John B. Bossaer

The use and misuse of prescription stimulants as "cognitive enhancers" by students at one academic health sciences center.

Purpose Prescription stimulant use as “cognitive enhancers” has been described among undergraduate college students. However, the use of prescription stimulants among future health care professionals is not well characterized. This study was designed to determine the prevalence of prescription stimulant misuse among students at an academic health sciences center. Method Electronic surveys were e-mailed to 621 medical, pharmacy, and respiratory therapy students at East Tennessee State University for four consecutive weeks in fall 2011. Completing the survey was voluntary and anonymous. Surveys asked about reasons for, frequency of, and side effects of nonprescription misuse of prescription stimulants. Given the sensitive material, an opportunity to win one of ten

Successful treatment of nilotinib-induced pleural effusion with prednisone

50 gift cards was used as an incentive. Results Three hundred seventy-two (59.9%) students completed the survey from three disciplines (47.6% medical, 70.5% pharmacy, and 57.6% respiratory therapy). Overall, 11.3% of responders admitted to misusing prescription stimulants. There was more misuse by respiratory therapy students, although this was not statistically significant (10.9% medicine, 9.7% pharmacy, 26.3% respiratory therapy; P = .087). Reasons for prescription stimulant misuse included to enhance alertness/energy (65.9%), to improve academic performance (56.7%), to experiment (18.2%), and to use recreationally/get high (4.5%). Conclusions Prescription stimulant misuse was prevalent among participating students, but further research is needed to describe prevalence among future health care workers more generally. The implications and consequences of such misuse require further study across professions with emphasis on investigating issues of academic dishonesty (e.g., “cognitive enhancement”), educational quality, and patient safety or health care quality.

Isavuconazonium sulfate: a triazole prodrug for invasive fungal infections

Chronic myeloid leukemia is characterized by a unique reciprocal translocation between chromosomes 9 and 22 resulting in deregulated tyrosine kinase activity. Tyrosine kinase inhibitors, such as imatinib, dasatinib, and nilotinib have revolutionized treatment of Chronic myeloid leukemia. However, tyrosine kinase inhibitors’ use has presented new challenges in managing both acute and chronic toxicities, particularly ‘off-target’ toxicities like pleural effusion. Pleural effusions are seen less often with imatinib and very rarely with nilotinib. A 66-year-old male presented to emergency department with complaints of mild chest pain and dyspnea of 3 days duration with progressive worsening, including dyspnea at rest. Patient was currently taking nilotinib after failing imatinib for chronic myeloid leukemia. Nilotinib was put on hold. After exclusion of cardiac and pulmonary etiologies patient was treated for community acquired pneumonia with minimal improvement. Despite the very low incidence of pleural effusion with nilotinib (<1%), he was started on 20 mg of prednisone PO for 3 days. Patient had a dramatic improvement within 48 h after beginning prednisone. This treatment approach suggests that pleural effusions associated with nilotinib can be successfully treated in the same way as pleural effusions associated with dasatinib.

Plagiarism Among Applicants for Faculty Positions

To review the place in therapy of isavuconazole, the active metabolite of isavuconazonium sulfate, via a review of the available literature on drug chemistry, spectrum of activity, pharmacokinetic/pharmacodynamic profile and trials assessing clinical efficacy and safety.

Low rate of cetuximab hypersensitivity reactions in Northeast Tennessee: An Appalachian effect?

