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Evaluation of Quetiapine for the Management of Delirium in Critically Ill Paediatric Patients Between 2-6 Years of Age: A Retrospective Cohort Study
No full textPharmacy residents have the opportunity to complete a research project during their residency training, which provides them with skills on how to conduct and manage a research project. Projects often represent an area of interest and need that has been recognized by the host institution’s pharmacy department. Projects are presented as a poster at an annual CSHP Ontario Branch Residency Research Night, and many eventually go on to be published in a peer-reviewed journal.Background: Delirium in paediatric critical care patients has been shown to increase morbidity and mortality. The Cornell Assessment of Paediatric Delirium (CAPD) score defines a score of ≥9 as the threshold for diagnosing delirium. Quetiapine is an antipsychotic currently being studied as an adjunct in the management of paediatric delirium.
Objective: To evaluate the effectiveness and safety of quetiapine for the treatment of delirium in patients between 2-6 years of age, admitted to a critical care unit (CCU).
Methods: A retrospective matched cohort study was conducted evaluating patients between 2-6 years of age with a baseline CAPD score of ≥9 admitted to the Hospital for Sick Children’s (SickKids’) CCU between June 1, 2018, and November 30, 2024. The primary endpoint was delirium resolution, defined as two consecutive CAPD scores of <9. Safety was assessed based on the QTc interval and development of extrapyramidal symptoms (EPS).
Results: 434 CCU admissions (377 patients) were screened for eligibility. 25 patients were included in the quetiapine cohort and matched 1:2 to patients who did not receive quetiapine. The median duration of quetiapine was 6 days (IQR 3-14). There was no statistically significant difference in the percent of patients who achieved delirium resolution (44% vs 42%, p=0.62) and time to reach resolution (median 5 days [IQR 2-5.5] vs 3 days [IQR 2-6], p=0.69) between the quetiapine and comparison cohort, respectively. Doses for benzodiazepines, opioids, and dexmedetomidine decreased in both cohorts. Clonidine doses increased during the study period. No quetiapine-induced EPS or QTc prolongation was reported.
Conclusions: Quetiapine did not lead to faster or increased resolution of delirium in critically ill paediatric patients. Short-term use of quetiapine appears to be safe. Quetiapine use should be reassessed frequently to evaluate its effectiveness and avoid prolonged durations
A Pre and Post Analysis of Vancomycin AUC Dosing and Monitoring Implementation at a Large Community Teaching Health System
No full textPharmacy residents have the opportunity to complete a research project during their residency training, which provides them with skills on how to conduct and manage a research project. Projects often represent an area of interest and need that has been recognized by the host institution’s pharmacy department. Projects are presented as a poster at an annual CSHP Ontario Branch Residency Research Night, and many eventually go on to be published in a peer-reviewed journal.Background: The 2020 Vancomycin Consensus Guidelines recommend a shift from traditional trough-based monitoring to area-under-the-curve (AUC)-guided dosing, targeting an AUC to minimum inhibitory concentration (MIC) ratio of 400–600 mg·h/L. This change is supported by evidence demonstrating that therapeutic targets can be achieved at lower trough concentrations, often <15 mg/L, while reducing the risk of nephrotoxicity and acute kidney injury (AKI). AUC-guided dosing has also been associated with optimized efficacy, lower vancomycin exposure, and improved safety outcomes.
Objectives: To evaluate the impact of a new vancomycin AUC/MIC pharmacy-driven protocol on drug exposure, nephrotoxicity, and monitoring practices compared to the previous trough-based dosing strategy.
Methods: A retrospective pre-post cohort study was conducted at Trillium Health Partners. Adult inpatients who received vancomycin from June–August 2023 (trough-based dosing) and June–August 2024 (AUC/MIC-based dosing) were included. The primary outcome was average daily vancomycin dose. Secondary outcomes included incidence of acute kidney injury (AKI), proportion of subtherapeutic and supratherapeutic levels, and number of vancomycin levels drawn per day.
Results: A total of 248 patients were included (124 per cohort). There was no significant difference in average daily vancomycin dosing between the trough-only and AUC/MIC groups (1549.20 mg vs. 1558.69 mg; P = 0.90). AKI occurred less frequently in the AUC/MIC group (8/124) compared to the trough group (19/124; RR 0.42; 95% CI, 0.19–0.93; P = 0.031). No significant differences were observed in the proportions of therapeutic, subtherapeutic, or supratherapeutic levels between groups. However, the trough group had more frequent level monitoring (0.40 vs. 0.34 levels/day; P = 0.009).
