG levels >5,000 mIU/mL, 0% had an ectopic mass >4 cm, and 4.3% (1/23) had cardiac embryonic activity. Among obese patients, 13.5% (5/37) had pre-methotrexate β-hCG levels >5,000 mIU/mL, 5.4% (2/37) had ectopic masses >4 cm, and 0% had cardiac embryonic activity. After accounting for relative contraindications to methotrexate administration in obese and non-obese patients within each group, there was a lower difference in resolution rates within the pre-implementation arm (obese, 81.3% vs non-obese, 76.2%) vs the post-implementation arm (obese, 66.7% vs non-obese, 57.1%)

Conclusions: In this retrospective study, adjusted resolution rates for relative contraindications showed a greater difference in success rates, favoring obese patients, in the post-implementation group compared to the pre-implementation group. Although total body weight dosing was associated with a higher frequency of adverse events, no serious adverse events were observed. These findings confirm that relative contraindications to methotrexate reduce efficacy, and further prospective studies with larger sample sizes are needed to define the optimal methotrexate dosing strategy in obese patients. Considerations for future studies include utilizing a 2-dose methotrexate regimen for patients with an initial elevated hCG, evaluating differences in success rates across obese subgroups stratified by differences in BMI, and excluding patients with relative contraindications to methotrexate.  

Title: Evaluating the Impact of Empiric Anti-MRSA Therapy on Length of Stay in Patients Hospitalized with Community-Acquired Pneumonia 
Authors: Jessica Giraldo, Dina Kheir, Timmy Do
Institution: AdventHealth Central Florida Division (AH-CFD)

Background 
Community-acquired pneumonia (CAP) remains one of the leading causes of hospitalization in the United States, contributing to morbidity, mortality, and healthcare costs. The 2019 American Thoracic Society/Infectious Diseases Society of America (ATS/IDSA) guidelines recommend reserving empiric anti-methicillin-resistant Staphylococcus aureus (MRSA) therapy for patients with validated risk factors. Despite these recommendations, anti-MRSA agents are frequently initiated empirically in patients without validated risk factors. Prior studies evaluating empiric anti-MRSA therapy in CAP have primarily focused on clinical outcomes such as 30-day mortality. These studies also reported increased rates of acute kidney injury (AKI), Clostridioides difficile infection (CDI), and prolonged hospitalization with anti-MRSA therapy. This study evaluated whether empiric anti-MRSA therapy impacts hospital length of stay (LOS) among adults hospitalized with CAP in a large, multi-hospital health system.  

Methods 
This retrospective observational cohort study included adults ≥18 years admitted with a diagnosis of CAP across AdventHealth Central Florida Division (AH-CFD) hospitals between January 1, 2023 and December 31, 2024. Exclusion criteria included documented MRSA risk factors, severe immunocompromise (absolute neutrophil count <500 cells/mm³, CD4 <200 cells/mm³, or recent transplant), or ICU admission at presentation. The primary outcome was hospital LOS and secondary outcomes included 30-day all-cause mortality, 30-day hospital readmission, antibiotic-associated adverse events (e.g. AKI and CDI), and time to clinical stability.  

Results 
A total of 178 patients met inclusion criteria, including 92 patients who received empiric anti-MRSA therapy and 86 who received standard CAP therapy. Median hospital LOS was 3.15 days (IQR 2.16–4.81) in the anti-MRSA group compared with 2.79 days (IQR 1.79–4.20) in the standard-therapy group, with no statistically significant difference (p = 0.091).  

Thirty-day all-cause mortality occurred more frequently in patients receiving empiric anti-MRSA therapy compared with standard therapy (4.35% vs 2.33%; RR 1.87, 95% CI 0.35–9.95; p = 0.68). Thirty-day readmission occurred significantly more frequently among patients receiving empiric anti-MRSA therapy (15.22% vs 3.49%; RR 4.36, 95% CI 1.30–14.66; p < 0.001). Antibiotic-associated adverse events were also more common in the anti-MRSA group (5.43% vs 0%; RR 10.29, 95% CI 0.58–183.37; p = 0.06). CDI occurred in more patients of the anti-MRSA group when compared to standard-therapy patients (1.09% vs 0%; RR 2.81, 95% CI 0.12–67.98; p = 1.00). Time to clinical stability was assessable in 40 patients in each treatment group. Median time to clinical stability was 2 days (IQR 2–3; p = 0.67) in both the anti-MRSA and standard therapy groups. 

Conclusions 
Empiric anti-MRSA therapy in adults hospitalized with CAP was not associated with shorter LOS, faster clinical stability, or improved mortality. While 30-day readmission occurred significantly more frequently among patients receiving empiric anti-MRSA therapy, antibiotic-associated adverse events, AKI, and CDI were numerically higher but did not reach statistical significance. These findings support guideline recommendations to reserve anti-MRSA therapy for patients with validated risk factors and highlight opportunities for antimicrobial stewardship interventions to reduce unnecessary antibiotic exposure and improve patient safety. 

Contact Information: [email protected] 
 

Factors Associated With Nocturnal Hypoglycemia In A Small Community Hospital
Nhien Nguyen, Maggie Braxton Green, Geren ThomasArchbold Memorial Hospital - Thomasville, GA

Background/Purpose: The American Diabetes Association guideline categorizes hypoglycemia in three levels. Level one hypoglycemia is a glucose concentration of 54–69 mg/dL. Level two hypoglycemia is a glucose concentration of <54 mg/dL. Level three hypoglycemia is a severe event characterized by altered mental and/or physical functioning that requires assistance from another person for recovery, irrespective of glucose level. Nocturnal hypoglycemia is defined as glucose falling below 70 mg/dL and lasting at least 15 minutes anytime from midnight to 6-am. It is important to avoid hypoglycemia in hospitalized patients as there are complications associated with increased cost, length of stay, morbidity, and mortality. The purpose of this study is to analyze and identify risk factors associated with nocturnal hypoglycemia occurring in hospitalized patients in a rural single site hospital.  

