Craig D. Cox

Effects of three fluoroquinolones on QT analysis after standard treatment courses.

Background: Fluoroquinolone (FQ) agents have been speculated to influence the risk of Torsades de pointes (Tdp). Methods of evaluating this risk are varied and not systematic. QTc interval (QTc) prolongation is the most commonly used marker of Tdp, but has questionable utility. QT dispersion (QTd) may be a more selective marker of Tdp. No assessment of QTd for FQs has been reported. The current study evaluates the effects of three commonly prescribed FQs by comprehensive QT analysis.

Preventing contrast nephropathy: What is the best strategy? A review of the literature

Patients receiving radiocontrast for diagnostic and interventional procedures are at risk for developing contrast nephropathy (CN). In fact, radiocontrast nephropathy is currently the third leading cause of hospital‐acquired renal failure. Understanding that CN has been associated with increased length of hospitalization and mortality, determining the best prevention strategy is of utmost importance. Patients at the greatest risk for developing acute renal failure are patients with diabetes and underlying renal insufficiency. Several therapies have been investigated for the prevention of CN; unfortunately, very few have shown a consistent benefit. Therapies that have been studied include saline hydration, N‐acetylcysteine (NAC), theophylline, calcium channel blockers, diuretics, dopamine, endothelin receptor antagonists, atrial natriuretic peptide, angiotensin‐converting enzyme inhibitors, and prostaglandin E‐1. Using adequate hydration, using low‐osmolar dyes, and minimizing the dose of contrast have all been shown to be effective in reducing CN and are considered the standard of care. While trials with many pharmacologic agents have produced conflicting results, intervention with NAC has also been promising. This article reviews the pathophysiology, risk factors, and therapies that are currently available for the prevention of CN.

Pharmacologic blockade of the renin-angiotensin system: vascular benefits beyond commonly understood pharmacologic actions.

Angiotensin‐converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs) are recognized primarily for their use in hypertension, in heart failure, and after myocardial infarction. New evidence, particularly with ACE inhibitors, has shown their ability to reduce acute coronary events associated with atherosclerosis in patients without a history of the aforementioned cardiac conditions. This is likely due to inhibitory effects on the renin‐angiotensin system—a system that adversely influences fibrinolytic balance, vascular endothelial function, and vascular inflammation, all key components of atherosclerotic progression and adverse coronary outcomes. Results of various studies suggest favorable effects of ACE inhibitors and ARBs on markers of these components, including effects on plasminogen activator inhibitor‐1, endothelin‐1, and nitric oxide by ACE inhibitors, and effects on vascular cell adhesion molecule‐1 and C‐reactive protein by ARBs. Although early evidence suggests that ACE inhibitors may provide a greater beneficial effect on some of these markers compared with ARBs, and that certain ACE inhibitors may provide greater vascular benefits than others, further investigation is required to verify such findings. Overall, understanding the distinct coronary vascular benefits of these agents will emphasize the importance of using them, particularly ACE inhibitors, to improve outcomes in patients with coronary atherosclerotic disease.

Antibiotic‐induced Cardiac Arrhythmias

This review aims to clarify the underlying risk of arrhythmia associated with the use of macrolides and fluoroquinolones antibiotics. Torsades de pointes (TdP) is a rare potential side effect of fluoroquinolones and macrolide antibiotics. However, the widespread use of these antibiotics compounds the problem. These antibiotics prolong the phase 3 of the action potential and cause early after depolarization and dispersion of repolarization that precipitate TdP. The potency of these drugs, as potassium channel blockers, is very low, and differences between them are minimal. Underlying impaired cardiac repolarization is a prerequisite for arrhythmia induction. Impaired cardiac repolarization can be congenital in the young or acquired in adults. The most important risk factors are a prolonged baseline QTc interval or a combination with class III antiarrhythmic drugs. Modifiable risk factors, including hypokalemia, hypomagnesemia, drug interactions, and bradycardia, should be corrected. In the absence of a major risk factor, the incidence of TdP is very low. The use of these drugs in the appropriate settings of infection should not be altered because of the rare risk of TdP, except among cases with high-risk factors.

