2025 Southeastern Residency Conference

Implementation of Barcode Medication Administration in Perioperative Areas
Trevyn Flanders, Tanner Shields, Emily Duncan, Danielle Yates, Summer Snowden, Alan Knauth


Purpose:
Previous studies have shown that BCMA can reduce medication administration errors, as well as reduce risk of harm from those errors. In May 2024, pharmacists at Blount Memorial Hospital began verifying perioperative orders through computerized provider order entry (CPOE). CPOE orders are entered to allow for barcode medication administration (BCMA) in the perioperative areas. Prior to CPOE and BCMA in these areas, medications were removed from the automated dispensing cabinet and administered to the patient without pharmacist review. After this implementation, pharmacists now review all medication orders prior to administration in perioperative areas. Our purpose is to assess these changes and the potential impact on patient safety and pharmacist workload.

Self Assessment Question: 
BCMA has the potential to improve patient safety by ensuring adherence to the "Five Rights" of medication administration
True or False


Methods: 
This is an IRB-approved, retrospective, cohort analysis to assess the impact of implementing BCMA in the perioperative setting, as well as to assess the impact of a surgery-specific pharmacist at our institution. We used the data collected to compare medication scan rates, automated dispensing cabinet overrides, and total order volume before and after BCMA implementation. We also evaluated the types of interventions being documented by the surgery pharmacists after implementing BCMA. The primary objectives were to analyze the medication scan rate, cabinet override rate and total order volume before and after BCMA implementation. The secondary objective was to evaluate the types of interventions documented by surgery pharmacists.


Results: 
Medication scan rates were reviewed, showing a 99% scan rate for 12,955 orders after BCMA implementation. There were 8,552 transactions reviewed for cabinet overrides, showing only 1.2% of orders were overridden. Total order volume increased by 51% after CPOE implementation in perioperative areas. Lastly, 285 interventions documented by surgery pharmacists were reviewed after implementation. Of those reviewed, 142 interventions pertained to patients in surgical areas. The most common interventions were related to ADE (adverse drug event) prevention (42%) and antibiotic related issues (22%).


Conclusion: 
The data we collected on medication scan rates and cabinet overrides suggests that BCMA had a positive impact on patient safety at our institution. Furthermore, the documentation of interventions made by a dedicated surgery pharmacist suggests that we are preventing potential adverse drug events, thus improving patient safety.

Title: Outcomes of a Pharmacy-Driven Electrolyte Replacement Protocol in Non-ICU Settings

Authors: Andrea Dobbs, Caroline Chappell, Carolyn Coulter, Alex Chappell

Objective: Participants will be able to explain the benefits and safety of implementing a pharmacy-driven electrolyte replacement protocol in non-ICU settings.

Self-assessment question:
Which of the following is a potential benefit of a pharmacy-driven electrolyte replacement protocol in non-ICU settings?
A. Decreased rate of over-replacement
B. Reduction in infusion-related adverse events
C. Shorter time to electrolyte replacement
D. Improved post-replacement monitoring
E. C & D

Background: Electrolyte replacement is a fundamental part of patient care but can be time-consuming and variable due to differences in provider training and clinical preferences. This variability may lead to inconsistent dosing, monitoring, and follow-up resulting in delays or inadequate replacement. In high acuity settings, this can increase the risk of complications such as arrhythmias and prolonged recovery. To address this, many institutions have adopted standardized electrolyte replacement protocols. In ICU settings, studies have shown that protocolization of electrolyte replacement reduces practice variation and improves timeliness and monitoring. At our institution, a pharmacy-driven electrolyte protocol, that allows pharmacists to initiate replacement and order follow-up labs, was implemented in the ICU. This has improved workflow efficiency and monitoring while enabling physicians to focus on more complex clinical issues. However, electrolyte management on general medicine floors remains unstandardized and largely dependent on individual provider judgment. This study evaluates whether extending the pharmacy-driven protocol to non-ICU settings yields similar benefits.

Methods: This IRB-approved, single-center, retrospective cohort study included patients >18 years admitted to one of four general medicine floors at Alamance Regional Medical Center in Burlington, North Carolina. In August 2024, a pharmacy-driven electrolyte replacement protocol was implemented, allowing pharmacists to replace potassium, magnesium, and phosphorus per protocol and order follow-up labs. Patients were excluded if they had end-stage renal disease on renal replacement therapy, metabolic disturbances (e.g., ketoacidosis or renal insufficiency), direct ICU or hospice admission, died before replacement, remained in the emergency department, or had scheduled daily replacement. Prior to protocol implementation, electrolyte replacement was primarily replaced by the attending physician. Data were obtained from electronic medical record reports identifying physician-ordered and pharmacy-ordered replacement. Manual chart review was used to collect demographics, electrolyte-specific data (labs, replacement), and adverse events (infiltration or supratherapeutic levels). Due to non-normal distribution, the Mann–Whitney U test was used for continuous variables and the Fisher exact test for categorical data.
 
Results: The representative pre-protocol group (June–July 2024) included 46 patients who received replacement by the physician. The representative post-protocol group (September–October 2024) included 48 patients who received electrolyte replacement per protocol by pharmacy. There were 110 replacement opportunities in the pre-protocol group and 148 in the post-protocol group. Following protocol implementation, the overall median time to replacement significantly improved from 4.9 to 3.7 hours (median difference: 1.2 hours; p < 0.00001). When analyzed individually, potassium replacement time decreased from 4.9 to 2.9 hours (p < 0.0001), and magnesium from 5.0 to 3.9 hours (p = 0.0053), while phosphorus showed no significant change (p = 0.88). Post-replacement monitoring, measured by follow-up labs ordered, also improved significantly with missed lab orders decreasing from 12.7% to 1.4% (p = 0.0003). No adverse events such as infusion reactions or supratherapeutic levels were observed in either group.

Conclusion: Protocolized electrolyte replacement has been shown to improve care in high-acuity settings such as ICUs by promoting timely and consistent management. However, limited evidence exists regarding its effectiveness on general medical floors. Our findings align with current literature and extend these benefits to the non-ICU setting. A key limitation of our study is the use of scheduled replacement time as a surrogate for actual administration time. While this approach helped reduce workflow-related variability, it may skew results toward best-case outcomes. Additionally, while the overall sample size was adequate, secondary analyses of individual electrolytes were limited due to smaller sample sizes. In conclusion, our results support the use of a pharmacy-driven electrolyte replacement to improve efficiency and monitoring on general medicine floors without compromising patient safety. Importantly, this study also highlights the value of pharmacy integration into protocol-driven care to free up physician time so they can focus on managing higher-acuity clinical issues.

Contact information: andrea.dobbs@conehealth.com

Comparison of Emergency Care Center and Mobile Stroke Unit Fibrinolytic Times in Resistant Hypertension Requiring Nicardipine
Authors: Kaitlyn Wallace, Andrew Yetka, Katleen Chester, Olivia Morgan
Background: 
Nicardipine is an intravenous antihypertensive medication often used for acute ischemic stroke (AIS) patients with acute hypertension resistant to IV push labetalol and/or hydralazine. Nicardipine is supplied as a premixed bag in the Grady Health System (GHS) mobile stroke unit (MSU) but must be compounded at bedside or in the main inpatient pharmacy when supplied in the emergency care center (ECC). The aim of this study was to analyze whether access to premixed nicardipine administered in the MSU shortens time to fibrinolytic administration in patients with resistant hypertension. 
Methods:
To analyze time to goal blood pressure for fibrinolytic therapy, a single center retrospective chart review was completed for patients treated with IV fibrinolytics within the Grady Health System for an AIS between May 10^th, 2021, and October 14^th, 2024. Patients treated with IV nicardipine prior to fibrinolytic administration in the ECC were compared to those treated similarly in the MSU. Patients younger than 18 years old, those presenting greater than 4.5 hours from symptom onset, and those who received a fibrinolytic for an indication other than stroke were excluded from analysis. The primary endpoint was time to fibrinolytic administration from the initial non-contrast computed tomography (CT) scan. Secondary endpoints included mean time to fibrinolysis from first antihypertensive medication, mean door (ECC) or arrival (MSU) to needle time, mean initial hypertensive blood pressure that excludes patient from fibrinolytic therapy, rate of symptomatic intracranial hemorrhage (ICH), and modified Rankin Scale (mRS) at discharge.
Results: 
A total of 39 ECC patients and 3 MSU patients were included in the final analysis. The median age was 63.5 years old, 52% of patients were male, and 81% identified as black or African American. Almost all patients had hypertension at baseline and the median National Institute of Health Stroke Score (NIHSS) was 7.5. Labetalol was the most used adjunctive agent, having been utilized in 64.3% of patients, and nicardipine alone was utilized in 33.3% of patients. The primary outcome of median CT-to-needle time was 33 minutes for the ECC and 35 minutes for the MSU. Door/arrival, 1^st antihypertensive, and nicardipine-to-fibrinolytic time were shorter favoring the MSU over ECC, though this was not statistically significant. 
Conclusions:
Within Grady Health System, intravenous nicardipine is not used frequently enough prior to IV fibrinolytics to draw statistically significant conclusions regarding faster times to fibrinolytic therapy in the MSU vs ECC.

EVALUATON OF EXTENDED POSTOPERATIVE ORAL TRANEXAMIC ACID AFTER TOTAL KNEE AND HIP ARTHROPLASTY 
Kayla Dodson, Alex Fagan, Shelby Hood, Sterling Torian
TriStar Centennial Medical Center – Nashville, TN
 
Background: Perioperative tranexamic acid has become the standard of care in total joint arthroplasty, aiming to reduce total blood loss and postoperative blood transfusions. Administered either intravenously and/or topically during surgery, tranexamic acid is believed to balance the fibrinolytic and procoagulant systems. Furthermore, its anti-inflammatory properties may offer additional benefits postoperatively for patients undergoing total knee arthroplasty, such as enhanced range of motion, commonly referred to as flexion. The use of extended courses of oral tranexamic acid postoperatively is an emerging therapy, though its clinical utility remains uncertain due to limited evidence regarding safety and efficacy. The purpose of this study was to evaluate the use of an extended course of postoperative oral tranexamic acid and establish a standardized protocol for its use in total knee and hip arthroplasty.
 
Methods: This was a single-center retrospective cohort study conducted through chart review from May 1, 2023 to July 1, 2024. Patients were identified based on the International Classification of Diseases-9 and International Classification of Diseases-10 codes for total knee or hip arthroplasty at admission. Patients who underwent elective knee or hip arthroplasty within the study timeframe were included. Exclusion criteria consisted of emergent or non-elective arthroplasty, documented religious preference that precludes use of blood products, tranexamic acid use on admission, end stage renal disease, and incarcerated patients. The primary outcome was the percentage reduction in hematocrit, calculated by subtracting the lowest postoperative hematocrit within 48 hours from the preoperative hematocrit. Secondary outcomes included the frequency of blood transfusions, flexion in total knee arthroplasty (TKA), and incidence of thrombotic complications. 
   
