National survey of pharmacy residency on-call programs

PURPOSE

The results of a national survey to evaluate on-call practices and responsibilities of pharmacy residents nationwide, as well as opinions related to duty-hour changes, are reported.

METHODS

A 39-question survey was distributed to 1292 residency program directors (RPDs) listed in the American Society of Health-System Pharmacists (ASHP) online residency directory, which includes programs in all stages of the accreditation process. The survey opened on November 7, 2011, and closed on November 28, 2011. The survey collected demographic information and answers to questions about the residency's on-call component (if applicable) and barriers to the creation of an on-call component. Respondents were also asked to indicate their support of or opposition to the adoption of the 2011 Accreditation Council for Graduate Medical Education (ACGME) duty-hour rules and identify the areas of greatest concern.

RESULTS

Of the 1292 RPDs listed in the ASHP online residency directory to whom the survey was sent, 521 surveys were completed, yielding a response rate of 40%. Of these, 471 identified their residency program as including or excluding an on-call component. Of the 138 programs with on-call services, 102 programs (74%) indicated the inclusion of an overnight experience. Programs that did not utilize an on-call component indicated barriers such as a perceived lack of demand (39%) and duty-hour limitations (21%). Common on-call activities included drug information consults and therapeutic drug monitoring. There was not a clear consensus from RPDs regarding the adoption of the 2011 ACGME duty-hour standards.

CONCLUSION

Among usable responses to a survey of pharmacy residency programs, 29% indicated that their program included an on-call component. On-call programs varied greatly in activities, location, hours, and requirements.

Increased mortality among patients taking digoxin--analysis from the AFFIRM study

AIMS

Digoxin is frequently used for rate control of atrial fibrillation (AF). It has, however, been associated with increased mortality. It remains unclear whether digoxin itself is responsible for the increased mortality (toxic drug effect) or whether it is prescribed to sicker patients with inherently higher mortality due to comorbidities. The goal of our study was to determine the relationship between digoxin and mortality in patients with AF.

METHODS AND RESULTS

The association between digoxin and mortality was assessed in patients enrolled in the AF Follow-Up Investigation of Rhythm Management (AFFIRM) trial using multivariate Cox proportional hazards models. Analyses were conducted in all patients and in subsets according to the presence or absence of heart failure (HF), as defined by a history of HF and/or an ejection fraction <40%. Digoxin was associated with an increase in all-cause mortality [estimated hazard ratio (EHR) 1.41, 95% confidence interval (CI) 1.19-1.67, P < 0.001], cardiovascular mortality (EHR 1.35, 95% CI 1.06-1.71, P = 0.016), and arrhythmic mortality (EHR 1.61, 95% CI 1.12-2.30, P = 0.009). The all-cause mortality was increased with digoxin in patients without or with HF (EHR 1.37, 95% CI 1.05-1.79, P = 0.019 and EHR 1.41, 95% CI 1.09-1.84, P = 0.010, respectively). There was no significant digoxin-gender interaction for all-cause (P = 0.70) or cardiovascular (P = 0.95) mortality.

CONCLUSION

Digoxin was associated with a significant increase in all-cause mortality in patients with AF after correcting for clinical characteristics and comorbidities, regardless of gender or of the presence or absence of HF. These findings call into question the widespread use of digoxin in patients with AF.

Pharmacologic approaches to smoking cessation

Cigarette smokers experience greater rates of morbidity and mortality. Despite the known health risks, use of tobacco products remains high throughout the United States (approximately 19.3% of adults). Tobacco use is associated with higher rates of cardiovascular illness, cardiovascular risk factors (ie, hypertension and atherosclerosis), chronic obstructive pulmonary disease, emphysema, and various types of cancer. Pharmacologic smoking cessation therapies have been used to facilitate abstinence from smoking. This article provides clinicians with instructions for the use of pharmacologic agents for smoking cessation, including considerations for special populations.

Nutrition and heart failure: impact of drug therapies and management strategies

Nutrition impairment commonly occurs in patients with heart failure and affects disease progression. Vitamin and mineral deficiencies are associated with early mortality, particularly in patients classified as cachectic. Guideline-based therapies approved for heart failure, such as loop diuretics, angiotensin-converting enzyme inhibitors and angiotensin receptor blockers, aldosterone antagonists, and beta-adrenergic blockers, can lead to electrolyte abnormalities and predispose to some vitamin and micronutrient deficits. Clinical trial evidence in support of supplementary vitamin and mineral therapies for heart failure patients is limited with the exception of documented calcium and possibly vitamin D, thiamine, and coenzyme Q10 deficiencies. This area is gaining significant attention, and research is ongoing. The clinician can help minimize morbidity from nutrition impairment through appropriate monitoring and correction of baseline and medication-induced electrolyte imbalances, in addition to vitamin and mineral supplementation when appropriate.