Methodology: This was a single site, retrospective, cross-sectional study of adult hospitalized patients at a 264-bed community hospital. Data was extracted from electronic the health record and included patient’s gender, race, weight, past medical history, length of stay, renal function, A1C, glucose levels, time of episode, diet orders, medication orders, and signs and symptoms which may have occurred during nocturnal episode. Patient’s blood glucose levels were collected on admission, 24 hours prior to nocturnal hypoglycemic episode and during hypoglycemic episode. Patient’s chart was reviewed 24 hours prior from the time of the episode to identify potential causes. Primary endpoint is identifying factors potentially associated with nocturnal hypoglycemia episodes in hospitalized patients. 

Results: From January to December 2025, a total of 451 patients were identified to have a hypoglycemic episode. Exclusion criteria included patient on insulin drip during hospital stay, history of DKA and/or HHS, sleep apnea, history of cirrhosis, hepatitis B and C, adrenal insufficiency, pancreatic diseases. The most common exclusion criteria met were factors related to past medical history, insulin drip or hypoglycemic episodes did not take place during 0000-0600. These patients were then reviewed for potential risk factors that were associated with the hypoglycemic episode. Among review, the blood glucose level ranged from 10 to 69 mg/dL with average of 59 mg/dL. Level one hypoglycemia occurred 691 times while level two occurred 210 times. Of the patients who experienced nocturnal hypoglycemia, 47% had diet order for “nothing by mouth,” 33% of patients were on at least one or more beta-blocker agents, 9% were on a quinolone agent, and 34% were on at least one or more nonsteroidal anti-inflammatory drugs during their hospitalization.  

Conclusions: Nocturnal hypoglycemia can be a dangerous medical complication that can be influenced by types of diet, the use of beta-blockers, quinolones, and nonsteroidal anti-inflammatory drugs. Due to the multiple confounders associated with increased risk, a larger population with closer real time monitoring may be needed to directly correlate associated risk factors. 

Presentation Objective: Identify potential risk factors associated with nocturnal hypoglycemia occurring in hospitalized patients in a single site community hospital.
Self-Assessment:
Which of the following is the definition of nocturnal hypoglycemic per the ADA guideline?
A.Glucose level < 69 mg/dL and lasting at least 5 minutes from midnight to 0600
B.Glucose level ≤ 70 mg/dL and lasting at least 15 minutes from midnight to 0300
C.Glucose level < 70 mg/dL and lasting at least 15 minutes from midnight to 0600
D.Glucose level < 54 mg/dL and lasting at least 10 minutes from 0300 to 0600

Background/Purpose: 
Extended-spectrum β-lactamase (ESBL)-producing Enterobacterales bacteremia is associated with increased morbidity and mortality. Although carbapenems are considered standard therapy, their use is not always feasible in clinical practice, emphasizing the need for evidence supporting effective alternative strategies. Newer β-lactam/β-lactamase inhibitor combinations, including ceftolozane/tazobactam and ceftazidime/avibactam, demonstrate activity against ESBL-producing organisms, but comparative effectiveness remains limited.  
 
The purpose of this study was to evaluate clinical outcomes of patients with ESBL bacteremia treated with meropenem compared with ceftolozane/tazobactam, or ceftazidime/avibactam.  
 
Methodology:  
This multicenter retrospective cohort study included adult patients (≥18 years) with at least one positive blood culture for ESBL-producing Escherichia coli, Klebsiella pneumoniae, or Proteus mirabilis who received ≥48 hours of definitive monotherapy with meropenem, ceftolozane/tazobactam, or ceftazidime/avibactam. Patients were identified through electronic medical records reports across AdventHealth hospital campuses. A retrospective chart review was conducted for encounter occurring between August 1, 2022, and December 31, 2025.  
 
The primary outcome was clinical efficacy, defined as a composite of: resolution of fever by day 5, improvement in leukocytosis (white blood cell count ≤10,000/µL) by day 5, no vasopressor requirement at day 5, survival at hospital discharge or 30 days from admission, and absence of recurrent primary infection due to ESBL-producing Escherichia coli, Klebsiella pneumoniae, or Proteus mirabilis at day 5. 
 
Secondary outcomes included 14-day all-cause mortality, hospital length of stay, need for transfer to a higher level of care ≥48 hours after treatment onset, escalation or change in antimicrobial therapy, and serious adverse events such as Clostridioides difficile infection and seizures. A Desirability of Outcome Ranking (DOOR) analysis was performed to evaluate overall clinical outcomes incorporating treatment response, safety events, and mortality. 
 
Results:  
A total of 68 patients met inclusion criteria and were included across three treatment groups: meropenem (MEM, n=44), ceftolozane/tazobactam (C/T, n=10), and ceftazidime/avibactam (CZA, n=14). Baseline characteristics were generally comparable between groups, with similar illness severity based on Pitt bacteremia scores. Clinical success rates did not significantly differ between treatment groups (MEM 68.2% vs C/T 70% vs CZA 78.6%; p>0.05). No statistically significant differences were observed in recurrence of infection, 14-day all-cause mortality, hospital length of stay, transfer to higher level of care, or adverse events such as seizures. However, antibiotic change occurred significantly more often in the BL/BLI groups compared with meropenem (C/T 30%, p<0.001; CZA 21.4%, p=0.002), with most changes involving transition to meropenem therapy. DOOR analysis demonstrated similar overall patient outcomes across treatment groups without statistically significant differences.   
 
Conclusions:  
In this multicenter retrospective cohort study, meropenem and novel β-lactam/β-lactamase inhibitor agents demonstrated comparable clinical efficacy and mortality outcomes for treatment of ESBL bloodstream infections. While overall outcomes were similar, meropenem showed greater therapeutic stability, reflected by the absence of antibiotic change. Interpretation is limited by the retrospective design and small sample size, highlighting the need for larger prospective studies to better define the role of these agents in ESBL bacteremia management. 