The impact of preceptor and student learning styles on experiential performance measures.

Objectives. To identify preceptors’ and students’ learning styles to determine how these impact students’ performance on pharmacy practice experience assessments. Methods. Students and preceptors were asked to complete a validated Pharmacist’s Inventory of Learning Styles (PILS) questionnaire to identify dominant and secondary learning styles. The significance of “matched” and “unmatched” learning styles between students and preceptors was evaluated based on performance on both subjective and objective practice experience assessments. Results. Sixty-one percent of 67 preceptors and 57% of 72 students who participated reported “assimilator” as their dominant learning style. No differences were found between student and preceptor performance on evaluations, regardless of learning style match. Conclusion. Determination of learning styles may encourage preceptors to use teaching methods to challenge students during pharmacy practice experiences; however, this does not appear to impact student or preceptor performance.

Quantity vs Quality in Experiential Education

As Dr. Svensson articulated, experiential training of future pharmacists has changed significantly. The responsibility to manage these clinical experiences has transitioned from state boards of pharmacy to colleges and schools. My family experienced this change first hand with my grandfather in the 1940s, my father in the 1970s, and then my wife, brother, and I in the 1990s and 2000s as we each completed our respective pharmacy degree programs. These changes coupled with the debate over the future of pharmacy practice have been the topics of many dinner conversations. Dr. Svensson states the main reason regulation of experiential training was moved to schools of pharmacy was to assure that students were spending their time in activities that were preparing them to function as practicing pharmacists.

Lack of effect on coronary atherosclerotic disease biomarkers with modest dosing of an angiotensin-converting enzyme inhibitor, angiotensin II type-1 receptor blocker, and the combination.

BackgroundAngiotensin-converting enzyme inhibitors and angiotensin II type 1 receptor blockers, used alone or in combination, have been shown to improve outcomes in certain populations, primarily when administered in high doses. For stable coronary atherosclerotic disease, however, the relative physiologic effect of these therapies is unclear. Furthermore, because of the notorious subtarget dosing of such agents in clinical practice, we explored the influence of a modest dosing of an angiotensin-converting enzyme inhibitor, angiotensin II type 1 receptor blockers, and the combination on common biologic markers of coronary atherosclerotic disease. MethodsThis randomized, cross-over study enrolled stable coronary atherosclerotic disease patients (n=20), each receiving three treatments: candesartan 16 mg daily, ramipril 5 mg daily, and candesartan 8 mg plus ramipril 2.5 mg daily. Treatments were administered for 2 weeks with a 2-week washout. Blood samples were collected before and after each treatment. Markers of endothelial function, fibrinolytic balance, and vascular inflammation were measured. ResultsNo significant differences were observed in the pretreatment concentrations of angiotensin-converting enzyme or of any measured biologic marker. Relative to pretreatment levels, candesartan alone was the only therapy to exhibit an action on any measured biomarker – a trend toward increased nitric oxide concentrations (P=0.054). Otherwise, no effects on biologic markers were observed with the treatments. ConclusionThis study of various methods of the renin–angiotensin system inhibition in stable coronary atherosclerotic disease patients demonstrates negligible effects of a modest dosing of ramipril and the combination of ramipril plus candesartan on common biologic markers of coronary atherosclerotic disease. Candesartan at modest doses may favorably influence endothelial function. Overall, however, the results indicate that the commonly practiced subtarget dosing of such treatments provides little, if any, benefit pertaining to key physiologic components of coronary atherosclerotic disease.

Sharing Ideas in Experiential Education

Experiential training is a critical component of pharmacy education. At the turn of the 20th century there was no required educational degree or experiential training for pharmacists prior to licensure, although many pharmacists chose to complete apprenticeships. Beginning with New York in 1910, the states slowly began requiring pharmacy degrees that ranged from 2 to 6 years.1 In 2000, all first professional pharmacy degrees became the 6-year doctor of pharmacy (PharmD) degree.