Results: A total of 229 patients were screened; 221 patients met inclusion criteria and 8 patients were excluded due to non-elective/emergent procedure. Baseline demographics were similar between groups. No significant difference was observed in reduction of hematocrit among those who received a course of extended postoperative oral tranexamic versus those who did not (mean difference -0.23; 95% CI (-1.27 – 0.8), p=0.660). The flexion degree of change in TKA was statistically significant in patients who did not receive oral TXA (mean difference 3.9; 95% CI (0.76 – 7), p=0.015). One patient developed a deep vein thrombosis in the non-oral TXA group. 
 
Conclusions: There was no observed difference in reduction of hematocrit in patients who received an extended course of postoperative oral tranexamic versus those who did not. There was also no difference in other clinically relevant outcomes including improved flexion in TKA, blood transfusion requirements and thrombotic complications. 
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.

Title: Dalbavancin Compared to Standard of Care for Acute Bacterial Skin and Skin Structure Infections in the Emergency Department
 
Authors: Liam Richardson, Katherine Weller, Christopher M. Bland, Jamie L. Wagner, Bruce M. Jones
 
Objective: By the end of this presentation participants will be able to describe the use of dalbavancin in the ED for ABSSSI admission avoidance, and discuss the clinical outcomes of dalbavancin compared to oral SOC antibiotics for treatment of ABSSSI in the ED
 
Self Assessment Question: Was there a significant difference in 30-day treatment failure between non-admitted patients treated with dalbavancin or oral SOC antibiotics for ABSSSI in the ED?
 
Background: Dalbavancin is a long-acting lipoglycopeptide antibiotic with broad gram-positive activity and is currently used per-protocol for admission avoidance and treatment of acute bacterial skin and skin structure infections (ABSSSIs) in both St. Joseph’s and Candler Hospital emergency departments (ED). There are limited data comparing clinical outcomes of dalbavancin and oral antibiotics for treatment of ABSSSIs in the ED. The aim of this study is to evaluate clinical outcomes of patients with ABSSSIs treated in the ED and not admitted with dalbavancin compared to oral antibiotics.
 
Methods: This retrospective quasi-experimental study evaluated clinical outcomes in ED patients treated with dalbavancin or oral antibiotics for cellulitis or abscess. The primary outcome was treatment failure, with a secondary outcome of adverse events reported. Patients who received oral antibiotics (the standard-of-care (SOC) group) (June 1, 2020–May 31, 2022) were identified using structured query language with ICD-10 codes for cellulitis (L03.XXX) and abscess (L02.XXX). Patients who received dalbavancin (June 1, 2022–September 1, 2024) were identified via a computer-generated list. Subjects were screened via random sampling for inclusion (ED visit for cellulitis/abscess without admission) and were matched 1:1 based on ICD-10 diagnoses. Demographics, infectious diagnosis, organism(s) isolated, infection-related labs, comorbidities, renal function, financial information, and antibiotics received were collected. Adverse events and culture/susceptibility data, if available, were recorded. Treatment failure was defined as hospital admission within 30 days or antimicrobial change due to the index infection. Data were collected and analyzed in Microsoft Excel. Categorical data were assessed using Chi-square or Fisher’s exact test, and continuous data with Student’s t-test or Mann-Whitney U, as appropriate. An alpha of 0.05 was deemed statistically significant.
 
Results: One hundred fifty patients (75 per group) were included. The median age was 56.5 years, and 50% were male. Most patients had cellulitis (136/150), with only 14 presenting with abscess as the primary diagnosis. Overall, 17 (22.7%) dalbavancin patients experienced treatment failure compared to 10 (13.3%) SOC patients (p = 0.137). Among those who failed treatment, the mean time to return was 4.8 days for dalbavancin patients versus 8.5 days for SOC patients (p=0.135). Prior oral antibiotic failure occurred in 54 (72%) dalbavancin patients and 15 (20%) SOC patients (p=<0.00001). Among SOC patients, cephalexin was the most prescribed discharge antibiotic (45%), followed by clindamycin (29.3%). A history of methicillin-resistant Staphylococcus aureus (MRSA) was present in 12 (16%) SOC patients and 7 (9.3%) dalbavancin patients. Positive cultures occurred in 10 (13.3%) dalbavancin patients (6 Staphylococcus aureus; 2 MRSA) versus 4 (5.3%) in the SOC group (3 Staphylococcus aureus; all MRSA). There were overall zero adverse events related to antibiotic therapy reported amongst both dalbavancin and SOC patients. Ten (13.3%) dalbavancin patients were un-insured compared to 22 (29.3%) SOC patients (p=0.0168). Mean inflation-adjusted reimbursement per patient was $4,478 for dalbavancin patients and $274 for the SOC patients. Additionally, 45/75 (60%) of dalbavancin patients had zero patient copay after insurance compared to 63/75 (84%) of SOC patients.
 
Conclusion: While dalbavancin had a numerically higher failure rate than SOC, more dalbavancin patients had failed prior SOC therapy, suggesting greater baseline infection severity; however, this study found no statistically significant difference in failure rates between the groups. Future studies controlling for other confounding variables, including prior treatment failures and more diverse infectious diagnoses should be performed to further evaluate these initial findings.  
 

Title:Evaluation of Safety and Efficacy of Rivaroxaban for Peripheral 
Artery Disease in Patients with Renal Dysfunction


Authors: Persia S. Nelson,  Laura Leigh Stoudenmire


Background: Rivaroxaban, a renally-cleared direct-acting oral anticoagulant (DOAC), has obtained FDA approval for patients with stable PAD. Guidelines for the Management of Lower Extremity PAD recommend rivaroxaban 2.5 mg twice a day combined with low-dose aspirin to prevent major adverse cardiovascular events and major adverse limb events in patients with PAD who are not at an increased risk for bleeding. While patients who are at an increased risk of bleeding are not clearly defined in the guidelines, the safety and efficacy of rivaroxaban in patients with renal dysfunction remains an area of clinical concern. The COMPASS and VOYAGER PAD trials, which assessed the use of rivaroxaban for the treatment of PAD, excluded patients with severe kidney impairment. Related trials discussing DOAC use in patients with chronic kidney disease (CKD) showed increased risk of clotting and bleeding in patients with renal dysfunction. Similar trials have also historically excluded patients with severe kidney impairment. Additionally, drug information resources have advised against the use of rivaroxaban in patients indicated for PAD with CrCl < 15 mL/min as the risk benefit associated with rivaroxaban use in patients with CrCl < 15 mL/min is uncertain.   


Methods: The purpose of this study was to assess the safety and efficacy of rivaroxaban in patients with renal dysfunction. This retrospective cohort study consisted of patients receiving rivaroxaban 2.5 mg BID with a diagnosis of PAD. Patients were eligible for inclusion if they were adults age 18 and older with a diagnosis of PAD and received rivaroxaban 2.5 mg twice daily from January 1, 2019 to June 30, 2024. Exclusion criteria consisted of pregnant patients, patients with a past medical history of hemorrhagic or ischemic cerebral infarction, active peptic ulcer disease with recent bleeding, and active bleeding prior to initiation of rivaroxaban 2.5 mg BID for PAD. Patients were divided into two groups being CrCl < 15 mL/min and CrCl > 15 mL/min. The primary endpoint was major bleeding events which was defined as a > 2 g/dL decrease in hemoglobin, documented transfusion > 2 units of packed red blood cells, or bleeding of a critical anatomical site (e.g intracranial, spinal, ocular) within 90 days post discharge with rivaroxaban. The secondary endpoint included efficacy and was assessed by evaluating the onset of myocardial infarction, ischemic stroke, acute limb ischemia, major amputation, or cardiovascular death within 90 days post discharge. Additionally, the secondary outcome included bleeding readmission within 90 days.


Results: The primary and secondary composite outcomes were not statistically significant between the CrCl < 15 mL/min group and CrCl > 15 mL/min. In reference to the primary outcome, bleeding events had a composite P-value of 0.69. Regarding the secondary outcomes, bleeding readmission had a composite P-value of 0.1 while major adverse cardiac events had a composite P-value of 0.37.    


Conclusion: Despite the lack of statistical significance between the groups, further research is necessary to evaluate the safety and efficacy of rivaroxaban in patients with reduced renal function.

Title: Evaluation of Midodrine Utilization in General Medicine Patients Admitted with Sepsis 


Authors: Martine Abouchabki, Stefanie Sarratt, Timothy Amison 


Background: Guidelines define sepsis as life-threatening organ dysfunction secondary to a dysregulated host response to infection. Septic shock is clinically recognized by persistent hypotension requiring vasopressors to maintain mean arterial pressure (MAP) at or above 65 mmHg despite adequate volume resuscitation. Current management of hypotension in sepsis includes fluid resuscitation to improve organ perfusion, appropriate source control, antibiotics, and maintaining MAP > 65 mmHg. Hypotension may persist after appropriate volume administration, necessitating intravenous vasopressor therapy and escalation of care. Literature has reviewed midodrine as an adjunct therapy for liberation from vasopressor therapy.  It is unclear whether midodrine can be used as an alternative to vasopressor therapy in patients with sepsis. The purpose of this study was to evaluate the impacts of midodrine utilization on resolution of hypotension in patients with sepsis.


Methods: This was a single-center, retrospective cohort study evaluating the utilization of midodrine therapy in general medicine patients admitted with sepsis and sustained hypotension after fluid resuscitation. Patients 18 years or older who were admitted to a general medicine service with a primary diagnosis of sepsis or septic shock were eligible for enrollment. Patients were excluded if they received vasopressors in the emergency department prior to midodrine initiation, had a known allergy to midodrine, or were on midodrine therapy for other indications. The primary outcome was time to resolution of hypotension. Secondary outcomes include in-hospital mortality, hospital length of stay, time to vasopressor initiation, total duration of vasopressor therapy, and time to ICU admission. The safety outcomes evaluated were bradycardia and hypertension after initiation of therapy.


Results: Among the 153 patients initially reviewed, 118 individuals were excluded for various reasons. Of the 35 patients included, 28 were included in the midodrine group and 7 were included in the midodrine followed by a vasopressor group. The primary outcome, median time to resolution of hypotension for the midodrine followed by vasopressor group was 6.7 hours compared to 3.15 hours in the midodrine only group (P-value = 0.2009). The results for the midodrine followed by vasopressor group versus midodrine only for the secondary outcomes of in-hospital mortality (0% vs 14.3%), hospital length of stay (19% vs 7%), time to vasopressor (15 hours), time to ICU admission (15 hours vs 15 hours), total duration of vasopressor utilization (15 hours), and MAP at discontinuation of midodrine > 65 (57% vs 79%) were also calculated. Safety outcomes evaluated included bradycardia (14% vs 11%) and hypertension after initiation of midodrine therapy (0% vs 14%).  


Conclusion: In this retrospective study of general medicine patients admitted with sepsis, there was no significant difference in time to resolution of hypotension between patients that received midodrine followed by vasopressor therapy compared to midodrine therapy alone. Of note, the midodrine only group had fluctuating improvement in hypotension after initially meeting the primary outcome, in addition to a lack of comparison of severity of illness between the groups. It is also important to note that this trial was underpowered due to limited patient enrollment, primarily due to the lack of eligible participants in the midodrine followed by vasopressor group. Based on these findings, additional studies are needed to further identify any utility in this patient population.

mabouchabki@srhs.com

Title: EVALUATION OF EMPIRIC ANTIBIOTICS IN SEPSIS VERSUS NON-SEPSIS UTI PATIENTS


Authors: Marquist Henderson, Megan Heath, Doug Carroll


Objective: Discuss the appropriate empiric antibiotic treatment for urinary tract infections and sepsis based on current guidelines and evidence-based literature. 