Conclusions: Implementation of an AUC/MIC-guided vancomycin dosing protocol was associated with reduced AKI incidence and fewer level monitoring, without reducing total daily vancomycin exposure
Incidence and Management of Tebentafusp Adverse Events: Retrospective Review of the Princess Margaret Cancer Centre Experience
No full textPharmacy residents have the opportunity to complete a research project during their residency training, which provides them with skills on how to conduct and manage a research project. Projects often represent an area of interest and need that has been recognized by the host institution’s pharmacy department. Projects are presented as a poster at an annual CSHP Ontario Branch Residency Research Night, and many eventually go on to be published in a peer-reviewed journal.Background
Tebentafusp (TEBE) is a bispecific T-cell engager indicated for patients with unresectable or metastatic uveal melanoma (u/mUM) who express HLA-A*02:01. It is administered weekly in a dose-escalating fashion. Cycle 1 Day 1 (C1D1) is 20 mcg, Cycle 1 Day 8 (C1D8) is 30 mcg, then Cycle 1 Day 15 (C1D15) and all following doses are 68 mcg each. Adverse events (AEs), namely cytokine release syndrome (CRS) and skin reactions, are more frequent during the first 3-4 doses, which are administered in the inpatient setting. In this single-centre retrospective study, we describe the incidence and management of TEBE-associated AEs at Princess Margaret Cancer Centre (PM) to inform local cancer centres on the safety and feasibility of inpatient treatment.
Methods
Electronic medical records were reviewed for all u/mUM patients admitted at PM to receive TEBE between June 2022 and December 2024. The primary objective was to describe the incidence of TEBE-associated CRS and skin reactions. Secondary objectives were to describe management strategies and their efficacy. Incidence rate of AEs, proportion of patients receiving each treatment, and time to discharge were collected for the first three to four doses per patient.
Results
Forty-six patients were included; 60.9% were male. Skin reaction was the most frequent AE (93.5%). Incidence of CRS (all events < Grade 2) was as follows: C1D1, 50%; C1D8, 51.1%; C1D15, 40%; C2D1, 25.8%. CRS was managed with antipyretics, intravenous (IV) fluids, and supplemental oxygen. Four patients required IV steroids; none required interleukin-6 blockade. CRS was resolved in all patients before discharge. Median time to discharge was consistent across doses (20.9hr [IQR 6.9hr] to 21.9hr [IQR 3.6hr]).
Conclusions
During the first three to four doses, TEBE was safely administered without the need for interleukin-6 blockade or critical care resources. The results of this study suggest it is safe and feasible for local cancer centres to administer TEBE during the dose escalation phase, given adverse events were well-managed with the standard of care that should be available in such cancer centres
Investigating Pharmacist Artificial Intelligence (AI) Readiness in Hospital Settings
No full textPharmacy residents have the opportunity to complete a research project during their residency training, which provides them with skills on how to conduct and manage a research project. Projects often represent an area of interest and need that has been recognized by the host institution’s pharmacy department. Projects are presented as a poster at an annual CSHP Ontario Branch Residency Research Night, and many eventually go on to be published in a peer-reviewed journal.Background: Artificial intelligence (AI) has the potential to be a transformative tool in hospital
pharmacy practice with potential applications including but not limited to; identifying drug
interactions, generating treatment recommendations and supporting administrative practice.
Successful implementation would largely depend on pharmacists’ readiness and acceptance of
its use.
Rationale: Literature regarding AI integration into hospital pharmacy practice mostly consists of
studies conducted in the Middle East. Little research has been done to assess the readiness of
Canadian Hospital Pharmacists’ readiness to implement AI in their day-to-day practice.
Objective: This study is aimed at quantifying Canadian hospital pharmacists’ level of readiness
towards the use of AI and its integration into clinical workflows. Additionally, this study aimed
to identify possible barriers to the successful implementation of AI in hospital pharmacy
practice.
Methods: A national cross-sectional survey was distributed to hospital pharmacists across
multiple institutions in Canada. The questionnaire assessed demographics, experience with
technology, attitude and opinions, perceived benefits, perceived risks, opportunities for
learning and patient outcomes related to AI adoption. Descriptive and inferential statistical
analyses are used to interpret the results.
Results: A total of 372 pharmacists responded to the cross-sectional survey with majority of
respondents from Ontario (40.7%). Preliminary analysis indicates that most pharmacists were
receptive to AI integration. Emerging themes emphasized the need for increased resources and
education, support for using AI in non-clinical roles, and highlighted the importance of
pharmacist oversight (human in the loop) in any clinical use of AI.