Title: Evaluation of apixaban dosing strategies for venous thromboembolism in patients receiving hemodialysis 

Authors: Hayden Caldwell, Blake Sloan, Ryan Tilton, Ryan Imel, Grace Barr, Caitlin Hastings, & Brittney Bright

Background: Venous thromboembolism (VTE) is categorized as deep venous thromboembolism (DVT) or pulmonary embolism (PE) caused by the formation of a thrombus in the veins of the lower extremities or pulmonary arteries. Apixaban is a factor Xa inhibitor approved for the indication of VTE treatment. Apixaban is mainly metabolized by CYP3A4 with other CYP enzymes contributing to minor metabolism. Apixaban is 87% protein bound and approximately 27% renally eliminated. However, patients with end stage renal disease (ESRD) receiving hemodialysis were not included in initial trials which established dosing. Existing literature is limited regarding whether to omit or include the loading dose of apixaban (10mg twice daily for 7 days) in this patient population.  Given that a percentage of apixaban is renally cleared, there is concern regarding an increased bleed risk in patients with ESRD on HD receiving the standard loading dose.  Current clinical practice varies and may be influenced by provider preference.  

Methods: This study evaluated the safety and efficacy of the apixaban loading dose versus no loading dose in patients with ESRD on hemodialysis receiving treatment for VTE. We conducted a multi-center, retrospective cohort study at North Carolina Baptist Hospital and Atrium Health High Point Medical Center. Eligible patients included adults who have ESRD receiving hemodialysis and developed a VTE treated with apixaban from April 2024 to October 2025. Patients were excluded if they had antiphospholipid syndrome, received concurrent CYP3A4 inducers/inhibitors, received continuous renal replacement therapy, received apixaban 2.5mg, or received greater than or equal to seven days of parenteral anticoagulation prior to starting apixaban. The primary outcome was the incidence of recurrent VTE or progression of DVT to PE within 90 days after apixaban initiation. Secondary outcomes were the occurrence of major bleeding and clinically relevant non-major bleeding within 14 days of apixaban initiation defined by the International Society on Thrombosis and Haemostasis . Statistical analyses included descriptive statistics using t-test for continuous variables, Fischer’s exact test for categorical variables, and mean and interquartile range for various characteristics.  

Results: There were 30 patients included in this study, 18 patients in the apixaban load group, and 12 patients in the apixaban no-load group. The most common reason for not being included in this study was receipt of parenteral agents for greater than seven days and chronic VTE. There were more patients in the apixaban load group with liver disease with seven in the load group and one in the no load group. Overall, comorbidities were similar between the two groups except there were more patients in the load group that had liver disease with seven patients in the load group and one patient in the no load group. The primary outcome was incidence of recurrent VTE or progression of DVT to PE, which occurred in one (5.6%) patient in the apixaban load group and zero (0.0%) in the apixaban no-load group. The secondary outcome of occurrence of major bleeding within 14 days occurred in two (11.1%) patients in the apixaban load group and zero (0.0%) in the apixaban no load group. The other secondary outcome of clinically relevant non-major bleeding within 14 days occurred in one (5.6%) patient in the apixaban load group and one (8.3%) patient in the no load group.  

Conclusion: The results of this study were inconclusive due to the small sample size and low incidence of outcomes. The overall low sample size limited the ability to perform appropriate statistical analysis. The observed data showed a possible increased incidence of major bleeding events, but statistical significance is indeterminant. Further studies with larger sample sizes are needed to determine any changes needed in clinical practice.

Background/Purpose: Asymptomatic bacteriuria (ASB) is common in the general population. The Infectious Diseases Society of America (IDSA) guidelines have recommended only screening for and treating ASB in pregnant women or before an invasive urological procedure. ASB is the presence of 1 or more species of bacteria growing in the urine between (≥105 colony-forming units [CFU]/mL or ≥108 CFU/L) in the absence of signs or symptoms of a urinary tract infection (UTI). The lack of pyuria or white blood cells (WBCs) in the urine makes the diagnosis of a UTI highly unlikely. However, the presence of pyuria alone is not an indicator of a UTI. 

At CHI Memorial Hospital, when a UTI is suspected, a culture can only be ordered through a urinalysis (UA) reflex process. The urinalysis must show ≥ 20 WBCs for a culture to be performed. Anecdotally, the antimicrobial stewardship team sees a large number of urine cultures performed despite patients clinically meeting criteria for ASB. This analysis was designed to evaluate our current urinalysis WBC count threshold for reflex to urine culture with the hope of determining an optimal cutoff to decrease the overculturing of urines without significantly missing true infections. 


Methods: This will be a single-center, IRB-approved, retrospective chart review evaluating hospitalized adult patients with a urinalysis with reflex to culture order during the month of July 2025. Patients who were treated as outpatients or those presenting with long term urinary catheters (> 4 weeks) were excluded. The primary objective of this study is to determine how the degree of pyuria relates to a symptomatic UTI: sensitivity, specificity, and positive and negative predictive values will be assessed at various urinary WBC count ranges.

Results: Most patients in the study were elderly females and over 90% of the orders were from the emergency department. About one-third of the patients grew a uropathogen in culture out of the total sampled patients. Uropathogens were generally more likely to grow at increasing urine WBC count; <1% at 0-10 WBC/hpf and 11% at > 100 WBC/hpf. Sensitivity, specificity, positive and negative predictive value were calculated at different urine white blood cell cutoffs which showed that as urine white blood cell count increases, sensitivity decreases significantly from 100% to about 20%. The specificity increases as white blood cell count in the urine increases from 20% to up to 95%. The positive predictive value remains low at less than 50% for all urine white blood cell counts and the negative predictive value remains high at greater than 85% for all urine white blood cell counts. About one-third of patients each grew a uropathogen, a non-uropathogen or had no growth. Among the uropathogens, The most prevalent organism was E. coli at 47%, followed by Klebsiella species at about 24%. 