Self Assessment Question: What is an appropriate empiric agent for a patient with sepsis and MRSA risk factors?


Background: UTIs are among the most common infections in the community and inpatient settings. As noted in the IDSA 2011 guidelines for treating uncomplicated cystitis and pyelonephritis, when selecting an antibiotic, it is essential to consider patient-specific factors, the severity of the infection, and the inpatient facility’s local antibiogram. However, since the IDSA guidelines have not been updated since 2011, UpToDate has reviewed literature with updated topics and guidance called “Acute complicated urinary tract infection (including pyelonephritis) in adults and adolescents,” which may be more applicable to clinicians in today’s current environment. 
If left untreated, UTIs can lead to sepsis. The Surviving Sepsis 2021 Campaign guidelines recommend that antimicrobials should be started within one hour when there is a high suspicion of sepsis or septic shock. However, the guidelines do not specify which antimicrobials should be used; instead, clinicians should utilize clinical judgment to decide on appropriate empiric antibiotics based on patient's risk factors and suspected source of infection. This project was completed to evaluate our management of patients with UTI that present with sepsis compared to those without sepsis. 




Methods: A list of patients admitted to the DCH Regional Medical Center from January 1, 2024, to August 31, 2024, was generated from the electronic health record with positive urine cultures and either an ICD-10 code for a urinary tract infection (cystitis and pyelonephritis) or an ICD-10 code for sepsis.  Patients were excluded if they were diagnosed with septic shock or had multiple sources of infection. Each patient was randomly stratified into the UTI cohort or UTI with sepsis cohort and reviewed until 75 patients were in each group. The primary outcome was determined by the appropriateness of empiric antibiotic therapy administered within the first 3 hours of admission. Appropriateness of therapy was determined by risk factors in stated in the UpToDate and Surviving Sepsis 2021 Campaign guidelines. The secondary outcomes collected were comparing the pathogens isolated from the culture results, incidences of MDROs, overbroad empiric therapy, and rates of bug-drug mismatch between each group. 
 
Results: In the sepsis cohort, 40% were treated appropriately per the guideline recommendations, and in the non-sepsis cohort, 78% were treated appropriately. E. Coli was the most common pathogen isolated from both sepsis and non-sepsis groups, 59% and 41.3%, respectively. In the sepsis cohort, there were 8 MDRO pathogens isolated, while there were 9 MDRO pathogens isolated in the non-sepsis cohort. In the sepsis cohort, 27.3% patients were treated with overbroad therapy, and 18.7% had a bug-drug mismatch. In the non-sepsis cohort, 5.3% were treated with over-broad therapy, and 30.7% had a bug-drug mismatch.


Conclusion: There was a lower percentage of patients treated appropriately in the sepsis cohort due to risk factors that warranted exteneded coverage or receiving extended coverage without any risk factors. In addition, more patients were treated appropriately per guideline recommendations in the non-sepsis cohort versus the non-sepsis, there were higher rates of bug-drug mismatch in this cohort. There is an opportunity for educating providers on assessing risk factors for broader coverage when treating a UTI.

Title: Assessment of Biomarker Testing in Hormone Receptor-Positive and Human Epidermal Growth Factor 2 Receptor-Negative Breast Cancer Patients 
Authors: Sarah Seward, Thomas Morris, Alexia Greene 
Background: Biomarkers are molecules within the body used to guide treatment of diseases. Genetic biomarkers can help predict the response to cancer therapy. Studies have shown inadequate utilization of biomarker testing despite high prevalence of mutations and significant improvements in clinical outcomes with targeted therapy. Previous literature supports the use of biomarker testing based on improved patient outcomes and suggests the need for improvement in routine clinical testing. The aim of this study is to assess the utilization of biomarker testing in accordance with guideline recommendations for ESR1, AKT1, PIK3CA, and BRCA mutations in endocrine-resistant metastatic breast cancer patients.   
Methods: This study was a retrospective, observational, cohort study utilizing electronic medical records. Data collection included FirstHealth Cancer Center patients between January 1st, 2023, and December 31st, 2023. Patients were included by the following criteria: 18 years of age or older, female, and with HR+, HER2- metastatic breast cancer. Exclusion criteria include

Title: Effect of Standard vs. Rapid Infusion Oxaliplatin on Neuropathy and Patient Outcomes in Colorectal Cancer


Authors: Sara Niazi, PharmD; Matthew Zakhari, PharmD; Courtney Mallon, PharmD, BCOP; Stephen Aiken, PharmD, BCOP


Objective: The purpose of this study is to assess the impact of oxaliplatin infusion rate on incidence of early oxaliplatin discontinuation due to neuropathy and patient outcomes in colorectal cancer.


Self Assessment Question:
Which is a well-known side effect of oxaliplatin treatment, sometimes leading to discontinuations/dose reductions of the medication?

1. Cardiac toxicity
2. Hyperglycemia
3. Rash
4. Peripheral Neuropathy

Background: National Comprehensive Cancer Network guidelines state oxaliplatin may be administered at 1 mg/m²/min in gastrointestinal-related malignancy treatment regimens, based on results by Cercek et al. in 2016. A study in 2023 by Huynh et al. found increased incidence of peripheral neuropathy and oxaliplatin discontinuation with rapid compared with standard-rate oxaliplatin infusions. There is a lack of studies evaluating patient outcomes secondary to early discontinuation of oxaliplatin associated with rapid-infusion rates.


Methods: This was a retrospective chart review of adult patients receiving oxaliplatin at the standard-infusion vs. rapid-infusion rate at a single institution academic medical center from January 2016 - December 2024. The primary endpoint was incidence of early oxaliplatin discontinuation due to neuropathy. Secondary outcomes included incidence of oxaliplatin dose reductions due to neuropathy and time to progression after starting an oxaliplatin-containing regimen. Patients were included if they received an oxaliplatin-containing regimen for colorectal cancer. Patients were excluded if they were treated with >1 active chemotherapy regimen, in a vulnerable population, and had a clearly documented transition of care to a different facility.  


Results: The percentage of patients with colon cancer studied was higher than those with rectal cancer in both the standard infusion rate (66.9% and 33.1%, respectively) and the rapid infusion group (70.5% and 29.5%, respectively). The distribution of cancer regimens used in the rapid vs standard infusion groups was similar, with the most common being mFOLFOX6 (74.7% in the standard rate group and 91.7% in the rapid rate group). Rapid rate oxaliplatin was not associated with a statistically significant increase in incidence of oxaliplatin discontinuation due to peripheral neuropathy compared to standard-rate oxaliplatin, (23.7% versus 16.5%, p = 0.11). There was a difference between the percentage of dose reductions due to peripheral neuropathy between the rapid infusion rate and the standard-rate (18.7% versus 10.1%, p = 0.03). There was no significant difference in documented disease progression between the rapid versus standard-rate oxaliplatin (32.7% versus 34.8%, respectively, p = 0.69). 
 
Conclusion: There was a clinically but not statistically significant increase in incidence of oxaliplatin discontinuation due to peripheral neuropathy in the rapid infusion rate group compared to the standard infusion rate group. However, there was a clinically and statistically significant increase in the incidence of dose reductions due to peripheral neuropathy in the rapid compared to the standard rate oxaliplatin infusion groups. Further studies need to be done to include various races, a means to gather data that may not have been documented or available in the electronic medical record, and on a larger scale.

Title: Evaluation of Enoxaparin Dosing for Venous Thromboembolism Prophylaxis in Low Body Weight Non-Critically Ill Patients


Authors: Andrew Stewart, Alisha B. Terry, Eric Shaw


Background: Enoxaparin is an anticoagulant used for venous thromboembolism (VTE) prophylaxis and treatment. Standard dosing for VTE prophylaxis in adult medical patients is 40 mg daily. There is currently guidance for the dosing of enoxaparin for obese patients with a BMI ≥40 kg/m² but there is minimal guidance for patients with low body weight who are not in the intensive care unit. This study aims to assess the safety and efficacy of reduced dosing strategies for low body weight patients under 50 kg. A retrospective study by Yam et al. found that enoxaparin 30 mg daily achieved target anti-Xa levels in about 74% of low-weight patients without significantly increasing bleeding risk. Other studies, including those by Nemeth et al., Barba et al., and Dybdahl et al., reported no significant difference in bleeding risk between standard and reduced dosing. However, Buckheit et al. and Cappetto et al. found reduced doses were associated with fewer bleeding events. This study compared dosing strategies, evaluated anti-Xa levels, and assessed bleeding and thrombotic events to determine the optimal approach for low body weight, non-critically ill patients.


Methods: This was a retrospective cohort study that was conducted from January 1, 2020, to August 30, 2024, at a 711-bed hospital. It included adult patients, weighing ≤50 kg, who received enoxaparin for VTE prophylaxis for at least 3 days, and had anti-Xa levels measured 3-5 hours after at least the third consecutive dose. Exclusion criteria included patients presenting with a bleed or thrombi, those on anticoagulation on admission, creatinine clearance <30 mL/min, admitted to the ICU, on an orthopedic or trauma service, received an alternative dose of enoxaparin for ≥2 days unless indicated by anti-Xa, did not receive VTE prophylaxis for 48 hours after admission, and pregnant or incarcerated patients. The study compared enoxaparin 20 mg daily vs. 30 mg daily for VTE prophylaxis. The primary outcome was the percentage of patients achieving target anti-Xa levels (0.2-0.4 IU/mL). Secondary outcomes included bleeding (gastrointestinal, genitourinary, hemoptysis, epistaxis, and surgical sites bleeds) and thrombotic events (VTE, pulmonary embolism). 


Results: Of the 1368 patients that were screened, 54 patients were included in the final analysis. Forty-four patients received enoxaparin 30 mg daily and 10 patients received enoxaparin 20 mg daily for VTE prophylaxis. For the primary outcome, the mean anti-Xa level was 0.30 (±0.13) for the 30 mg group and 0.17 (±0.09) for the 20 mg group. The number of patients whose anti-Xa level was in goal for the 30 mg group was 33 (75%) and the number for the 20 mg group was 3 (30%). For the secondary outcomes neither group had a clotting event but the 30 mg group had 2 bleeding events.


Conclusion: This study found that 20 mg of enoxaparin daily for VTE prophylaxis does not on average provide therapeutic anti-Xa levels for non-critically ill adult patients that weigh less than 50 kg. Enoxaparin 30 mg daily for VTE prophylaxis does on average provide therapeutic anti-Xa levels for the specified patient population. Enoxaparin 30 mg daily had more bleeding events compared to 20 mg daily. Therefore, based on this study, non-critically ill adult patients that weigh less than 50 kg should be started on enoxaparin 30 mg daily for VTE prophylaxis because this will result in more therapeutic anti-Xa levels.