Conclusion: While preliminary results suggested a general acceptance towards the
implementation of AI, there were concerns outlined regarding pharmacists understanding of
AIs limitations and the current lack of resources to support its integration in Canada. There was
a consensus that ongoing efforts to provide further education on AI are required so that
pharmacists could be better prepared for its implementation into hospital practice in the
future
Pharmacists’ Perceptions of Epic’s Impact on Pharmacy Practice
No full textPharmacy residents have the opportunity to complete a research project during their residency training, which provides them with skills on how to conduct and manage a research project. Projects often represent an area of interest and need that has been recognized by the host institution’s pharmacy department. Projects are presented as a poster at an annual CSHP Ontario Branch Residency Research Night, and many eventually go on to be published in a peer-reviewed journal.Background: Significant literature exists regarding Electronic Health Record (EHR) use among healthcare providers, like physicians; however, little discussion exists regarding EHR impacts on pharmacy practice. As many Canadian hospitals are transitioning to Epic, a better understanding of Epic’s impact on pharmacy practice is needed.
Objective: To gather insight into pharmacists’ perceptions of Epic’s impact on pharmacy practice at Unity Health Toronto (UHT), an organization comprised of three practice sites.
Methods: Qualitative data were collected through one-to-one semi-structured interviews with pharmacists across UHT five to six months after Epic go-live. Participants were interviewed until data saturation was achieved. Interview transcripts were manually coded through inductive coding. Using a thematic analysis approach, codes were collated into relevant themes and depicted as a thematic map.
Results: Eleven pharmacists across UHT were interviewed: eight from St. Michael’s Hospital, who transitioned from Soarian and Cerner systems, with two of the interviewed pharmacists using paper-based workflows; two from St. Joseph’s Health Centre, who transitioned from Sunrise and BDM systems; and one from Providence Healthcare, who transitioned from a paper-based system with Meditech. Five main themes were identified: 1. Epic provides more access to patient data. 2. Epic saves time as information is accessible on one platform, and Epic tools streamline tasks. 3. Epic adds time to pharmacists’ workdays due to difficulties with its visual organization, its enablement of practices by other healthcare providers that increase pharmacists’ workload, and its infancy within the organization. 4. Epic increases documentation leading to more comprehensive but less concise documentation, and increases difficulties with workload tracking. 5. Epic enhances communication within the healthcare team by features like Epic chat, and increasing pharmacy documentation visibility.
Conclusion: Pharmacists did not perceive Epic to have changed their clinical thought process, but it did impact their efficiency and comprehensiveness in completing their duties
Advancing a Best Possible Medication History (BPMH) Training Program for Pharmacy Technicians in an Acute Care Setting Using Simulation
No full textPharmacy residents have the opportunity to complete a research project during their residency training, which provides them with skills on how to conduct and manage a research project. Projects often represent an area of interest and need that has been recognized by the host institution’s pharmacy department. Projects are presented as a poster at an annual CSHP Ontario Branch Residency Research Night, and many eventually go on to be published in a peer-reviewed journal.Rationale
At North York General (NYG), 8 of 41 Registered Pharmacy Technicians (RPhTs) are trained in conducting BPMH and currently support surgical units and/or outpatient clinics, but there may be a need to expand their role to other areas. While simulation-based training has shown benefits for medication history-taking, its utility in RPhT training has not been examined.
Objectives
The objectives of this project were to test a simulation-based BPMH training session by the RPhTs, and use their feedback to provide suggestions for improving the simulation exercise for future BPMH training.
Methods
The simulation case was developed by adapting one of the role-play scenarios from the existing NYG BPMH training program. Eight BPMH-trained RPhTs were invited to participate in individual simulation sessions at the NYG Simulation Centre. Each participant was provided with a pre-brief, followed by a 20-minute interview with the simulated patient (SP) and a debrief session. A 30-item questionnaire was then distributed to the participants via SurveyMonkey to gather their feedback. Data were analyzed using descriptive statistics and thematic analysis.
Results
All eight participants who completed the questionnaire reported a safe, positive, and engaging experience. Six participants preferred simulation over role-play for developing patient interaction skills, while seven reported increased confidence in conducting patient interviews. Participants valued the realistic setting and real-time SP feedback. Most identified language barriers and poor patient recall as common challenges in obtaining a BPMH based on their real-life experience, which should be considered for incorporation into future cases.