Conclusion: Despite growing more uropathogens at urine WBCs > 100, only 6% of the patients had a clinically significant UTI. The low prevalence of UTIs in our study of 377 patients is reflective of inappropriate testing and maintaining our urine culture reflex criteria at > 20 WBCs/hpf keeps sensitivity high at above 95% However, specificity is low at 35%. There may be a future role in increasing the threshold for urine reflex to culture to sacrifice some sensitivity for improved specificity and a decrease in unnecessary labor for microbiology labs. 



Email: [email protected]

Title: Lipoglycopeptides Unleashed: The Power of Dalbavancin and Oritavancin 

Authors: Michael Wallace, Heather Gibson, Gretchen Arnoczy, Allison Cid  

Background: Lipoglycopeptides are newer antimicrobial agents used to treat gram positive bacterial infections that would otherwise require long term therapy. Advantages include less frequent dosing, no need for pharmacokinetic monitoring, and long half-lives. The long-acting effects of dalbavancin or oritavancin are useful to help prevent patients from needing long-term intravenous access for IV antibiotics and hospital admission. The purpose of this study was to compare the costs between dalbavancin and oritavancin use compared to traditional therapy for gram-positive infections.   
Methods: This was a retrospective, multicenter cohort study at a rural, community health system that included patients who received either dalbavancin or oritavancin at an outpatient infusion center. Patients were included if they received dalbavancin or oritavancin from September 2022 to September 2025. Excluded patients were those that are incarcerated, pregnant women, those younger than 18 years old, or received dalbavancin or oritavancin inpatient. The primary outcome of the study was cost minimization with comparisons between oritavancin and dalbavancin and the standard treatment for gram-positive infections. Secondary outcomes included adverse events, clinical failure, and mortality. Clinical characteristics such as organism, type of infection, and rationale for dalbavancin or oritavancin use were recorded.  

 Results: A total of 110 patients were included in this study, 103 in the dalbavancin group and 7 in the oritavancin group. The total cost savings were stratified based upon indication for both medications. Overall total cost savings for dalbavancin was $308,788.83 and total cost savings for oritavancin was $54,327.54. Total hospital days saved for dalbavancin were 298 and 26 days for oritavancin. The 90-day hospital readmission rate was 20/103 (19%) in the dalbavancin group and 1/7 (14%) in the oritavancin group. The most common organisms in the dalbavancin group were Methicillin-resistant Staphylococcus aureus (MRSA) with 30/104 (29%) and polymicrobial with 31/103 (30%) and in the oritavancin group was unknown organism with 3/7 (43%). Clinical failure rates for dalbavancin were 14/103 (13%) of patients and oritavancin was 2/7 (28%). 90-day mortality rates for the dalbavancin group were 3/103 (3%) and none in the oritavancin group. 

Conclusions: In this study, the clinical utility, cost saving, and decreased length of hospital stays was shown with implementation of dalbavancin and oritavancin. Total cost avoided for both medications during the period was $363,114.37.  These results show that the medications will cut costs and facilitate quicker discharge. Further research to showcase the use of long acting lipoglycopeptides at other institutions could reinforce the cost savings potential on a larger scale.  

Background: Ribociclib is a cyclin-dependent kinase 4 and 6 inhibitor approved for treatment of   advanced or metastatic hormone receptor (HR) positive, human epidermal growth factor receptor 2 (HER2) negative breast cancer at a dose of 600 mg and adjuvantly for high-risk, early-stage HR+, HER2- breast cancer at a dose of 400 mg . While ribociclib has resulted in improved cancer-related outcomes, the incidence of ribociclib-induced serum creatinine (SCr) elevations has been reported in 8-65% of patients in phase 3 trials although up to 73% of those cases are attributed to a phenomenon known as pseudo-acute kidney injury (AKI). The proposed mechanism is thought to be due to ribociclib’s competitive inhibition of renal tubular secretion transporters, OCT2, MATE1, MATE2-K, blocking creatinine secretion into urine without affecting actual glomerular filtration rate. Cystatin C is an alternative surrogate marker of renal function that is not affected by ribociclib’s inhibition of renal tubular transporters and thus may be utilized to distinguish pseudo-AKI from true kidney injury. This study aimed to further describe the nature and clinical significance of ribociclib-induced SCr elevation in patients with HR+, HER2- breast cancer in a real-world setting.  

Methods: This IRB approved, single-center, retrospective chart review included all adult patients prescribed ribociclib for HR+, HER2- breast cancer at Emory Winship Cancer Institute between October 2022 and August 2025. Patients were excluded if ribociclib was prescribed by an external provider, used for investigational purposes, or if baseline SCr documentation at least 6 months prior to ribociclib initiation was missing. The primary outcome was incidence of ribociclib-induced SCr elevation, defined as ≥ grade 1 per CTCAE v5.0. Cystatin C, defined as > 0.95 mg/dL, was utilized to assess reduced renal function. Use of concomitant nephrotoxic medications including CT contrast, zoledronic acid, diuretics, NSAIDs, metformin, antihypertensives, and antibiotics was assessed.  

Results: 168 females and 2 males were reviewed, median age 58 years old. The majority (139 patients, 81.7%), were prescribed ribociclib for metastatic disease; 31 (18.2%) adjuvantly. Ribociclib-induced SCr elevation occurred in 49 patients (28.8%). Of those patients, 40 (81.6%) had metastatic disease, the initial dose was 600 mg for 36 (73.5%), and 47 (95.9%) were prescribed concomitant nephrotoxic medications though not statistically significant (p-value, 0.515). Median absolute change in SCr from baseline was 0.45 mg/dL (range, 0.34-0.54 mg/dL); median time to SCr elevation was 33 days (range, 15-83 days). Most events were grade 2 (35, 71.4%); 14 (28.6%) were grade 1. Of those with elevated SCr, 5 patients (10.2%) had true kidney injury as indicated by an elevated cystatin C warranting consideration of dose interruption or reduction. Median time to SCr recovery was 155 days (range, 27-316 days).

Conclusion: Ribociclib-induced SCr elevation often occurred within the first or second cycle and remained elevated yet stable through the first six cycles. The majority were grade 1 or 2 events and did not require dose reductions or interruptions.