Title: Evaluation of Direct Oral Anticoagulant Utilization for Venous Thromboembolism Treatment in Obese Spinal Cord Injury Rehabilitation Patients


Authors: Bryce Lackey, Virginia Montgomery, Dina Nakhleh, Raeda Anderson, Chloe Sellers, Carly B. Warner 


Background: Venous thromboembolism (VTE) is a continuous risk for hospitalized patients. Trauma, hypercoagulability, and sedentary lifestyle can increase risk of VTE due to venostasis and clotting factor proliferation. Each of these factors occurs following a spinal cord injury (SCI). Direct oral anticoagulants (DOAC) represent the mainstay of guideline recommended treatment for VTE.  Literature on DOAC use in obesity is evolving, but guidance is limited for DOAC use in patients with both SCI and obesity. This study aims to evaluate DOAC use for VTE treatment in patients with SCI and obesity.  


Methods: A retrospective, single center, cohort study was performed of obese SCI rehabilitation inpatients treated for VTE with a DOAC between July 1, 2019, and July 31, 2024.  The primary objective evaluated the effectiveness of DOAC therapy at preventing recurrent VTE.  Secondary objectives determined the frequency of anticoagulation interruptions, compared rates of VTE recurrence between American Spinal Injury Association (ASIA) scores (ASIA A, B, C, D, and E), and described bleeding events requiring blood transfusions.  For patients meeting inclusion criteria, data collected included: baseline characteristics, select past medical history, body mass index (BMI), weight, level of SCI, ASIA impairment scale, DOAC regimen, and type of VTE.  Patients were evaluated for whether the initial VTE happened prior to admission or at Shepherd Center, and the subsequent initiation of the DOAC regimen.  Those less than 18 years of age, with an indication for anticoagulation other than VTE, or a history of bariatric surgery were excluded.  Data was analyzed using descriptive statistics. Normally distributed data was analyzed via crosstabulations, chi-squared, and gamma tests.  This study was approved by the Institutional Review Board.


Results: The population included 72 patients with an average weight of 110.5kg and BMI of 34.7kg/m2. Average age was 43 years with 83% male and 60% quadriplegic. Patients were treated with apixaban (n=66, 92%) and rivaroxaban (n=6, 8%). Recurrent VTE occurred in eight patients (11%), including three recurrent VTEs while actively on a DOAC regimen.  A DOAC interruption occurred in 25 patients (35%) including five who experienced a recurrent VTE.  A majority of patients (n=39, 54%) had their initial VTE prior to admission and most (n=27) were admitted on a DOAC.  The remaining 33 patients (46%) had their initial VTE while admitted with ten of those patients started on a DOAC within 24 hours of their VTE.  There was no significant association between ASIA scores and the likelihood of having a recurrent VTE (p = 0.194).  There were six patients who required a blood transfusion, and four of those six patients had an accompanying blood hemoglobin level < 7mg/dL.  


Conclusions: This study explores important efficacy and safety outcomes regarding DOAC utilization in obese spinal cord injury patients. The rates of recurrent VTE, interruptions in DOAC therapy, and major bleeding suggest room for optimization in DOAC utilization.  Further research, including multi-center and randomized controlled trials, is needed to validate the findings of this study.  

SAFETY AND EFFICACY OF IV FOSAPREPITANT VERSUS IV APREPITANT Ha Nguyen Trinh, Sajia Kotwal, Karishma Patel Emory Decatur Hospital, Decatur, GA 
Background/Purpose: Chemotherapy-induced nausea and vomiting (CINV) remains a common and distressing side effect that can have a negative impact on the quality of cancer patients’ lives. Neurokinin-1 receptor antagonists (NK1RAs) effectively prevent CINV for moderate to high emetogenic chemotherapy regimens. The two most common NK1RAs are aprepitant and fosaprepitant. While IV fosaprepitant has been shown to be non-inferior to aprepitant, it is associated with a higher incidence of infusion-related adverse reactions (IRARs), compared to IV aprepitant. This occurs because IV fosaprepitant contains polysorbate 80, a surfactant known to increase the risk of hypersensitivity and IRARs. Both agents have been used for CINV prevention; however, IV fosaprepitant has recently become the preferred formulary NK1RA at our institution. This research project aimed to compare the safety and efficacy of IV fosaprepitant and IV aprepitant in patients who received chemotherapy inpatient and at the outpatient infusion center at Emory Decatur Hospital (EDH).  

Methods: This study was a single-center, retrospective analysis of 86 patients aged 18 years or older who received either IV fosaprepitant or IV aprepitant as part of the antiemetic regimen for CINV at EDH between October 2022 and August 2024. Patients who were intolerant to either agent, received either agent for indications other than CINV or received oral aprepitant were excluded. The primary outcome was the incidence of IRARs, characterized by injection site pain, swelling, erythema, phlebitis, thrombophlebitis, and hypersensitivity (e.g., hypotension or hypertension, dyspnea, bronchospasm, edema, blisters, rash, flushing, chills or fever). Secondary outcomes included CINV complete response (CR) rates in the acute phase (defined as the absence of vomiting and use of rescue medications within 24 hours), number of vomiting episodes, use of rescue medications for breakthrough emesis, incidence of discontinuation and the incidence of switching from one NK1RA to another NK1RA. Descriptive statistics were used to summarize baseline characteristics, primary and secondary outcomes. Continuous variables were reported as means +/- standard deviation or median with interquartile ranges, while categorical variables were expressed as frequencies and percentages. Primary and secondary outcomes were compared using odds ratio (OR), 95% confidence interval (CI), and p-value of 0.05. 

Results:  For the primary outcome, there were no incidences of infusion reactions in the IV aprepitant group but there were 5 (11.4%) incidences of infusion reactions in the IV fosaprepitant group (p = 0.025, OR = 11, 95% CI [0.6 - 205]). There was no significant difference in CINV CR rates between the two groups (p = 0.64, OR = 1.8, 95% CI [0.1 - 2.4]). No patients reported experiencing vomiting episodes. Both groups had low and similar incidences of the use of rescue medications or breakthrough nausea (p = 0.62, OR = 0.71, 95% CI [0.2 - 3.4]). There were 5 incidences of discontinuation or switching from fosaprepitant to aprepitant (p = 0.025, OR = 11, 95% CI [0.6 - 205]). 

Conclusions: Both IV fosaprepitant and IV aprepitant were effective in CINV prevention. However, IV fosaprepitant was associated with a higher incidence of infusion-related adverse reactions.

Title: Evaluation of Antibiotic Allergies in Patients Who Underwent a Desensitization to Determine if a Desensitization Would Still Be Clinically Indicated Today


Authors: Sydney C. Hunt, Joanna L. Stollings, Elizabeth J. Phillips, and Cosby A. Stone, Jr


Background: The creation of antibiotic allergy risk stratification tools has called into question whether many of the previously performed antibiotic desensitizations would still be clinically indicated today. The purpose of this study was to evaluate how many of the desensitizations performed due to penicillin, cephalosporin, and trimethoprim-sulfamethoxazole allergies could have been avoided if current risk stratification tools were utilized. 


Methods: A retrospective review was conducted to risk stratify the allergy labels of patients who underwent a penicillin, cephalosporin, or trimethoprim-sulfamethoxazole desensitization between January 1, 2016 to December 31, 2023 at a quaternary referral center. The primary outcome was the incidence of low-risk allergy labels based on validated risk stratification criteria. Secondary outcomes included desensitization success rate and possible cost avoidance had an oral challenge been performed instead of a desensitization for allergies meeting low-risk criteria. 


Results: A total of 25 desensitizations were included: 13 (52%) for a penicillin, 6 (24%) for a cephalosporin, and 6 (24%) for trimethoprim-sulfamethoxazole. The most common desensitization antibiotics were penicillin G (n = 7, 28%) and trimethoprim-sulfamethoxazole (n = 6, 24%), and the most common desensitization indication was bacteremia (n = 7, 28%). Overall, 7 (28%) allergies were categorized as being low-risk. Out of the 25 desensitizations, 23 (92%) were successfully completed. An estimated $73,711.68 in healthcare spending could have been avoided had an oral challenge been performed instead of a desensitization in the patients identified to have low-risk allergies.


Conclusions: Nearly on-third of the antibiotic desensitizations could have been avoided had current allergy risk stratification tools been utilized, leading to decreased healthcare costs and possible allergy de-labeling.

TITLE: Comparison of Analgesia Following Coronary Artery Bypass Grafting with the Use of Scheduled Acetaminophen
 
AUTHORS: Morgan Carhart, Brock Dorsett, Emily Johnson, Kayla Pangburn
BACKGROUND: Enhanced Recovery After Surgery (ERAS) protocols are comprehensive, patient-centered, and evidence-based protocols that improve post-operative patient outcomes. Pain management is a major focus of ERAS protocols, which advocate for a multimodal, opioid-sparing approach to reduce hospital length of stay (LOS), complications, and opioid use following surgery. Intravenous (IV) acetaminophen (Ofirmev) is often used as a part of ERAS protocols and its use in the post-operative setting has been established for many different procedures. However, there are relatively few studies examining its use post-cardiac surgery and its benefits in terms of reducing post-operative opioid consumption are unclear. In January 2024, Cape Fear Valley Medical Center implemented an ERAS protocol for patients undergoing coronary artery bypass grafting (CABG) that includes one dose of IV acetaminophen followed by scheduled oral acetaminophen and as-needed hydromorphone via patient-controlled analgesia (PCA) pump. The purpose of this study was to evaluate the effects of initiating scheduled acetaminophen following CABG on the utilization of opioids during the first 48-hour post-operative period.
METHODS: This was a retrospective, single-center cohort study that included patients receiving CABG at Cape Fear Valley Medical Center from January 2023 to December 2024. The pre-ERAS group included patients receiving CABG from January to December 2023, and the post-ERAS group included patients receiving CABG from January to December 2024 that received the scheduled acetaminophen protocol. The primary endpoint was the difference in mean oral morphine milligram equivalents (oMMEs) used by patients receiving CABG before and after the implementation of the ERAS protocol at Cape Fear Valley Medical Center.
RESULTS: 301 patients met inclusion criteria with 143 in the pre-ERAS group and 157 in the post-ERAS group. Patients in the pre-ERAS group used a mean of 179.25 oMMEs compared to 193 oMMEs in the post-ERAS group (difference 13.75, 95% CI -42.22 to 14.72, p=0.34). There were no significant differences in secondary endpoints including as-needed opioid use, length of stay, or naloxone use between groups, but patients in the pre-ERAS group used more non-opioid pain medications than patients in the post-ERAS group (40 vs. 26, p=0.017).
CONCLUSION: The use of scheduled acetaminophen post-CABG did not significantly reduce the amount of total oMMEs for patients undergoing CABG within the 48-hour post-operative period. Limitations to the study that should be considered include the retrospective nature of this study, utilization of acetaminophen post-CABG in the pre-ERAS group, and a higher number of opioid-tolerant patients on admission in the post-ERAS group.

Title: Effect of Bupivacaine Liposome Injectable Suspension Administration in Abdominal Surgery


Authors: Allison Daneault, John Shadowen, Will Johnson, Elizabeth Oglesby


Objective: Define the efficacy outcomes used for bupivacaine liposome injectable suspension in the studied abdominal surgical population.