To the Editor. Recently, Dr. DiPiro published an article in the Journal1 that discussed several aspects pertinent to the process of faculty recruitment, emphasizing an individuals “fit” within the culture of the hiring institution. In the present article, we discuss another aspect of “fitness” that became evident to our search committee during the 2010-2011 academic year. Our search committee was established in May 2010 to hire a tenure-track faculty member at the level of assistant/associate professor in the department of pharmaceutical sciences. The committee consisted of faculty members in the departments of pharmaceutical sciences and pharmacy practice. Throughout the year, the search committee met 4 times and discussed 48 applicants. The committee members recommended several applicants to the department chair for screening calls and interviewed 2 candidates on site. During a review of applications, the search committee members discovered that several applicants submitted teaching philosophies that contained text that could be found verbatim elsewhere. Specifically, portions of these documents had been copied from online sources and pasted into the application. Obviously, our enthusiasm for these and other candidates with similar issues was significantly diminished and their applications were not pursued further. Plagiarism is defined as “to steal and pass off (the ideas or words of another) as ones own, to use (anothers production) without crediting the source, to commit literary theft, or to present as new and original an idea or product derived from an existing source.”2 Unfortunately, plagiarism is far too common. “Turnitin” reported 110 million instances of matched content found in 40 million papers submitted by students during a 10-month period.3 However, this problem is not limited to students. The occurrence of plagiarism in the scientific literature has been well documented.4,5 In fact, several publishers have implemented software programs to detect plagiarism in manuscripts submitted to their journals.5 Additionally, peer-reviewers for journals have been encouraged to be vigilant in searching for any matched content.6 Plagiarism in application materials is also not a new concept.7 Segal and colleagues reported plagiarism in medical residency application essays.8 In fact, this group found an evidence of plagiarism in more than 10% of essays submitted for a residency program at Brigham and Womens Hospital in Boston, Massachusetts. Although the rate of occurrence was higher among international students, plagiarism was observed in the application of US citizen as well. Surprisingly, students with academic honors were among those applicants with plagiarized application essays. A 2007 report in the journal Family Medicine also cites examples of plagiarism among applicants for medical fellowships, hypothesizing that the increased availability of content on the Web has led to a decreased awareness of the issue of plagiarism.9 The easy availability of technology may make plagiarism easier to commit, but it can also make it easier to detect.5,10 For instance, with some of our applicants, plagiarism was detected using a simple Google search. Faculty members are considered role models for students; their conduct has the potential to affect the reputation of the academic institution involved. As such, it is essential to check all application materials submitted by faculty applicants for any evidence of plagiarism. Faculty members have a responsibility to train students not only in their content areas, but also in areas such as research ethics. Additionally, because graduate students and postdoctoral trainees are the main group of applicants who apply for junior faculty positions, it would be helpful to educate graduate students and trainees about the negative impact of plagiarism on the educational system.10

Antibiotic Use in Home Health A Primer

Purpose Cetuximab is a monoclonal antibody with a known risk of hypersensitivity reactions. Early studies showed hypersensitivity reaction rates of 3%, but there appears to be a higher incidence in the southeastern United States. To confirm the findings from nearby institutions that cetuximab-associated hypersensitivity reactions occur in approximately 20% of patients in the southeastern United States. Methods A retrospective chart review was conducted at Johnson City Medical Center in Johnson City, Tennessee. Each patient’s first infusion was analyzed for hypersensitivity reaction, as well as for demographic information such as allergy and smoking history, pre-medications, and malignancy type. Results Data from the first infusion of cetuximab were collected for a total of 71 patients with various malignancies. The overall rate of grade 3 or higher hypersensitivity reaction was 1.4%, and total rate of hypersensitivity reaction was 8.5%. These findings more closely correlate to the early clinical trials and package insert. Both severe (p = 0.001) and any-grade (p = 0.002) hypersensitivity reaction occurred less frequently in one Southeastern Appalachian medical center compared to academic medical centers directly to the east and west. Conclusions Patients in southern Appalachia may be less likely to develop cetuximab hypersensitivity reactions compared to surrounding areas in the Southeastern U.S. These results lend support to the theory that exposure to lonestar ticks (Amblyomma americanum) may be responsible for the development of IgE antibodies to cetuximab that cause hypersensitivity reactions. The development of quick and reliable bedside predictors of cetuximab hypersensitivity reactions may aid clinicians considering the use of cetuximab.