Graham Anglin, Adam L. Wiss 
Ascension Saint Thomas Hospital West - Nashville, TN 

Introduction: Multimodal analgesia has become a cornerstone of perioperative pain management, reducing opioid exposure and associated adverse effects. At Ascension Saint Thomas Hospital West (ASTHW), continuous intravenous lidocaine infusions have been utilized to improve postoperative pain control in minimally invasive direct coronary artery bypass (MIDCAB) procedures. However, safety concerns and intensive care unit (ICU) monitoring requirements limit their broader use. In June 2022, liposomal bupivacaine, a long-acting local anesthetic, was added to the formulary as an alternative strategy for prolonged analgesia. While studies have shown mixed outcomes depending on surgical type and administration technique, data specific to cardiothoracic surgery remain limited. The objective of this study was to compare intravenous lidocaine and liposomal bupivacaine for postoperative pain management in patients undergoing MIDCAB. 

Methods: This single-center retrospective chart review included adults who underwent MIDCAB at ASTHW between June 2022 and July 2025. Patients received either a single dose of liposomal bupivacaine or a continuous intravenous lidocaine infusion for postoperative analgesia. Exclusion criteria included substance use disorder, concurrent buprenorphine, methadone, or naltrexone therapy; pregnancy, incarceration, surgical re-exploration for bleeding within 24 hours of MIDCAB, or use of mechanical circulatory support. The primary outcome was postoperative opioid use, reported as morphine milligram equivalents (MME) within 72 hours. Secondary outcomes included postoperative pain scores, ICU and total hospital length of stay (LOS), and incidence of adverse effects such as hypotension, bradycardia, arrhythmia, and nausea. 

Results: One-hundred fifty patients were included in the study (intravenous lidocaine = 75; liposomal bupivacaine = 75). Baseline characteristics were comparable, with both groups consisting predominantly of Caucasian males (median age 66 years). All patients received multimodal analgesia; however, the intravenous lidocaine group had higher use of methocarbamol (17% vs 3%, p = 0.007) and erector spinae plane blocks (77% vs 1%, p < 0.001).  There was no statistically significant difference in postoperative MME usage between the intravenous lidocaine group and liposomal bupivacaine group on postoperative day 0/1 (61 vs. 72; p = 0.659), postoperative day 2 (23 vs. 23; p = 0.467) or postoperative day 3 (8 vs. 8 ; p = 0.92). The groups were also similar in postoperative pain scores, hospital and ICU LOS, and incidence of adverse effects.

Conclusion: In this study evaluating postoperative analgesia following MIDCAB surgery, patients who received continuous infusion of intravenous lidocaine had comparable postoperative opioid consumption to those who received a single administration of liposomal bupivacaine with no difference in adverse events between groups. While either of these analgesia strategies may be effective in patients undergoing MIDCAB, further investigation is warranted to determine the role other treatments (i.e., local anesthetic blocks and muscle relaxers) may have had on outcomes in our population.

Title: Evaluation of Thromboprophylaxis Strategies for Orthopedic Surgery Patients

Background: Orthopedic surgery patients are high-risk for post-operative venous thromboembolism (VTE) and often require prolonged prophylaxis. Several studies demonstrated that aspirin (ASA) is non-inferior to traditional prophylactic regimens, such as enoxaparin (LMWH), in orthopedic surgery, however these studies are limited regarding therapeutic durations, transitions of care, and inpatient versus outpatient practices. This has led to significant heterogeneity in practice regarding VTE prophylactic agents. This study aims to compare local rates of post-operative VTE and bleeding for patients receiving ASA vs LMWH prophylaxis.

Methods: This retrospective, observational cohort study included adults with surgical femur fractures or femur fractures with prosthetic replacement at Prisma Health Midlands sites between May 2024 and May 2025 receiving either ASA or LMWH for inpatient post-operative VTE prophylaxis. Therapeutic anticoagulation and those with contraindications to either therapy were excluded. The primary outcome was a composite of VTE events or bleeding during post-operative admission. Secondary outcomes included outpatient VTE or bleeding within 60 days, and evaluation of factors that may affect choice of agent. Tertiary outcomes evaluated therapeutic durations, duplications, and transition opportunities.

Results: Rates of the primary outcome of VTE and bleeding during post-operative admissions were not significantly different between groups (adjusted OR 1.05, 95% CI 0.39-2.28), nor were rates of VTE and bleeding from discharge to 60 days post-op (adjusted OR 0.78, 95% CI 0.26-2.40). Provider factors had the largest influence on choice of agent. Half of patients who received LMWH inpatient were switched to ASA on discharge and only 62% of patients had an appropriate stop date on their prophylactic agent.

Conclusion: No significant differences in VTE and bleeding were found between ASA and LMWH groups, both inpatient and post-discharge. Opportunities for improvement exist for several aspects of prophylactic therapy related to transitions of care.

Authors: Lauren Baugh, Karen Babb 

Background:
Lacosamide is an FDA approved medication for the treatment of focal onset seizures and primary generalized tonic-clonic seizures and is also used off-label for status epilepticus.1 The Neurocritical Critical Care Guidelines for the Evaluation and Management of Status Epilepticus propose 200 mg lacosamide given over 15 minutes as an alternative for rapid administration, while acknowledging the risk for possible adverse effects, such as hypotension or QT prolongation.2 Recent studies suggest an increased incidence of cardiovascular, neurological, and infusion site related adverse events with intravenous push as compared to intravenous piggyback administration.4

This study will assess the incidence of adverse events associated with intravenous push compared to intravenous piggyback lacosamide within our institution.

Methodology:
This was a single-center retrospective cohort analysis. Chart review was utilized to compare patients that received lacosamide via intravenous piggyback or push administration. Included in the study were adult patients 18 years old or older that received at least one dose of IV push or IV piggyback lacosamide from May 1, 2024 - October 31, 2024 and December 1, 2024 - May 31, 2025. Exclusion criteria was doses greater than 400 milligrams. The primary outcome was incidence of adverse drug events (hypotension, bradycardia, infusion site reactions, sedation) in patients receiving intravenous push lacosamide compared to those that receive intravenous piggyback lacosamide. Secondary outcomes reviewed time to administration of intravenous push lacosamide compared to that of intravenous piggyback lacosamide.