Self Assessment Question: Based on the findings of this study, which outcome was reduced in the bupivacaine liposome injectable suspension treatment group?
A. Patient reported pain scores
B. Hospital length of stay
C. Opioid usage


Background: Uncontrolled post-operative pain can lead to an increased need for analgesics and contribute to increased length of hospital stay. Bupivacaine liposome injectable suspension is an extended-release local anesthetic approved to reduce post-surgical pain for up to 72 hours. This study compared outcomes in patients that received bupivacaine liposome injectable suspension versus patients that received another local anesthetic prior to an abdominal procedure. The goal of this study was to determine if there is additional benefit associated with injectable bupivacaine liposome in decreasing opioid use as compared to other local anesthetics. 


Methods: A retrospective chart review was conducted comparing surgical patients who received bupivacaine liposome injectable suspension compared to those receiving an alternative local anesthetic. Abdominal surgical patients from April to October 2023 that received injectable bupivacaine liposome prior to the procedure were analyzed to be included in the study. Data from the comparator group were collected from April to August 2016 prior to the utilization of injectable bupivacaine liposome at Mobile Infirmary Medical Center. The primary outcome of this study was to compare the difference in mean morphine milligram equivalents (MME) administered within the first 72 hours after surgery between the two treatment groups. Secondary outcomes included length of hospital stay (LOS), pain scores (12, 24, 48, and 72 hours post-operation) on a numeric 0-10 scale, time to first post-operation bowel movement, discharge opioid prescriptions, and all cause 30-day readmission. Exclusion criteria included non-abdominal procedures, patients with less than a 24-hour hospital stay, outpatient surgeries, and patients that remained intubated for the first 72 hours post-operation.


Results: Each group contained 75 patients amounting to a total of 150 patients in the study sample.  65% of the abdominal surgeries in the injectable bupivacaine liposome group were colectomies compared to 77% of procedures using an alternative anesthetic. 93% of the injectable bupivacaine liposome group underwent robotic surgeries versus 58% of the control group. There was no significant difference in the primary outcome of mean number of MME between the two groups (injectable bupivacaine liposome 69.91 ± 55.26 vs control 74.47 ± 59.01, p = 0.618). There was, however, a significant difference found between the average LOS in the injectable bupivacaine liposome group compared to control (111.23 hours ± 67.01 versus 212.52 hours ± 171.21, p < 0.0001), which equates to approximately double the LOS for the patients prior to injectable bupivacaine liposome use at Mobile Infirmary. Subgroup analysis of LOS of robotic and laparoscopic procedures also showed a significantly shorter LOS for patients receiving injectable bupivacaine liposome (105.76 hours ± 57 (n = 70) versus 180.77 hours ± 164.44 (n = 42), p = 0.0007).    


Conclusion: Bupivacaine liposome injectable suspension did not exhibit a significant difference in MME utilization in the patients reviewed in this study. However, there was a statistically significant shorter length of hospital stay. A limitation of this study was that the comparator sample was from before injectable bupivacaine liposome was used at Mobile Infirmary, leading to an 8-year gap between the patient groups. In this timeframe, surgical techniques have advanced, and the hospital has instituted enhanced recovery protocols that this study was not able to account for. Further research is needed to account for these variables.

Tittle: Description of a 24-hour Therapeutic Target in Hospitalized Patients with Acute Coronary Syndrome or Atrial Fibrillation Before and After Implementation of a Maximum Initial Weight-Based Unfractionated Heparin Dosing Limit
 
Authors: Ivonne Marie Santiago Lopez, Kristen Keen, Justin Hodges, Ruthanne Baird, Catherine L. Wente, Dustin Wilson & Richard Drew
Cape Fear Valley Betsy Johnson Hospital – Dunn, NC
 
Objective: To describe the rate of 24-hour therapeutic target attainment in hospitalized adult patients ³ 85 kg with ACS or AF receiving UFH before and after implementation of a maximum initial dose protocol.


Self-Assessment Question: What is one reason that dose capping was implemented in this study?

Background: Unfractionated heparin (UFH) is commonly used for anticoagulation in critically ill patients but presents challenges in dosing for those weighing over 100 kg due to altered pharmacokinetics. Conservative dosing practices, such as capping doses, can delay therapeutic target attainment, potentially increasing the risk of adverse outcomes like venous thromboembolism (VTE) and coronary events. This study evaluates the impact of a weight-based, capped UFH dosing protocol on 24-hour therapeutic target attainment and bleeding complications in patients with acute coronary syndrome (ACS) and/or atrial fibrillation (AF)
Methods: This retrospective cohort study reviews medical records from patients admitted to Cape Fear Valley Betsy Johnson and Central Harnett Hospitals between September 2023 and December 2024. Eligible patients (≥ 85 kg with ACS/AF as dose cap begins at this weight) who received UFH were analyzed for the rate of achieving therapeutic levels within 24 hours before and after the implementation of a weight-based capped dosing protocol in May 2024. Secondary outcomes include the incidence of bleeding complications, number of coagulation tests required to achieve therapeutic targets (anti-Xa 0.3 – 0.7 units/mL or aPTT 53 – 73 seconds, and the use of heparin reversal agents. Data were collected via electronic health records (EHR) and analyzed using an intention-to-treat approach with JMP version 17.


Results: The primary outcome of achieving therapeutic anticoagulation at 24 hours was observed in 78% of patients in the control group, compared to 64% in the intervention group (OR 1.09; 95% CI 0.4,2.96). Regarding secondary outcomes, bleeding complications were reported in 7% of the first group and 12% in the second group, with all cases being minor. Protamine was not administered in any of the patients during their hospital stay. The number of coagulation laboratory draws required to achieve therapeutic targets was lower in the control group, with 60% patients needing only one draw compared to 46% in the intervention group.

Conclusions: There was no statistically significant difference between the groups in achieving therapeutic targets at 24 hours. While no major bleeding events occurred in either group, the intervention group had a higher incidence of minor bleeding. Additionally, neither group required protamine for reversal. These findings suggest that, overall, both treatments were safe, but further research with a larger sample size is needed to better understand the true impact of the intervention.

Title: Evaluation of Low Molecular Weight Heparin Dosing in Obese and Non-Obese Patients Using Anti-Factor Xa Levels


Authors: Samantha Bailey, Paige Nickelsen, Hana Davis, Laura Beth Parsons


Background: Enoxaparin is a low molecular weight heparin widely used in the inpatient setting for the treatment and prevention of venous thromboembolism (VTE). Hospitalized patients with a BMI ≥ 40 kg/m2 are at an increased risk of developing VTE due to increased abdominal pressure, inactivity, chronic low-grade inflammatory state, and impaired fibrinolysis. However, enoxaparin’s pharmacokinetics in obese patients are unpredictable and may be altered by rate of absorption, volume of distribution, and renal clearance. Due to its variable kinetics, there is no clear consensus on dosing enoxaparin in obese patients. It is necessary to establish more distinct dosing recommendations to ensure that patients are adequately anticoagulated without increasing the risk of adverse events, such as bleeding and thrombosis. In order to further assess adequate anticoagulation with enoxaparin in extremes of weight, investigators of this study aimed to compare peak anti-factor Xa levels and enoxaparin dosing regimens between patients with varying weights.


Methods: This is a retrospective cohort study conducted at a tertiary medical center. Patients were identified via a generated report of low molecular weight heparin anti-factor Xa orders from August 1, 2019 through August 1, 2024. Exclusion criteria consisted of patients with no active order for enoxaparin at time of anti-factor Xa level drawn, anti-factor Xa level not drawn at steady state, less than 18 years of age, pregnant, and incarcerated patients. The primary endpoint was incidence of therapeutic anti-factor Xa levels in patients receiving enoxaparin at prophylactic or treatment doses based on BMI. Secondary endpoints included incidence of therapeutic anti-factor Xa levels in patients receiving enoxaparin at prophylactic or treatment doses based on weight, incidence of thrombotic events, and incidence of bleeding events. Additional secondary endpoints were assessed by a subgroup analysis of patients with only therapeutic anti-factor Xa levels: dose evaluation in mg/kg for VTE prophylaxis or treatment based on BMI group and dose evaluation in mg/kg for VTE prophylaxis or treatment based on weight group.


Results: A total of 64 patients were included in this study: n=14 in the prophylaxis group and n=50 in the treatment group. In the prophylaxis group, the mean weight and BMI were 148.1 (±52.1) kg and 51 (±17) kg/m2, respectively. The mean prophylactic enoxaparin dose was 0.45 (±0.14) mg/kg, with 7 (50%) patients having a therapeutic anti-factor Xa level. In the treatment group, the mean weight and BMI were 113.1 (±37.6) kg and 38 (±13) kg/m2, respectively. The mean treatment enoxaparin dose was 0.95 (±0.11) mg/kg, with 18 (36%) patients having a therapeutic anti-factor Xa level. Among the non-therapeutic levels, the majority were supratherapeutic in both the prophylaxis (36%) and treatment (52%) groups. There were no major differences between anti-factor Xa levels when comparing weight versus BMI. Adverse events only occurred within the treatment group: bleeding in 6 (12%) patients.


Conclusion: Standard enoxaparin dosing may not be appropriate in patients with extremes of weight. While anti-factor Xa levels varied between different weight and BMI groups, our results suggest that we may be overdosing obese patients. Anti-factor Xa levels may be beneficial in guiding enoxaparin dosing in obese patients. 


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.

Title: Comparison of Dostarlimab to Pembrolizumab in Combination with Chemotherapy in Patients with Advanced or Recurrent Endometrial Cancer

Authors: Aaliyah Parchment, Stephen Tomasek, Sarah Gifford, Nhi Tran, Joann Gold

Background/Purpose: Carboplatin and paclitaxel, combined with either dostarlimab or pembrolizumab, are National Comphrehensive Cancer Network approved standard-of-care regimens for the first line treatment of stage III or IV or recurrent endometrial cancer. However, despite the widespread use of dostarlimab and pembrolizumab, no clinical studies have been conducted to directly compare these two agents head-to-head when combined with cytotoxic chemotherapy. The objective of this study is to compare the efficacy and safety of dostarlimab and pembrolizumab when used in conjunction with carboplatin and paclitaxel for the first-line treatment of patients with stage III or IV endometrial cancer and those experiencing their first recurrence of the disease.

Methodology: This study is a retrospective chart review conducted at AdventHealth to compare the impact of dostarlimab and pembrolizumab with concurrent chemotherapy. The study has received approval from the Institutional Review Board. Those included in the study are patients with advanced or recurrent endometrial cancer who have received dostarlimab or pembrolizumab in combination with carboplatin and paclitaxel within AdventHealth from August 1, 2022, to January 31, 2024. Patients included are women 18 years of age and older with historical confirmed diagnosis of primary stage III or IV endometrial cancer, or first recurrence of disease. Patients with more than one recurrence of endometrial cancer will be excluded. Data collection from the electronic medical record will include patient demographics (age, race), tumor characteristics (histology type, stage at diagnosis, microsatellite instability status/mismatch repair status), and any prior therapies.  

The primary outcome is rate of progression free survival (PFS), defined as the proportion of patients who remained alive and without disease
 progression. The secondary outcome is overall survival (OS), measured as the duration from the initiation of treatment to death from any cause. Safety outcomes will be evaluated by common side effects associated with immunotherapy. The primary, secondary, and safety outcomes will be analyzed by basic statistical analyses. 