Severe sunitinib-induced myelosuppression in a patient with a CYP 3A4 polymorphism:

Cost containment measures within hospital systems push for earlier discharges on stable patients. Due to patient placement difficulties and costs associated with skilled facilities, antibiotic use in home health care settings is becoming a common occurrence. This trend will likely increase as care continues to shift to outpatient areas. Lack of sufficient serum drug concentrations needed in severe infections and increasing resistance to many of the oral options often necessitates the use of the intravenous (IV) route. Home health care practitioners may have minimal information on patients or limited experience with IV antibiotics that may impact quality of care. This review summarizes key points relevant to IV antibiotics routinely used by home health prescribers, nurses, technicians, and care managers. This review will focus on antibacterial agents including vancomycin, aminoglycosides, beta-lactams, daptomycin, tigecycline, and telavancin. Appropriate dosing, indications, adverse events, monitoring parameters, and feasibility of using IV antibiotics are discussed.

Drug interaction between idelalisib and diazepam resulting in altered mental status and respiratory failure.

Sunitinib, an oral vascular endothelial growth factor receptor, is a first-line option for metastatic renal cell carcinoma and widely used in clinical practice. Despite the proven benefit of sunitnib in metastatic renal cell carcinoma, patients may suffer from a variety of adverse events including hypertension, fatigue, hypothyroidism, hand–foot skin reactions, rash, depigmentation, and myelosuppression. Myelosuppression is usually mild, transient and resolves during the two weeks at the end of each cycle where no drug is taken. We present a case of severe and early grade 3 neutropenia and thrombocytopenia occurring two weeks into a six-week cycle. Because of the extreme nature of the toxicity, CYP 3A4 polymorphisms were explored. The patient was found to be heterozygous for CYP 3A4*22, at least partially explaining the early-onset and severity of myelosuppression. This pharmacogenetics information resulted in a rechallenge of dose-reduced sunitinib, which was well tolerated by the patient. The current state of pharmacogenomics concerning sunitinb is also presented, and the need for greater research in this area is highlighted.

Mannitol Prescribing Practices With Cisplatin Before and After an Educational Newsletter Intervention

In recent years, several new oral anticancer drugs have been approved, many via an accelerated approval process. These new agents have the potential for drug interactions, but lack of familiarity with these drugs by clinicians may increase the risk for drug interactions. We describe an interaction between the new anticancer agent idelalisib (CYP 3A4 inhibitor) and diazepam (CYP 3A4 substrate) that resulted in altered mental status and type II respiratory failure resulting in hospitalization. After discontinuation of both agents, the patient recovered quickly. Idelalisib was reinitiated after discharge. Lorazepam was substituted for diazepam since it is not metabolized via CYP 3A4. Both agents were tolerated well thereafter. This interaction was only flagged by two of four commonly used drug interaction databases. Clinicians should exercise caution with initiating new oral anticancer agents and consider the potential for drug interactions without solely relying on drug interaction databases.

Review ArticleCardiovascular Toxicity and Management of Targeted Cancer Therapy

Background: Mannitol has been used in the past for the prevention of cisplatin-induced nephrotoxicity. Studies on its efficacy have conflicting results. An educational newsletter was designed for local oncologists on the conflicting data of mannitol use in preventing cisplatin-induced nephrotoxicity. Purpose: The purpose of this study was to determine whether a pharmacist-created newsletter intervention led to changes in the mannitol prescribing practices of local oncologists. Methods: A newsletter describing the paucity of evidence to support mannitol use to prevent cisplatin-induced nephrotoxicity was distributed via e-mail to local oncologists in October 2010. Mannitol prescribing rates were retrospectively evaluated before and after newsletter distribution. The Mann-Whitney U test was used to compare nonparametric continuous data. The chi-square test was used for nominal data. Descriptive statistics were performed for baseline demographics, and odds ratios were calculated for possible risk factors for acute kidney injury (AKI). The primary endpoint was a change in mean mannitol dose before and after the newsletter intervention. The secondary endpoint was the difference in the rate of AKI before and after the intervention. Data were collected for 67 patients with various malignancies. Results: There was a difference in the average mannitol dose before and after newsletter intervention (P = .02). The rates of AKI before and after newsletter were similar. Conclusion: A pharmacist-led newsletter intervention was associated with significantly decreased rates of mannitol usage after intervention.