Results:
A total of 110 patients were included in the study, with 50 in the intravenous piggyback group and 60 in the intravenous push group. Baseline characteristics, such as age, sex, weight, race, home lacosamide use, and pre-existing comorbidities, were comparable between the two cohorts. Of the 110 patients, a total of 747 doses were observed, with 379 doses given intravenous push and 368 given intravenous piggyback. Of the primary outcomes, incidence of bradycardia, hypotension, medication related sedation, and administration site reaction, there were no statistically significant differences. The median time to first dose administration was 50 minutes in the intravenous push group and 62 minutes in the intravenous piggyback group.

Conclusion:
This study highlights the advantages of administering intravenous push lacosamide without increased risk of adverse events. The findings indicate that the incidence of adverse events was not higher than that seen in the intravenous piggyback administration, while providing shorter time to first dose administration. However, limitations of the study should be considered in the interpretation of the results. The primary limitation of this study was the missing documentation of heart rate, blood pressure, and sedation scores with each dose of lacosamide given. Furthermore, findings should be interpreted in light of the fact that patients requiring hospitalization are often critically ill and exposed to a multitude of factors which could independently contribute to adverse outcomes rather than solely lacosamide administration. In the future, the findings should be presented to the pharmacy and therapeutics committee to further support the current implemented practice. The results of this study should also encourage education on the importance of standardized nursing documentation.

[email protected]

Title: Evaluation of Two Four-Factor Prothrombin Concentrates for Anticoagulant Reversal   
Authors: Mary G. Johnson, Jessica Hernandez, Annmarie Vallomthail, Kristina Larizadeh, Nina Casanova, Feras Akbik
Background: Vitamin K antagonists (VKAs) and factor Xa inhibitors are oral anticoagulants used for the treatment and prevention of thromboembolic events. Bleeding is the most common adverse effect of oral anticoagulants, and rapid reversal may be required in cases of severe hemorrhage or when urgent surgery is indicated. Four-factor prothrombin complex concentrates (4F-PCCs), including Kcentra® and Balfaxar®, are standard treatments for reversal of VKAs and factor Xa inhibitors. Emory University Hospital recently changed formulary agents from Kcentra® to Balfaxar®. In one clinical trial, Balfaxar® was found to be non-inferior to Kcentra® for the reversal of warfarin for urgent surgery; however, there is a paucity of data directly comparing these agents for VKA and factor Xa inhibitor-related bleeding. Limited data and lack of guideline recommendations for a preferred 4F-PCC contribute to clinical uncertainty in selecting an optimal reversal agent. The objective of this study is to evaluate the safety and efficacy of Balfaxar® vs. Kcentra® for reversal of VKAs and factor Xa inhibitors.   
Methods: This study is an Institutional Review Board-approved, single-center, retrospective chart review of patients who received 4F-PCC from December 4, 2024 to August 1, 2025. Patients were included if they were at least 18 years of age, presented to Emory University Hospital, and received at least one dose of 4F-PCC for reversal of a VKA or factor Xa inhibitor. Patients were excluded if they received 4F-PCC at an outside hospital or for procedural use, were concomitantly taking a P2Y12 inhibitor, had a history of a congenital bleeding disorder, or were pregnant, nursing, or incarcerated. The primary outcome was hemostatic efficacy. Hemostatic efficacy in intracerebral hemorrhage (ICH) patients was defined as change in hematoma volume ≤ 20% or 21-35% within 24 hours of baseline without a repeat 4F-PCC dose or surgical intervention within 24 hours. In non-ICH patients, hemostatic efficacy was defined as a hemoglobin drop ≤ 2g/dL within 24 hours, or transfusion of < 2 units of packed red blood cells without a repeat 4F-PCC dose or surgical intervention within 24 hours. Secondary outcomes include in-hospital mortality, thrombotic events, ICU length of stay, hospital length of stay, and number of repeat doses within 48 hours. Descriptive statistics will be used to summarize the continuous and categorical variables. Chi-squared tests will assess differences in outcomes between treatment groups.  
Results: Out of 71 patients, 37 patients were included in the Kentra® group and 34 in the Balfaxar® group. Baseline characteristics were similar between the groups except BMI of 25-29.9 kg/m2 was notably different (45.9% vs. 14.7%, p=0.004). A total of 20 patients in the Kcentra® group and 19 in the Balfaxar® group met the primary outcome of hemostatic efficacy (54.1% vs. 50.0%, p=0.877). There were notable differences between in-hospital mortality (13.5% vs. 32.4%, p=0.058) and number of repeat doses (0.0% vs. 8.8%, p=0.065), but these findings, along with the other secondary outcomes, were not statistically significant. However, there was a significant increase in thrombotic events (ischemic stroke) in the Balfaxar® group (0.0% vs. 14.7%, p=0.016).  
Conclusion: There was no significant difference in hemostatic efficacy between Kcentra® and Balfaxar®. While no difference in efficacy was observed, ischemic stroke, in-hospital mortality, and repeat doses within 48 hours were more notable in the Balfaxar® group. Larger studies are needed to validate these results and further guide the selection of the optimal reversal agent.

Primary Author: Jessica Kennedy

Co-Authors: Taylor Burich; Michael Brandon Hardison; Jeremy Walley

Title: Optimizing Postoperative Pain Management in Total Hip Arthroplasty with Liposomal Bupivacaine

Background: Total hip arthroplasty (THA) is associated with significant postoperative pain, prolonged hospitalizations, early mobilization, and increased opioid utilization.  In the United States, over 500,000 THA occur every year and can often lead to opioid over prescribing. Effective postoperative pain control is critical in THA to facilitate early mobilization, reduce opioid consumption, and support recovery. Liposomal bupivacaine is Food and Drug Administration (FDA) approved as a long-acting local and regional anesthetic. The purpose of this study is to assess liposomal bupivacaine utilization as a part of a multimodal analgesia approach to improve pain control and reduce opioid consumption following THA.