Results: Baseline characteristics, including age, treatment history, and molecular profiles, were similar between groups. Median progression-free survival (PFS) was 144 days (95% CI, 106.58–181.42) in the dostarlimab group and 173 days (95% CI, 0.00–379.44) in the pembrolizumab group; this difference was not statistically significant (P = 0.656). No deaths occurred in the pembrolizumab group, limiting overall survival (OS) comparison. Adverse events occurred in all patients. Treatment interruptions were more frequent with pembrolizumab (20% vs. 5%, P = 0.034). Constipation (P = 0.027) and myalgia (P = 0.023) were significantly more common in the pembrolizumab group, while grade ≥3 anemia was more frequent in the dostarlimab group (P = 0.006).

Conclusion: Dostarlimab and pembrolizumab demonstrated similar PFS outcomes, with no significant differences observed. The absence of deaths in the pembrolizumab group limited OS comparisons. Pembrolizumab was linked to more frequent treatment delays and gastrointestinal and musculoskeletal adverse events, while dostarlimab was associated with a higher rate of severe anemia. Overall, both regimens had comparable safety profiles. Further investigation in larger cohorts is warranted to confirm these findings.

Presentation Objective: Identify clinical data comparing dostarlimab to pembrolizumab with chemotherapy in advanced endometrial cancer

Self-Assessment Question: 
Which of the following correctly describes the intervention arm of the RUBY trial for first-line therapy in advanced or recurrent endometrial cancer?
A. Pembrolizumab 200 mg + chemotherapy for 6 cycles q3w, followed by pembrolizumab 400 mg q6w
B. Dostarlimab 500 mg + chemotherapy for 6 cycles q3w, followed by dostarlimab 1000 mg q6w up to 3 years
C. Chemotherapy alone for 6 cycles
D. Dostarlimab 1000 mg q3w + chemotherapy, followed by pembrolizumab 400 mg

EFFECTIVENESS OF PARTIAL VS. FULL-LEAD-IN APIXABAN IN ACUTE VTE AFTER INITIAL PARENTERAL THERAPY


Background: Apixaban, a direct oral anticoagulant (DOAC), is commonly used to treat venous thromboembolism (VTE). The AMPLIFY trial established a seven-day apixaban lead-in regimen following parenteral therapy for acute VTE treatment, but clinical practice often results in extended parenteral anticoagulation preceding apixaban exposure, creating uncertainty regarding optimal apixaban lead-in strategies. A partial lead-in regimen, where apixaban completes the full seven-day regimen including days of parenteral therapy, contrasts with the full lead-in regimen of seven days of apixaban regardless of prior parenteral treatment duration. The impact of these diverse strategies on bleeding and VTE recurrence risk is not well understood. This study aimed to evaluate whether a full apixaban lead-in regimen increases bleeding risk compared to a partial apixaban lead-in regimen in patients with VTE.


Methodology: This was a single-center, retrospective chart review of patients who were started on high dose apixaban 10 mg twice daily after more than 36 hours of parenteral anticoagulation for VTE treatment between August 2015 and September 2024. Patients were included in the full lead-in group if they were ordered 7 days of high dose apixaban after parenteral anticoagulation and patients were included in the partial lead-in group if they were ordered enough high dose apixaban doses to completed 7 full days of anticoagulation, started by the parenteral anticoagulants. The primary outcome was the incidence of major bleeding as defined by the ISTH guidelines. Secondary outcomes included non-major bleeding, readmission for bleeding, and medical contact for VTE recurrence or bleeding within 90 days. 


Results: 418 patients were screened and 61 were included in the study. A total of 58 patients were assigned to the full lead-in group and 8 patients to the partial lead-in group. The primary outcome of incidence of major bleeding was seen in 2 (3.8%) patients in the full lead-in group and 2 (25%) patients in the partial lead-in group (P= 0.247). The secondary outcome of readmission for bleeding was seen in 2 (3.8%) patients on the full lead-in group and 1 (12.5%) patient in the partial lead-in group (P=0.349). Medical contact for VTE recurrence or bleeding within 90 days was not present in either group. 


Conclusions: This study found that real world prescribing practices favors the full lead-in apixaban therapy dosing strategy. The full lead-in group did not show a higher rate of ISTH major bleeding. However, the small sample size, especially in the partial lead-in group, limits conclusions. Larger studies and randomized controlled trials are needed to establish the real safety and efficacy of these two dosing strategies.  

Title: IMPACT OF PHARMACIST-LED TRANSITIONS OF CARE SERVICES FOR PATIENTS DISCHARGING ON ORAL CHEMOTHERAPY


Authors: Nathan Park, Courtney Mallon, Ashley Mull


Objective: To determine the effect of pharmacist-led transitions of care services for patients discharging on oral chemotherapy at the University of Tennessee Medical Center.


Background:
Oral anticancer therapies have changed the course of therapy in a growing number of malignancies that have traditionally been managed with intravenous (IV) chemotherapy. The increasing use of oral anticancer therapies benefits patient convenience and quality of life. However, several challenges now exist for patients from medication procurement, adherence, and safe handling and administration of these agents. Pharmacists are uniquely trained to improve outcomes through increased medication adherence, patient knowledge, and drug monitoring. This study aims to determine the effect of pharmacist-led transitions of care (TOC) services for patients discharging on oral chemotherapy at the University of Tennessee Medical Center.


Methods:
This prospective, single-center, quality improvement initiative included adult patients being discharged from the inpatient oncology service who filled a prescription for an oral chemotherapy at the University of Tennessee Specialty Pharmacy from January 1^st, 2024 to October 1^st, 2024. The primary endpoint was the average number of interventions made by oncology pharmacists regarding oral chemotherapy prescribed at discharge. Interventions included in the study included: drug-drug interactions, drug-disease clarification, dosing adjustments (non-renal/hepatic/toxicity), toxicity adjustment, drug acquisition, renal adjustments, hepatic adjustments, and other interventions. Secondary endpoints were the average number of interventions made within 1 week of discharge and the length of time in days between the prescription being sent to the pharmacy and the patient receiving their medication. 


Results:
A total of 23 patients were included in the study. At time of discharge, a total of 10 interventions were made with the average number of interventions per patient being 0.43. Of the 10 interventions made at discharge, five of them were involving drug acquisition. At follow-up, four interventions were made for an average number of interventions per patient of 0.17. All follow-up interventions involved patient counseling. The average length of time for patients to receive their medication was 8.83 days with a median (IQR) time of 4 (6.5) days. 


Conclusion:
Pharmacists most frequently intervened at time of discharge with most interventions being related to drug acquisition. Follow-up calls resulted in fewer interventions, but all interventions involved patient counseling. The study supports the need for further pharmacist involvement with transitions of care services.

Title: Randomized, Blinded Study of Olanzapine 2.5mg versus 5mg in Quadruplet Prophylaxis of Nausea/Vomiting after High-Dose Melphalan for Autologous Transplantation (The FONDO-LOW Trial)


Authors: Hanh Tran, E. Behren Ketchum, Vamsi Kota, Amber Clemmons


Objective: This study aims to determine the optimal dose of olanzapine when added to triplet prophylaxis in preventing CINV while minimizing the risk of daytime sedation after high-dose melphalan for patients with multiple myeloma receiving auto-HCT.


Self Assessment Question: In the FONDO-LOW study, subjects were assessed for emesis episodes, nausea severity, and sedation severity over five consecutive days. Each day, they rated their nausea and sedation severity using a 4-point scale based on their experiences in the past 24 hours. (True)


Background: Chemotherapy-induced nausea and vomiting (CINV) is a common and difficult to manage side effect. Olanzapine is an FDA-approved atypical antipsychotic that blocks multiple neuronal receptors involved in nausea/vomiting pathways. The FOND-O trial conducted at our institution by Clemmons and colleagues previously determined that adding olanzapine 10 mg to triplet prophylaxis (fosaprepitant, ondansetron, dexamethasone) improved CINV for patients undergoing high-dose chemotherapy for autologous stem cell transplantation (auto-HCT). Results from that trial led to the American Society of Clinical Oncology (ASCO) and National Comprehensive Cancer Network (NCCN) guidelines offering the olanzapine-based quadruplet regimen as an option for this population. Despite the high efficacy, several studies have shown that the 10 mg olanzapine dose may be associated with substantial daytime somnolence. Current NCCN guidelines recommend low-dose olanzapine of 5 mg or 2.5 mg if 10 mg or 5 mg, respectively, causes excessive sedation. Additionally, many transplant centers endorse utilizing lower doses to avoid the sedating effect of olanzapine. Despite the use of lower doses in practice, no publications have evaluated an optimal dose of olanzapine in reducing CINV and minimizing daytime sedation when added to standard triplet therapy for patients receiving high-dose melphalan for auto-HCT.


Methods: This is a single-center, prospective, randomized, double-blind study. Inclusion criteria are adult patients 18 years and older who receive high-dose melphalan 140-200 mg/m2 prior to auto-HCT. Patients will be randomized to receive encapsulated olanzapine 5 mg or 2.5 mg tablet orally on the day of high-dose melphalan and for three additional days post-chemotherapy in addition to standard triplet antiemetic prophylaxis consisting of an NK-1 receptor antagonist, ondansetron, and dexamethasone. Primary endpoint is percentage of patients achieving overall CINV complete response (CR), defined as no emesis and no more than mild nausea on 0-4 scale (0-none, 1-mild, 2-moderate, 3-severe), between the two olanzapine dosing groups. Secondary endpoints are complete protection (CR plus no breakthrough antiemetic use), total number of emetic episodes and breakthrough antiemetic doses, rate of study drug discontinuation, and incidence of no more than mild daytime sedation per patient report on the 4-point scale (none to severe). All outcomes will be reported in acute (chemotherapy day), delayed (four days after chemotherapy), and overall 5-day assessment periods. With an 80% power alpha of 0.05, 86 patients recruited for each arm to detect a 10% difference between groups. Hence, a total of 172 patients will be accrued for 3 years. Descriptive statistics are utilized to analyze patient demographics whereas Chi-square and t-test are used for primary and secondary outcomes.


Results: In Progress


Conclusion: In Progress

Title: Paclitaxel infusion reaction evaluation and prevention strategies at a large community hospital outpatient chemotherapy infusion center
 
Authors: Emma Pride1; Allison Bass1; Amanda Ouzts1; Melissa Strobel2; F. Joseph Kelly2
Pharmacy Department, Huntsville Hospital – Huntsville, Alabama1
Tennessee Valley Gynecologic Oncology – Huntsville, Alabama2
 
Purpose/Background: Paclitaxel, a widely used drug in the treatment of gynecologic malignancies, is associated with hypersensitivity reactions in an estimated 2-4% of patients, and infusion related reactions in around 27% of patients, despite pre-medications.  There are known risk factors for paclitaxel reactions including respiratory dysfunction, obesity (defined as a body mass index ≥ 25), no history of alcohol consumption, and postmenopausal status. Recent updates to the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) provide new insights into managing infusion-related reactions and hypersensitivity reactions in this setting, yet practical applications remain limited for management and prevention. Utilizing this information and other literature, this study aimed to evaluate the incidence of paclitaxel reactions at a large outpatient infusion center and implement a process improvement initiative focused on optimizing infusion protocols and premedication timing to enhance patient safety and support continued use of first-line therapy.
 