Using the OSCE strategy for APPEs

To the Editor. We read with great interest Dr. Sturpes description of objective structured clinical examinations (OSCEs) at United States Schools/Colleges of Pharmacy.1 Improving test reliability is a central tenet to the “objective” term in OSCEs. Content specificity is a concern with OSCE assessments and increasing the number of stations vastly improves test reliability.2 Dr. Sturpes instruction on the number of OSCE stations required for suitable test reliability is very instructive, with a suggested 12-16 stations. Assessment drives learning so the test reliability of assessments should be a key concern for pharmacy educators. While numerous versions of advanced pharmacy practice experience (APPE) evaluations are used at colleges and schools of pharmacy around the country, test reliability of evaluations should be an important consideration. If APPEs were conceptually thought of as analogous to OSCE stations, then together as an OSCE they can speak to a common ability of learners, ie, the ability to practice pharmacy in a number of environments. This ability continuum can range from limited to expansive, but students can fall anywhere along that spectrum. Individual APPE rotation objectives must be linked to terminal school or college outcomes, and overall experience assessments mapped to these required objectives. Overall experience assessments should be standardized between preceptors and sites to ensure that students are assessed in a similar manner. An example using SOAP notes as part of an overall experience assessment, notes should be assessed more than once in a single APPE and then repeated among multiple core APPEs (ie, 3 notes/APPE over 4 APPEs would provide 12 evaluations). Additional “stations” also could be included to complement APPE assessments, similar to the variations that Hodge describes.3 Test reliability should be enhanced with additional rigorous assessments of similar APPE objectives – as long as all evaluations are assessing a similar ability in students. An advantage of including additional assessments is that they provide a reliable, standardized means of critical evaluation for all students. Examples of additional assessments include: a final-year student presentation demonstrating evidence-based medicine skills,4 the National Association of Boards of Pharmacys Pharmacy Curriculum Outcomes Assessment, or an individual college or schools outcome-based examination prior to APPEs. Undoubtedly, colleges and schools of pharmacy are investing significant resources into experiential programs and sites. How rigorous (ie, reliable) are methods of evaluation? We forward an alternate paradigm for thinking of APPE evaluations using the strengths of an OSCE approach (ie, improved assessment reliability through greater station numbers). Additionally, some colleges and schools interested in performance-based assessment (such as with an OSCE) may be struggling with finding resources to implement this evaluation. Using experiential programs may foster use of an OSCE approach to assessment. Michael J. Peeters, PharmD, MEd,a Craig D. Cox, PharmDb aUniversity of Toledo College of PharmacybTexas Tech University Health Sciences Center School of Pharmacy

National preceptor development program (PDP) prototype. The third of a 3-part series

INTRODUCTION Preceptor development is critical to successful delivery of experiential learning. Although many preceptor development programs exist, a more individualized approach to training is needed. To accomplish this a national preceptor development program should be considered based on the continuing professional development model. A detailed prototype for this program has been described. METHODS In this final installment of the series, the twelve evidence-based recommendations from the first installment were utilized to construct a prototype for a preceptor development program. Over a three-month period, investigators experimented with different designs and models before approving the final prototype. RESULTS The prototype took the form of an electronic learning platform. Several categories were integral to the design and included sections entitled preceptor spotlight, mentorship, global outreach, choose your own adventure, continuing professional development, feedback, virtual online community, highlights/advertisements, whats new, competency assessment, and frequently asked questions. A graphic was developed to depict the process by which a preceptor would navigate through the web-based learning platform. DISCUSSION The authors purposefully maintained a creative and unlimited vision for preceptor development. This conceptual model is intended to spark discussion and augment, refine, or develop entirely innovative ideas to meet preceptor needs. Development of a preceptor development platform could foster improved competency performance, enhanced interest in learning, and promote continuing professional development. CONCLUSION With a greater focus on experiential education in pharmacy, the need for a national preceptor development resource is only expected to increase.