Methods: This study aims to evaluate the efficacy of liposomal bupivacaine as a part of a multimodal analgesic approach in patients undergoing THA. Data will be collected through patient interviews via a standardized questionnaire to determine opioid utilization, pain score, and time to regain mobility and sensation. Patients included in this study are those 18 years or older who underwent THA with liposomal bupivacaine utilization. Exclusion criteria will be patients receiving liposomal bupivacaine for any other indication and those with a documented hypersensitivity or allergic reaction to liposomal bupivacaine or any of its analogs. The primary objective of this study is to examine opioid requirements after surgery as well as pain scores in patients who received liposomal bupivacaine. Secondary objectives will include the time to regain mobility and sensation post-operatively, as well as cost savings from a reduction in length of stay.  

Results: The primary endpoint saw the pain scores of those who received liposomal bupivacaine 17 individuals fell within mild pain scores (0-3), and 5 within the moderate pain scores (4-6). Compared to the standard of care group who had 13,16,13 in their mild, moderate, and severe pain scores. As for opioid requirements there was change of an increase in usage within both groups, however, those who received liposomal bupivacaine required19 mg compared to standard of care which required on average 27.1 mg. As for secondary endpoints  there was no difference within the mobility and sensation as both groups were moving about every hour at a minimum. Analysis for cost is still in progress. 

Conclusion: Utilization of liposomal bupivacaine provides a multimodal approach for postoperative pain management in THA. Those individuals who received liposomal bupivacaine had a reduction in pain scores and opioid usage when compared to the standard of care. 

Primary Author: Charles Pitts
Co-Authors: Hope Allen, Brittany Till, Morgan Moulton, Perry Thompson, Walter Minger, Tiffany Lyght

Background: Venous thromboembolism (VTE) is a common cardiovascular diagnosis, with many cases linked to recent hospitalizations. Prophylactic anticoagulation is used to prevent VTE, guided by patient risk factors. Risk Assessment Models (RAMs), such as the Padua VTE RAM, help determine when VTE prophylaxis is appropriate or should be avoided due to bleed risk, as recommended by the American Society of Hematology. This project was designed to evaluate the current utilization of prophylactic anticoagulation using the Padua VTE RAM to determine its appropriateness in patients admitted to the inpatient setting. According to the Padua RAM, scores of 4 or more are indicative of high VTE risk and should receive anticoagulation.

Methods: This project was a retrospective, observational review of Veterans' charts who received prophylactic anticoagulation in the inpatient setting within the Central Alabama Veterans Health Care System (CAVHCS). Data collected included Veteran demographics, active prescriptions, ICD codes, recent surgeries, age, body mass index (BMI), birth sex, kidney function, presence of a central venous catheter, critical care admissions, liver function tests, platelet counts, and recent bleeding events. The data was compiled in a de-identified Microsoft Excel spreadsheet for analysis. The primary outcome assessed was the percentage of Veterans appropriately placed on prophylactic anticoagulation based on inclusion/exclusion criteria. Secondary outcomes included the number of admitted Veterans receiving prophylactic anticoagulation who experienced bleeding-related events and thrombosis-related events.

Results: One hundred Veteran charts were evaluated for this project. Of the evaluated charts, prophylactic anticoagulation was appropriately administered or withheld in 53 Veterans and prophylactic anticoagulation was inappropriately administered or withheld in 47 Veterans based on their individual Padua RAM scores. Of the 47 Veterans, 45 received inappropriate prophylactic anticoagulation and two Veterans had prophylactic anticoagulation withheld inappropriately. None of the Veterans evaluated experienced bleed or thrombosis-related events.

Conclusions: Nearly 50% of Veterans reviewed had anticoagulation inappropriately administered or withheld while admitted. While this evaluation did not find any bleed or thrombosis-related events, the current anticoagulation prescribing trends leave room for improvement. The creation of a policy to standardize the criteria for VTE prophylaxis could increase appropriate anticoagulation prescribing patterns within the CAVHCS inpatient setting. This project also exposes an area of Veteran healthcare that Clinical Pharmacy Practitioners could assist in optimizing and monitoring.

Title: Impact of Midodrine on Optimization of Guideline-Directed Medical Therapy in Patients with Heart Failure with Reduced Ejection Fraction
Authors: Isabelle Perling, Jessica Starr, Nathan Pinner, Alyssa Osmonson, Kenda Germain
Objective: Discuss whether the addition of midodrine in patients with heart failure with reduced ejection fraction (HFrEF) facilitates optimization of Step 1 guideline-directed medical therapy (GDMT)
Self-Assessment Question: True or false, the addition of midodrine for HFrEF patients led to optimization of GDMT compared to those not started on midodrine.
Background: Heart failure is a complex syndrome that results from impairment of ventricular filling or blood ejection from the heart. It is classified by ejection fraction with the most common types being heart failure with reduced ejection fraction (HFrEF) and heart failure with preserved ejection fraction.
Guideline-directed medical therapy (GDMT) for HFrEF includes four step 1 agents: renin-angiotensin system inhibition with an angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, or angiotensin receptor-neprilysin inhibitors, beta blockers, mineralocorticoid receptor antagonists, and sodium-glucose cotransporter 2 inhibitors. These treatments prolong patient life, improve symptoms, and reduce hospitalizations for HFrEF patients. Due to the notable blood pressure lowering effects of many of these agents, some patients cannot tolerate full GDMT.
Midodrine is a peripheral alpha-1 agonist that increases arterial and venous tone resulting in increased BP. It is FDA approved for symptomatic orthostatic hypotension but has been used off-label for vasopressor weaning in the intensive care unit and hemodialysis associated hypotension. Because combining multiple agents of GDMT can lower BP, some clinicians are beginning to use midodrine to counteract hypotension and ensure full optimization of GDMT.
Methods: This is a single center, IRB approved, retrospective chart review in patients with HFrEF and at least one Step 1 GDMT agent(s) on their home medication list. Patients with ≥3 normotensive blood pressure readings, contraindications to GDMT, mixed heart failure, end stage kidney disease, liver failure, and addition of midodrine for vasopressor de-escalation or no prescription fill data post-discharge were excluded. The primary endpoint was optimization of Step 1 GDMT, including addition of further agents or dose increases in current. Secondary outcomes include addition of GDMT, dose increase in current GDMT, reduction of GDMT, dose decreases in current GDMT, 30-day re-admission, mortality within a year, ability to come off midodrine, and improvement in ejection fraction.
Results: 28 patients were analyzed, 14 on midodrine and 14 without midodrine. There was no difference in optimization of Step 1 GDMT between the midodrine and matched control group. 3/14 patients in the midodrine group were optimized on step 1 GDMT compared to 6/14 in the control group (p=0.225). There was a meaningful difference in mortality within a year between the midodrine and control groups, 5/14 and 1/14, respectively (p=0.065).
Conclusion: Midodrine did not result in a difference in optimization of GDMT. Mortality was higher in the midodrine group, emphasizing the need for further studies evaluating the safety of the medication in HFrEF patients.