Methodology: This single-center, IRB-approved, pre-post implementation study evaluated female patients aged ≥18 years with gynecologic malignancies who received 3-hour paclitaxel infusions at Huntsville Hospital’s outpatient infusion center. The pre-intervention group included 224 patients who received paclitaxel from February 1, 2022, to December 31, 2024. Data collected from the electronical medical record included demographic factors, known reaction risk factors, and premedication timing. A new paclitaxel titration protocol and modified premedication timing strategy were implemented starting February 3, 2025 through April 1, 2025. Post-intervention data included patients receiving paclitaxel beginning on that date, regardless of treatment cycle. The primary endpoint was the occurrence of any documented reaction to paclitaxel. 
 
Results: A total of 224 patients were included in the pre-implementation analysis, of whom 44 (19.6%) experienced a reaction to paclitaxel. Of these, 11 (25%) were classified as hypersensitivity reactions, 28 (63.6%) as infusion-related reactions, and 5 (11.4%) could not be clearly classified. Common risk factors identified included BMI ≥ 25 (n=156), with 23% of these patients experiencing a reaction. Additionally, 84% of patients who reacted had premedications administered ≥45 minutes before paclitaxel. Following the implementation of updated premedication timing and infusion titration protocols, no reactions were documented in the initial 43 post-implementation administrations across cycle 1, cycle 2, and subsequent cycles. 
 
Conclusion: Implementation of an updated paclitaxel infusion protocol—including more prompt administration of premedications, priming lines with paclitaxel rather than normal saline, and a modified titration schedule—was associated with a reduction in infusion-related and hypersensitivity reactions. While initial post-intervention data is promising, continued monitoring is warranted to confirm the long-term impact in a larger cohort. 

Title: Evaluating Iron Sucrose Discordance Among Patients Within  
Cone Health Outpatient Infusion Centers   


Authors: Jessica Robles, Yatin Patel


Objective: Evaluate the impact of transitioning iron sucrose administration to IV push on iron sucrose discordance and infusion reactions


Self-Assessment Question: True or False: The incidence of infusion reactions with iron sucrose 200 mg is similar between administration via IV push vs IVPB infusion.


Background: Discordance is defined as an inappropriate dose or timing of administration of intravenous (IV) iron based on institutional policies. Social drivers of health, which are nonmedical factors impacting health outcomes, likely play a role in IV iron discordance. Social drivers of health can be quantified through a social vulnerability index (SVI), which is a novel composite measure encompassing variables that correspond to key social drivers of health; however, SVIs have not been studied in the evaluation of iron discordance. The dosing schedule of IV iron products also likely contributes to discordance. Older-generation IV iron products require more frequent dosing and have a higher incidence of discordance, but these products continue to have high utilization due to payor coverage and lower cost per dose. Iron sucrose, an older-generation IV iron product, is Cone Health’s preferred IV iron product, therefore it is essential to continually optimize its use by the health-system. In response to the nationwide fluid shortage, Cone Health outpatient infusion centers transitioned the administration of iron sucrose 200 mg doses from an IV piggyback (IVPB) infusion to an IV push. The purpose of this study was to evaluate the impact of this transition on iron sucrose discordance.


Methods: This was an IRB-reviewed and exempt, multi-center, pre-post study which evaluated iron sucrose discordance over three-month periods in the pre- and post-intervention groups. Adults who received their prescribed course of iron sucrose within the study period at one of the ten Cone Health outpatient infusion centers were included. Patients who did not have a Federal Information Processing Standards (FIPS) code available were excluded. The primary outcome was the incidence of iron sucrose discordance. A treatment course was deemed discordant if the patient did not receive at least one gram of iron sucrose within a 14-day period. Secondary outcomes included reason for iron sucrose discordance, incidence of iron sucrose infusion reactions, and Centers for Disease Control and Prevention and Agency for Toxic Substances and Disease Registry (CDC/ATSDR) SVI rankings. Primary and secondary outcomes were analyzed using descriptive statistics and a multiple regression model.


Results: There were 613 treatment courses included in the pre-intervention group, while 543 treatment courses were included in the post-intervention group. Among both groups, patient demographics were not statistically different, and most treatment courses were administered at a Cone Health cancer center (82.5% in the pre-intervention group vs 79.6% in the post-intervention group). After the transition of 200 mg doses to IV push, the usage of 200 mg doses increased from 71.2% to 82.7% (p < 0.001), and the incidence of discordance was statistically unchanged (88.9% vs 87.7%; p < 0.26). The incidence of discordance due to insufficient dose decreased in the post-intervention group (68.4% vs 57.3%, p=0.001); however, the incidence of discordance due to prolonged duration increased in the post-intervention group (15.4% vs 19.5%, p=0.001). The incidence of infusion reactions was not statistically different between groups (0.3% vs 0.06%, p=0.15). There was not a clear difference in SVI rankings between concordant and discordant treatment courses. 


Conclusion: The transition of 200 mg iron sucrose doses to administration via IV push did not impact the incidence of discordance or infusion reactions, suggesting utility in the continued use of 200 mg push doses even after the resolution of the fluid shortage. The transition appeared to result in more patients receiving at least one gram of iron sucrose but increased the duration of the treatment course. There was no clear relationship found between SVI rankings and iron sucrose discordance.

Title: A Review of the Incidence of Pneumocystis Pneumonia Infection with or without Pneumocystis Pneumonia Prophylaxis in Patients with Brain Tumors 


Authors: Gabrielle McCammack, Marley Watson, Danielle Rustem, Brooke Rowling, Benjamin Albrecht, Kimberly Hoang, Manali Rupji, Xiyuan Ji, Jeffrey Switchenko


Background: Temozolomide is an oral alkylating agent administered with radiation for high-grade gliomas. According to the temozolomide drug monograph, patients should receive prophylaxis against Pneumocystis pneumonia (PCP) while receiving concurrent chemotherapy and radiation treatment. However, the Infectious Diseases Society of America recommends prophylactic antibiotics in chemotherapy regimens with less than 3.5% risk of contracting PCP. There are many suspected risks factors for development of PCP, yet recent studies have shown the incidence of PCP infection in this patient population is low, less than 1%. In addition, prophylactic antibiotics for PCP are associated with side effects and additional costs for patients. The decision to prescribe PCP prophylaxis for patients at Emory Healthcare is provider specific. The purpose of this study is to determine the incidence of PCP development with or without PCP prophylaxis and evaluate possible risk factors correlating with PCP development. 

Methods: This is a retrospective chart review of adult patients with brain tumors treated with concurrent phase temozolomide with radiation therapy at Emory Healthcare. Patients with high grade gliomas on concurrent temozolomide with radiation therapy will be included and will be categorized based on use of prophylactic antibiotics for PCP. Patients will be excluded for use of prophylactic antibiotics with activity against PCP for another indication, having reduced radiation courses, starting PCP prophylaxis after one week of chemotherapy treatment, or having insufficient documentation to confirm chemotherapy cycles. The primary outcome is to determine the incidence of PCP development with or without PCP prophylaxis, with safety as a secondary outcome. Descriptive statistics using mean and standard deviations for numerical variables and frequency and percentages for categorical clinicopathological variables. 

Results: A total of 67 patients were included in the study, 20 received PCP prophylaxis, 47 did not receive PCP prophylaxis. The mean age of patients was 54 years old in the prophylaxis group, and 55 in the without prophylaxis group. Most patients were on high dose steroids (prednisone equivalents > 20mg daily) for 1 month prior to treatment; 15 (75%) in the with prophylaxis group and 38 (80.9%) in the without prophylaxis group. Three patients in the without prophylaxis group had an immunocompromising condition at baseline; with 2 (4.3%) patients on hydroxychloroquine and 1 (2.1%) patient on infliximab. For patients on PCP prophylaxis, 9 (45%) were on trimethoprim/sulfamethoxazole, 10 (50%) inhaled pentamidine, and 1 (5%) on atovaquone. No patients developed a PCP infection; therefore, an analysis was not performed.

Conclusion: No cases of PCP were found for patients on treatment or 90 days post treatment in either the with or without prophylaxis groups. No events occurred despite 79.1% and 4.5% of the patient population being on high dose steroids or immunocompromising medications, respectively. Though some patients had a reduction in ALC while on treatment, more data is needed to determine if this is a true risk factor for development of PCP infection. Larger studies are needed to further assess and define risk factors for developing PCP infection while on concurrent temozolomide and radiation treatment and ultimately create a risk stratification tool that can better identify patients requiring PCP prophylaxis to minimize additional medication use and side effects.

Title: Assessment of Infusion Reaction Rates with Day 1 administration vs Day 5 Administration of Rituximab or biosimilars in Dose-adjusted R-EPOCH
Authors: Xiaoshan Chai, Elena Cukurs, Chynna Bambico, Sarah Gifford

Background
Infusion-related reactions (IRRs) are a significant concern with rituximab, especially when combined with cytotoxic chemotherapy, such as EPOCH (etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin) for treating B-cell non-Hodgkin lymphomas. Rituximab, a monoclonal antibody targeting CD20 on B-cells, is known to elicit IRRs, including symptoms like fever, chills, and hypotension, particularly during the first infusion. Factors that increase the chance of developing IRRs include bulky disease with high tumor burden, increased cytokine release, and bone marrow involvement. The administration of rituximab for aggressive lymphomas with higher tumor burden further increases the risk of IRRs, necessitating vigilant supportive care to mitigate these reactions effectively. Management strategies involve premedication, titration of infusion rates, and monitoring. One approach to mitigate IRRs is by administering EPOCH first to debulk the tumor mass prior to introducing rituximab.  This study conducted a retrospective chart review to compare the incidences of infusion reactions in B-cell lymphomas patients who received rituximab on either day 1 (D1) or day 5 (D5) of   R-EPOCH from 2022 to 2024.

Methods
A retrospective chart review was conducted on patients over the age of 18 who had not previously received anti-CD20 monoclonal antibodies and had completed at least one cycle of R-EPOCH. Patient records were obtained from the electronic health records (EHR) systems of the oncology departments across sites at AdventHealth Central Florida Division. The primary outcome measured was the incidence of IRRs. Secondary outcomes included incidences of tumor lysis syndrome, types of IRRs, the maximum rate of rituximab infusion achieved, and the average time from the start of infusion to the onset of reactions.

Results
A total of eighty-three patients were included in the IRB-approved study, with 63 qualifying for primary analysis (11 in the D5 group and 52 in the D1 group). The primary endpoint revealed an incidence of IRR of 27.3% (3/11) in the D5 group and 30.8% (16/52) in the D1 group (P = 1). The most common type of infusion related reaction was hypotension in both groups. The median maximum infusion rate was 75 mL/hr in the D5 group and 100 mL/hr in the D1 group. The median time from infusion to the occurrence of IRRs was 110 minutes in the D5 group compared to 75 minutes in the D1 group.

Conclusion
We observed a similar rate of infusion-related reactions between groups. Further analysis will be necessary to confirm these findings and inform the optimal scheduling of rituximab administration within the R-EPOCH regimen.