Conclusion
Simulation-based training offered an engaging, positive learning experience that enhanced RPhTs’ skills and confidence. The simulation has not yet been tested with new RPhT trainees, which should be addressed going forward. Future scenario design should include more complex patients and varying difficulty levels to better reflect real-life challenges
Evaluation of the Population Pharmacokinetic Model-Derived Vancomycin Precision Dosing Approach in Neonates
Full text linkPharmacy residents have the opportunity to complete a research project during their residency training, which provides them with skills on how to conduct and manage a research project. Projects often represent an area of interest and need that has been recognized by the host institution’s pharmacy department. Projects are presented as a poster at an annual CSHP Ontario Branch Residency Research Night, and many eventually go on to be published in a peer-reviewed journal.Background: Vancomycin is a common antibiotic used in the neonatal intensive care unit (NICU), yet dosing remains a challenge due to its significant pharmacokinetic variability. In-house data indicated 70% of neonates did not achieve vancomycin trough target (10-15mg/L) with the postmenstrual age (PMA)- and weight-based formulary dosing. A neonatal population pharmacokinetic model-derived vancomycin precision dosing approach was implemented, accounting for patient’s PMA, weight and serum creatinine (SCr) (https://app.firstline.org/en/clients/41-sickkids/antimicrobials/14631- vancomycin/dosing/97-neonatal).
Objective: To achieve a proportion of target attainment (PTA) of the first steady-state (SS) vancomycin trough within 10-15mg/L of at least 65% or greater.
Methods: A quality improvement framework was used to evaluate the vancomycin precision dosing approach (post-implementation) and compared to previous formulary dosing (pre-implementation) in neonates admitted to the NICU. SS was based on trough concentrations drawn at least pre-3rd dose if dosing interval >q12h or pre-4th dose if <q8h.
Results: 81 neonates with 91 vancomycin courses (mean PMA: 36±5 weeks, 33% female) were included. The proportion of initial vancomycin trough target attainment was significantly higher after implementing the precision dosing approach at 57% (n=26/46) compared to 38% (n=17/45) pre-implementation (p=0.046). Target attainment proportion increased to 65% (n=20/31) post-implementation, compared to 42% (n=8/19) pre-implementation, when SS concentrations analyzed were based solely on sampling time. However, 45% (n=5/11) of abnormal vancomycin concentrations post- implementation were collected in patients with fluctuating kidney function (±20% change in SCr from baseline), which implied non-SS. Fewer dose adjustments (up to 1) were needed post-implementation compared to up to 5 pre-implementation. Study limitations included a small sample size, patients with non-SS concentrations due to changing renal function, or pharmacists’ proactive dosage adjustments before SS to avoid supratherapeutic concentrations pre-implementation.
Conclusion: The proportion of target attainment significantly improved after implementing vancomycin precision dosing approach in the NICU. Future directions include proactively adjusting vancomycin doses based on latest SCr and expansion of the precision dosing approach to other paediatric populations
Stability of skin-testing concentrations of penicillin G 10,000 units/mL in glass vials under refrigeration and at room temperature for 15 days
No full textPharmacy residents have the opportunity to complete a research project during their residency training, which provides them with skills on how to conduct and manage a research project. Projects often represent an area of interest and need that has been recognized by the host institution’s pharmacy department. Projects are presented as a poster at an annual CSHP Ontario Branch Residency Research Night, and many eventually go on to be published in a peer-reviewed journal.Background: Penicillin allergy is one of the most commonly reported drug allergies. Although 10% of patients have a penicillin allergy on their medical record, only 1% have a true allergy. Labelling patients with a penicillin allergy can cause lifelong avoidance of penicillins, complete avoidance of the beta-lactam antibiotic class, and prescribing of second line antibiotic therapies which are often less effective, more toxic, and more expensive.
Skin testing with penicillin G is a key tool in allergy testing. There are no validated stability data for dilute penicillin G at skin testing concentrations. The current practice is to prepare a bulk vial of penicillin G 10,000 units/mL daily and assign a 24 hour beyond-use-date (BUD) when stored under refrigerated conditions. Extension of the BUD could facilitate more sustainable and cost-effective practices, with conservation of active drug, materials and workload.
Objective: To evaluate the chemical stability of penicillin G 10,000 units/mL diluted in 0.9% sodium chloride stored in glass vials at room temperature (25°C) and refrigerated (4°C) for 15 days.
Methods: On study day 0, six penicillin G vials were reconstituted then diluted with 0.9% sodium chloride to 10,000 units/mL and stored in glass vials. Three vials of each were stored under refrigeration and at room temperature. Concentrations were determined on study days 0, 1, 2, 3, 7, 9, 11, 15 using a validated, stability-indicating liquid chromatographic method with UV detection. The chemical stability was determined by calculating the intersection of the lower limit of the 95% confidence interval of the observed degradation rate and the time to achieve 90% of the initial concentration.
Results: The analytical method separated penicillin G from its degradation products such that the concentration of penicillin G was measured specifically, accurately (deviations from known averaged 0.79%), and reproducibly (within-day variation, measured by the coefficient of variation [CV] averaged 0.30% and the between-day CV averaged 1.06%).
