Caroline S. Zeind

Incorporation of Institute of Medicine competency recommendations within doctor of pharmacy curricula.

Objectives. To determine the extent of implementation of Institute of Medicine (IOM) recommendations for 5 core competencies within the doctor of pharmacy (PharmD) curricula in US colleges and schools of pharmacy. Methods. A survey instrument that used IOM language to define each of the recommended competencies (patient-centered care, interdisciplinary teaming, evidence-based practice, quality improvement, and informatics) was sent to 115 US colleges and schools of pharmacy. Results. Evidence-based practice and patient-centered care were the most widely implemented of the 5 core competencies (in 87% and 84% of colleges and schools, respectively), while informatics, interdisciplinary teaming, and quality improvement were implemented to a lesser extent (at 36%, 34%, and 29% of colleges and schools, respectively). Conclusions. Significant progress has been made by colleges and schools of pharmacy for inclusion of IOM competencies relating to evidence-based practice and patient-centered care within curricula. However, the areas of informatics, interdisciplinary teaming, and quality improvement are lagging in inclusion.

Breastfeeding Travelers: Precautions and Recommendations

With increased travel globally, more women travel while breastfeeding their infants as well as during pregnancy. The transfer of drugs and chemicals into human milk differs from transfer via umbilical cord during pregnancy. Because there is little evidence‐based literature on recommendations for breastfeeding travelers, we review factors that influence drug passage into breast milk and available safety data on common medications that may be encountered by breastfeeding travelers. Biologic and immunologic events in the mother may affect the breastfeeding infant. We review those that are relevant to the breastfeeding woman who is preparing to travel. We also review the use of vaccines in breastfeeding women and the mechanisms by which they could affect the infant. Physiologic changes that occur with breastfeeding involve the hormones oxytocin and prolactin. The hyperplasia of milk ducts and production of immunologically rich human milk occur through the feedback mechanism of suckling. Changes to the mothers immune system following vaccine administration should not differ from the non‐breastfeeding state, though little research has been directed to this question. Breast milk does not adversely impact the response to vaccines administered directly to the infant. 1,2 Specific antibody responses to travel‐related vaccines have not been studied in nursing mothers. Maternal plasma volume expands by 50% through pregnancy and returns to normal level in most women by 8 weeks postpartum. 3 This increases the volume of distribution of drugs administered, related to the amount of protein binding of the given compound. Although most medications transfer into human milk, many are found at low concentrations in breast milk and are relatively safe for the infant. The clinician should consider the risk of the drug versus the benefit of breastfeeding for the infant. Maternal, drug, and infant factors influence the amount of drug available to the nursing infant. The factors influencing drug … Corresponding Author: Lin H. Chen, MD, Travel Medicine Center, Mount Auburn Hospital, 330 Mount Auburn Street, Cambridge, MA 02138, USA. E‐mail: lchen{at}hms.harvard.edu

Cryptococcal Meningitis in Patients with the Acquired Immunodeficiency Syndrome

The optimum therapy for cryptococcal meningitis in patients with the acquired immunodeficiency syndrome (AIDS) remains unresolved. Traditional therapy consists of amphotericin B with or without flucytosine. Obstacles exist in administering these agents to patients with AIDS. Mortality rates during initial therapy are relatively high. Given the lack of proved benefit, we do not recommend adding flucytosine to amphotericin B routinely. The search for more efficacious and less toxic agents continues. The oral triazoles, especially fluconazole, have increased the options for treatment of this disease. New strategies and novel approaches in managing cryptococcal meningitis in patients with AIDS continue to be developed.

Yellow Fever Virus Transmission via Breastfeeding: Follow‐up to the Paper on Breastfeeding Travelers

This letter to the editor highlights a report published by the Centers for Disease Control and Prevention (CDC) which documents the transmission of yellow fever vaccine virus through breastfeeding in an infant in Brazil who mother received a primary yellow fever vaccination eight days prior to the onset of symptoms in the infant.

Prevention of food and waterborne diseases while traveling.

T he number of travelers worldwide has dramatically increased during the past century. In 2000, international arrivals averaged 664 million, with predictions by the World Tourist Organization of an 80% increase between 1995 and 2010. In addition to this increased volume of travelers, the speed of travel due to modern technology has resulted in quicker access to international borders. Moreover, international migration in 1990 exceeded 120 million, with an annual growth of 1.9%. This increase in migration has contributed to 45% of the population growth in developed countries and, more specifically, 88% in Europe during 1990Y1995. The increased number of travelers has led to a greater incidence of travel-related disease. More than 50 million people travel annually from industrialized countries to developing countries, and 20% to 70% of travelers report some illness associated with their travel. Diarrhea has been reported as the most commonly encountered healthcare problem experienced by travelers to foreign countries, particularly to developing countries, followed by respiratory tract infections and dermatoses. Significant morbidity can occur with infectious diseases associated with travel. Preventive health advice, including nutrition information, is an essential component of travel preparation. Guidance for the prevention of food and waterborne illnesses is a key focus of pre-travel advice because travel-related infectious diseases are usually transmitted from contaminated food or water. A paramount aspect of pre-travel advice is to understand that risk avoidance is crucial and that preventive measures such as vaccination and chemoprophylaxis are not 100% effective. In response to these and other travel-related issues, the discipline of travel medicine has evolved to address the needs of traveling populations on a global scale. This interdisciplinary specialty has been recognized in the United Kingdom by the Department of Health in its new strategy for combating infectious disease. Resources relating to travel medicine are available from the Centers for Disease Control and Prevention (CDC), the World Health Organization (WHO), the Department of Public Health, and many other sources (Table 1). These organizations provide up-to-date and accurate information for clinicians and the general public. In addition, new surveillance systems that are beginning to yield data regarding travel-related illness have been established (Table 1). Prior to travel, the healthcare provider must begin with a careful assessment of the travel itinerary, type of travel (urban vs rural, business vs backpacking), accommodations (hotels, hostels, homes, or camping), length of stay in each area, planned activities, age of traveler, history of past and current medical problems, and vaccination, drug, and allergy history. It is important to identify travelers who are at high risk, including those with preexisting medical conditions that compromise their immunity, as well as those who plan to travel away from the usual tourist routes, backpackers, foreign-born individuals who are returning to visit family and friends, and those traveling for long periods of time. Pediatric travelers present unique challenges for travel medicine providers, and care should be taken in assessing infants and children preparing for travel. Pediatric issues, such as ages when certain vaccines may be used, availability of oral suspension, dosages, and drug safety, must be considered. In addition, pregnant and elderly travelers must be given careful consideration and care because they pose challenges relating to vaccination needs and chemoprophylaxis.