Introduction: Traumatic brain injury (TBI) is a major cause of long-term disability, with persistent cognitive and functional deficits affecting millions of survivors. Neurostimulants such as amantadine are recommended for disorders of consciousness after TBI; however, limited evidence exists evaluating the impact of combination neurostimulant therapy with methylphenidate on functional recovery. This study evaluated the effect of single versus dual neurostimulant therapy on functional-cognitive outcomes in patients with moderate to severe TBI.
Methods: A single-center retrospective observational study was conducted at a Level I trauma center from January 1 to December 31, 2024. Adult patients (age >16 years) with moderate to severe TBI, defined as a Glasgow Coma Score (GCS) < 12 within 72 hours of arrival, who received amantadine alone or amantadine plus methylphenidate for ≥3 days during intensive care unit (ICU) admission were included. The primary outcome was discharge functional-cognitive capacity measured by the Rancho Los Amigos Scale-Revised (RLAS-R). Secondary outcomes included change in GCS, ICU and hospital length of stay (LOS), and discharge disposition. Propensity matching (1:4) and multivariable analyses were performed.
Results: Seventy-six patients were included (amantadine n=57; dual therapy n=19). Baseline demographics and injury characteristics were similar between groups. Median discharge RLAS-R scores did not significantly differ between dual therapy and monotherapy groups (4 vs 5, p=0.12). ICU and hospital LOS were comparable between groups, and discharge disposition distributions were similar. Multivariable regression adjusting for initial GCS demonstrated no significant association between treatment strategy and discharge functional-cognitive outcomes (OR 0.73, 95% CI 0.30–1.81). ICU (21 vs 19 days, p = 0.20) and hospital LOS (29 vs 33 days, p = 0.10) were comparable between groups, and discharge disposition distributions were similar, with more than 50% of patients being discharged to an acute rehab facility.
Conclusions: Early initiation of dual neurostimulant therapy (amantadine plus methylphenidate) produced functional-cognitive outcomes comparable to amantadine monotherapy without decreasing resource utilization. These findings suggest no clear additive benefit of combination therapy in moderate to severe TBI and highlight the need for

Optimizing Migraine Management in Veterans: A Pharmacist-Led Review of Triptan Use in Primary Care Clinics
Justin Barnett, Jessica Parks, Stephanie Hopkins, Karyn Fabo
Fayetteville NC VA Coastal Health Care System – Fayetteville, NC

Background: Acute migraine headaches affect approximately 16% of the United States population. Triptans (e.g., sumatriptan, rizatriptan, etc.) are often the first-line option for acute migraine management. Triptans provide symptom relief by promoting vasoconstriction of intracranial blood vessels, and while this mechanism is the primary source of therapeutic benefit, it also increases cardiovascular risks, especially coronary vasospasm. As a result, the triptan class is contraindicated in patients with a history of cardiovascular disease, and use should be limited in patients with risk factors for cardiovascular disease. Nationwide prescribing patterns suggest that nearly 14% of patients using triptans meet at least one contraindication.


Methods: This quality improvement initiative identified adult Veterans at a Veterans Affairs (VA) Health Care Center who had an active prescription for a triptan medication. Patients qualified for review if they were managed by one of six designated primary care clinics and were disqualified if their migraine disorder was actively managed by a VA or private-sector neurologist.

Contraindications (including ischemic heart disease, arrhythmias, uncontrolled hypertension, history of gastrointestinal ischemia, history of stroke, peripheral vascular disease, and structural heart disease) and cardiovascular risk factors (including hypertension, hyperlipidemia, diabetes mellitus, hepatic or renal failure, obesity, age >65 years, and current tobacco use) were identified via electronic health record (EHR) review. The primary author attempted telephone contact with each identified Veteran to reconcile any potential discrepancies in EHR documentation.

At the conclusion of the patient encounter, the primary investigator recommended the following: no intervention, referral by primary care provider (PCP) to neurology service, referral by PCP to cardiology service, discontinuation of triptan prescription, or referral directly to clinical pharmacist practitioner (CPP) for chronic disease state management. Recommendations were assessed as “accepted” or “not accepted”, and the results were analyzed using descriptive statistics. Findings will be communicated to the designated primary care clinics in order to improve future prescribing practices.


Results: Of the 86 patients identified, 13 patients (15.1%) had at least one contraindication to triptan use, and the most frequent contraindication was uncontrolled hypertension (n=9, 10.4%). Interventions were recommended for 33 Veterans but were accepted for only 17. The most frequently recommended intervention was for a neurology consult (n=20). The most frequently accepted intervention (n=10) was for referral to a CPP for management of chronic disease states that can increase cardiovascular risk.


Conclusions: Data from this quality improvement initiative demonstrate that pharmacists should be actively engaged in monitoring triptans and counseling patients to ensure those with contraindications do not use this class of medications.