Assessment Question
Based on the study's findings, which of the following statements best describes the impact of administering rituximab on Day 5 (D5) versus Day 1 (D1) in the R-EPOCH regimen regarding infusion-related reactions (IRRs)?
A. Patients in the D5 group experienced significantly fewer IRRs compared to the D1 group.
B. The incidence of IRRs was similar between the D1 and D5 groups
C. Rituximab infusion rates were lower in the D1 group compared to the D5 group, proving that early administration improves infusion tolerance
D. D1 rituximab administration resulted in less severe IRRs

Title: 
Evaluating Adherence to Eye Care Recommendations Amongst Patients Receiving Antibody Drug Conjugates for Gynecologic Malignancies


Authors: 
Ram Patel, PharmD
Kelli McCrum, PharmD
Michael Saxon, PharmD, BCPS


Objectives: 

1. Primary Objective: Assess compliance with prescribed eye drops.
2. Secondary Objectives:
   1. Identify correlations between adherence and ocular toxicity.
   2. Evaluate the effectiveness of patient education in mitigating adverse effects.

Self Assessment Questions: 
How does adherence to eye care measures correlate with the incidence of ocular toxicity? What factors influence patient adherence to prophylactic eye drop regimens?


Background: 
Antibody-drug conjugates (ADCs) such as mirvetuximab soravtansine and tisotumab vedotin have demonstrated efficacy in treating gynecologic malignancies but are associated with ocular toxicity, necessitating preventive eye care measures. This study aims to evaluate adherence to prophylactic eye drop regimens among patients receiving these therapies. The primary objective is to assess compliance with prescribed eye drops, while secondary objectives include identifying correlations between adherence and ocular toxicity and evaluating the effectiveness of patient education in mitigating adverse effects.


Methods: 
A cross-sectional, prospective study was conducted to assess adherence to prophylactic eye drops in patients receiving mirvetuximab soravtansine or tisotumab vedotin. Eligible patients completed a structured questionnaire evaluating adherence to steroid, lubricating, and vasoconstrictor eye drops (for tisotumab patients only). Inclusion criteria consisted of patients actively receiving ADC therapy, those prescribed prophylactic eye drops, and English-speaking patients. Data collection included duration of eye drop prophylaxis, frequency, dosage, and adherence, measured via a Likert scale. Patients also assessed their understanding of eye care importance and reported any ocular symptoms.


Results:
Preliminary data from four patient encounters indicate adherence to eye drop regimens at 100%, adequate understanding of their regimen at 100%, and minimal ocular toxicities. Reported toxicities include dry eyes being reported in 100% of patient encounters, blurry vision reported in 25%, and sensitivity to light reported in 25%. Our current hypothesis suggests that higher rates of adherence correlates with a lower incidence of ocular toxicity. With the limited number of patient encounters thus far demonstrating adherence and understanding of their regimens, more data is needed to draw any further conclusions or correlations. This study also examines patient-reported barriers to adherence, such as difficulty remembering doses, perceived ineffectiveness, or discomfort caused by the drops. 


Conclusion: 
This study provides valuable insights into adherence patterns, ocular toxicity risks, and the effectiveness of patient education in mitigating adverse events. Identifying key adherence barriers and their impact on toxicity rates may inform strategies to improve compliance and patient outcomes. Enhanced adherence to prophylactic eye care measures could reduce treatment-related complications, improving tolerability and quality of life for patients receiving ADC therapy. Ultimately, these findings may contribute to the development of standardized adherence protocols to optimize patient care and minimize ocular toxicity in clinical practice. 

Title: 
Incidence of nausea and vomiting with modified antiemetic regimens for patients receiving carboplatin AUC ≥ 4


Authors: Ramsey Shane, Amanda Cass


Objective: 
The purpose of this study is to determine the incidence of CINV with different antiemetic regimens and alterations in antiemetic regimens in patients receiving a modified antiemetic regimen with carboplatin AUC ≥ 4. 


Background: 
Chemotherapy-induced nausea and vomiting (CINV) is a major side effect of cancer treatment that affects patient quality of life. The National Comprehensive Cancer Network (NCCN) provides CINV recommendations for patients based on the emetic risk of the chemotherapy agents in their regimen, previous use of antiemetic agents, and patient risk factors. In the updated 2017 NCCN CINV guidelines, carboplatin emetic potential was updated from all carboplatin doses being moderately emetogenic to carboplatin AUC < 4 classified as moderately emetogenice and AUC ≥ 4 as highly emeticemetogenic. This recommendation adds neurokinin-1 receptor antagonists (NK-1 RA) to the standard regimen of a 5-HT3 receptor antagonists and dexamethasone with or without olanzapine for antiemetic prophylaxis in patients receiving carboplatin with AUC ≥ 4 mg/mL. There is debate amongst clinicians if the highly emetic classification is clinically necessary empirically citing additional adverse effects of antiemetic agents and financial burden for the healthcare system as reasons. The current practice at Vanderbilt University Medical Center (VUMC) includes a variety of antiemetic options for treatment plans including carboplatin AUC ≥4, and antiemetic regimens are decided by disease state groups based on their experience. Thus, not all regimens using carboplatin AUC ≥ 4 are treated as a highly emetic chemotherapy regimen.


Methods:
A retrospective, single-center cohort analysis was conducted including patients who received chemotherapy regimens containing carboplatin AUC ≥ 4 between January 2019 through July 2024 at the Vanderbilt Ingram Cancer Center (VICC). The treatment plans included in this study came from patients receiving treatment for either lung, gynecologic, or gastrointestinal cancers. Additionally, patients had to complete at least 2 cycles of therapy with carboplatin AUC ≥ 4. Patients were excluded if their treatment plan contained other cytotoxic chemotherapy agents except for paclitaxel. Data was collected through chart review in electronic medical record. The primary objective was to determine the incidence of CINV with different antiemetic regimens and if there was a change in the antiemetic regimen during treatment with carboplatin and up to three weeks after the carboplatin dose.  


Results: 
A total of 243 patients were screened for inclusion across the three disease states. There were 50 patients included from gynecology and lung cancers, and there were 41 patients included from the gastrointestinal cancers. Data analysis is still ongoing. 


Conclusion:
In Progress
 

Title: Reduced Corticosteroid Dosing in Pediatric Renal Transplant Patients
 
Authors: Alexander Durant, Aubrey Slaughter, Bailey Horne


Objective: To investigate the effects of maintenance corticosteroid dose reduction on blood pressure, hemoglobin A1c, and bone mineral density in pediatric renal transplant patients.
 
Background: Renal transplantation requires immediate and chronic immunosuppression to avoid acute organ rejection, which can compromise the integrity of the transplanted organ and be fatal. Consequently, a lifelong immunosuppressive regimen is required for all renal transplant recipients. One integral component of the backbone immunosuppressive regimen is corticosteroid therapy. In pediatric patients, there is a notable lack of data evaluating the deleterious effects associated with chronic corticosteroid therapy post-renal transplantation, as pediatric patients are often excluded from clinical trials and are consequently underrepresented in the literature. Wellstar MCG Health has recently transitioned from using prednisone or prednisolone doses of 0.1 mg/kg/day to 0.05 mg/kg/day, representing a 50% dose reduction in maintenance corticosteroid therapy. The purpose of this chart review is to investigate the effects of maintenance corticosteroid dose reduction on blood pressure, hemoglobin A1c, and bone mineral density in pediatric renal transplant patients.


Methods: This single-center, observational chart review included pediatric patients followed in the Wellstar MCG Health pediatric renal transplant clinic between 01/01/2022 and 12/31/2024. Exclusions included patients undergoing treatment for renal transplant rejection and patients no longer followed at the pediatric renal transplant clinic. The primary outcomes included a reduction in antihypertensive dosage or number of antihypertensive agents, an improvement in hemoglobin A1c or reduction in hyperglycemic agent dosage, and an improvement in BMD Z-score above -2.0 or a ≥20% improvement from baseline. Data analysis will utilize descriptive statistics for a non-parametric data set (e.g., median, IQR).


Results: A total of 13 patients were included in this chart review. The median patient age was 17 years. There were no notable differences between pre-reduction and post-reduction median systolic or diastolic blood pressure measurements or Z-scores. Dose reduction appeared to be associated with a decrease in median A1c of approximately 0.15 mg/dL. Corticosteroid dose reduction was also linked to a decrease in the number of prescribed osteoporosis medications in 57% of patients. The reduction had little impact on the number of prescribed anti-hypertensive and hyperglycemic agents prescribed per patient.


Conclusions: Corticosteroid dose reduction may contribute to improved glycemic control and a decrease in the number of osteoporosis medications prescribed per renal transplant patient. However, this review did not find a corresponding improvement in bone mineral density or blood pressure readings following the dose reduction.

Title: Assessing Utilization Trends of Granulocyte Colony-Stimulating Factors (G-CSF) in an Outpatient Cancer Setting   
Authors: Shayan Tavassoli, Alexia Greene, Thomas Morris 
Background: This study aims to identify gaps between current utilization and guideline recommendations by evaluating usage trends of granulocyte colony-stimulating factors at FirstHealth Outpatient Cancer Center. Previous literature showed that granulocyte colony-stimulating factors have shown both overuse and underuse when comparing to guideline recommendations.  
Methods: A retrospective observational study was conducted to evaluate the use of granulocyte colony-stimulating factors in cancer patients at FirstHealth Outpatient Cancer Center between March 1, 2022, and March 30, 2024. The study included patients with active diagnoses of breast, lung, pancreatic, or colorectal cancer who received a dose of granulocyte colony-stimulating factors. Exclusion criteria applied to patients receiving secondary prophylaxis for febrile neutropenia, weekly chemotherapy cycles, investigational agents, or those who underwent bone marrow or hematopoietic transplants within 30 days of chemotherapy. Patient characteristics included age, gender, cancer type, chemotherapy regimen, absolute neutrophil count, creatinine clearance, bilirubin levels, and provider documentation related to granulocyte colony-stimulating factors use. Patients were classified into three risk groups—high, intermediate, and low—based on the risk of febrile neutropenia according to NCCN guidelines. The primary outcome looked to find the percentage of patients who received at least one dose of granulocyte colony-stimulating factors for primary prophylaxis of febrile neutropenia during their chemotherapy regimen for the treatment of either lung, pancreatic, breast, or colorectal cancer. The secondary outcome looked to evaluate the characteristic differences between patients who received granulocyte colony-stimulating factors and those who did not during the study period. All patient data has been stored in a password-protected file with access restricted to investigators, ensuring confidentiality and data security throughout the study. 
Results: During the study’s timeframe, 4% (214/4931) patients with either lung, pancreatic, colorectal, or breast cancer received granulocyte colony-stimulating factors. Individual baseline characteristics were evaluated in total for 50 patients who received granulocyte colony-stimulating factors and 44 patients who did not receive granulocyte colony-stimulating factors. In the treatment group, 28% (14/50) vs. 6.8% (3/44) patients would be categorized as intermediate risk factor for febrile neutropenia based on guideline recommendations, and 86% (12/14) in treatment group vs. 100% (3/3) in control group of patients with intermediate risk chemotherapy regimen had risk factors to consider adding granulocyte colony-stimulating factors.
Conclusions: Overall, granulocyte colony-stimulating factor usage aligned closely with NCCN guideline recommendations in this study. Intermediate risk groups require consideration from providers when deciding if granulocyte colony-stimulating factors are necessary based on patient characteristics. Limited sample size may require further research to determine significant gaps of granulocyte colony-stimulating factors in comparison to guideline recommendations.