Penicillin G stored at 4°C retained 42.45% of its initial concentration at 15 days and when stored at room temperature, it degraded to 43.71% of its initial concentration within 1 day. The calculated time to achieve 90% of the initial concentration with 95% confidence was 2.46 days when stored in the refrigerator and less than 1 day when stored at room temperature.
Conclusions: Penicillin G 10,000 units/mL in 0.9% sodium chloride stored in glass vials is stable for 2 days under refrigeration and for less than 1 day at room temperature. This finding suggests that the same diluted vial can be used for up to 2 days when stored appropriately, thus saving time, money and resources
Factors Affecting the Utilization of Guideline-Directed Medical Therapy for Heart Failure
No full textPharmacy residents have the opportunity to complete a research project during their residency training, which provides them with skills on how to conduct and manage a research project. Projects often represent an area of interest and need that has been recognized by the host institution’s pharmacy department. Projects are presented as a poster at an annual CSHP Ontario Branch Residency Research Night, and many eventually go on to be published in a peer-reviewed journal.Background: Guideline-directed medical therapy (GDMT) is recommended to reduce hospitalizations and mortality among patients with heart failure. Despite strong evidence supporting its efficacy, the use of GDMT in practice remains suboptimal. Disparities in GDMT utilization may exist across various patient, provider, or system-related factors.
Objective: To characterize the use of GDMT in patients discharged from Sunnybrook Health Sciences Centre (SHSC) for heart failure, and to identify gaps in the prescribing of GDMT.
Methods: A retrospective chart review was conducted on adult patients with a primary discharge diagnosis of heart failure between March 1 to September 1, 2024. Baseline characteristics, as well as GDMT usage before hospital admission and at discharge were collected using SHSC’s electronic medical record. Multivariable ordinal regressions were performed to identify variables associated with the use of a greater number of GDMT.
Results: Among the 170 patients included in this study, 16 (9.4%) were discharged on all 4 classes of GDMT, 33 (19.4%) were discharged on 3 classes of GDMT, 56 (32.9%) were discharged on 2 classes of GDMT, 52 (30.6%) were discharged on 1 class of GDMT, and 13 (7.6%) were not prescribed any GDMT. Multivariable ordinal regression revealed that age, type of heart failure, contraindications, severity of frailty, and number of prescription medications were significantly associated with pre-admission GDMT (p<0.05), while type of heart failure and contraindications were significantly associated with discharge GDMT (p<0.05). Out of the 71 patients without contraindications to GDMT, 55 (77.5%) were not discharged on quadruple therapy.
Conclusions: The majority of eligible patients are not receiving all 4 classes of GDMT at admission or discharge. More factors were associated with the utilization of GDMT in the community setting compared to at SHSC
A Crip Incarnational Model of Ministry
Full text linkThis dissertation presents an incarnational theology and practice of ministry and, drawing on disability studies and crip theory, re-imagines an incarnational crip theology and practice of ministry through preaching the Word, administering the sacraments, and providing pastoral care. Incarnational theology challenges the Church to an honest and imaginative embracing of embodiment in all its created diversity, specifically disabled and crip bodies constricted by ableism. An interdisciplinary methodology brings incarnational and ecclesial theology into conversation with crip and disability studies to construct an incarnational crip practical theology of ministry. The specific context of The United Church of Canada shows a history of work in disability theology and provides a lens for examining collaborative ministry.
This thesis uses the incarnational ecclesiological work of Bonhoeffer to posit that the church embodies Christ as and in community and that Christ is in solidarity with humanity. Incarnational theology embraces the goodness of embodiment and the gift of diversity, and disability theologians contribute to understanding these concepts through disabled and crip bodies. The thesis employs several disability theologians to open a conversation about leadership in the church drawing on the resources of both theological and disability and crip studies, illustrating the value of this critical correlational method. Drawing this out, the thesis focuses on preaching, sacraments and pastoral care to construct an alternative expression of a crip theology and practice of ministry. Regarding the proclamation of the Word, crip concepts of disclosure and performance enrich the understanding and expression of testimony and collaborative preaching. Regarding the sacraments of baptism and communion, the contributions of crip liturgical time and space enrich the theology and practice of these rites shaped by crip bodies. Finally, crip care webs and access intimacy help imagine an alternative model of pastoral care that shows how we can encounter Christ as we recognize each other’s needs and appropriately care for each other. The research has implications for the construction of a disability theology of ministry and the role of communities of faith and denominations in its practice.Doctor of Philosophy (PhD