Karen L. Kier

Thrombocytopenia in intensive care patients: a comprehensive analysis of risk factors in 314 patients.

Objective: To define the incidence and severity of thrombocytopenia in a mixed medical-surgical population of critically ill patients and to examine factors that may be related to the development of thrombocytopenia. Design: Retrospective chart review of 314 critically ill patients requiring at least 3 days of critical care. Setting: A 17-bed combined medical-surgical intensive care unit (ICU) in a 560-bed tertiary care community hospital. Patients: Medical and surgical patients admitted to the ICU. Interventions: All medical records over the duration of the ICU stay were reviewed. All scheduled medications, including dosage and start/stop dates, were recorded. All platelet counts, placement of pulmonary artery catheters, liver function test results, and admission serum creatinine concentrations were collected. Measurement and Main Results: Thrombocytopenia (platelet count less than 200 × 109L) was observed frequently, but rarely reached a severe stage (7 patients). No single diagnostic category was significantly associated with thrombocytopenia alone, although the combination of sepsis syndrome/septic shock and respiratory failure was strongly correlated (p < 0.0001) with thrombocytopenia. Liver function abnormalities were correlated strongly with thrombocytopenia, and the majority of patients (5 of 7) with severe thrombocytopenia (less than 20 × 109/L) were found to have concurrent severe alterations in liver function test results. Pulmonary artery catheter placement and heparin exposure were associated strongly with thrombocytopenia (p < 0.0001). Drug therapies that were correlated with thrombocytopenia included heparin and vancomycin (p < 0.05). Hemodynamic instability was correlated strongly with the presence and severity of thrombocytopenia. In a stepwise linear regression model, the admission platelet count accounted for the largest proportion of the variance (43%), followed by hemodynamic instability (8%) and the requirement for inotropic agents (2%). Conclusions: Thrombocytopenia in the critically ill occurs frequently, rarely reaches severely depressed concentrations, and primarily represents a manifestation of disease processes initiated prior to admission. Hemodynamic instability and/or heparin exposure appear to be the strongest identifiable correlates with thrombocytopenia. Although these may cause infrequent isolated cases, other specific drug causes of thrombocytopenia are not responsible for the majority of cases of thrombocytopenia in the critically ill.

Potential Interaction between Clarithromycin and Warfarin

Objective To report a possible drug interaction between clarithromycin and warfarin in a patient with chronic atrial fibrillation. Case Summary A patient with chronic atrial fibrillation was placed on warfarin therapy. International normalized ratios (INRs) ranged from 1.61 to 3.99 while the dosage was being adjusted during the first 5 months of warfarin therapy. The dosage was titrated to 20 mg/wk; laboratory tests obtained 2 weeks after this dosage was started indicated an INR of 2.1. The same dosage was continued. Clarithromycin 500 mg bid was started for an acute exacerbation of bronchitis 10 days after the last INR was obtained and was continued for 14 days of therapy. An INR obtained 3 days after completion of the clarithromycin therapy was 16.8. The warfarin was withheld and vitamin K 20 mg im was administered. The INR obtained the next day was 1.52. The warfarin was restarted and the dosage was titrated to between 22.5 and 25 mg/wk, with INRs ranging from 0.85 to 3.14. Discussion Many factors influence the metabolism of warfarin, including disease states, medications, age, and diet. Data collected in this case suggested clarithromycin may have contributed to the increase in the effect of warfarin. Inhibition of the cytochrome P450 oxidizing system appears to be the reason for the increase. Numerous drugs and disease states affect the rate at which this system metabolizes drugs. Conclusions The potential interaction between clarithromycin and warfarin warrants prudent monitoring of the INR during concurrent administration of these drugs. Warfarin dosages may need to be reduced during concurrent clarithromycin therapy to prevent bleeding complications. Further controlled clinical trials are needed to substantiate the interaction between clarithromycin and warfarin.

Knowledge and use of folic acid among college women: a pilot health promotion program led by pharmacy students and faculty

As pharmacists and pharmacy students are increasingly called upon to assume roles in public health activities, it is important to recognize unique opportunities to educate community members on health, wellness, and disease prevention. Objective To evaluate the impact of a pilot health promotion program on college women’s knowledge regarding folic acid and prevention of neural tube defects (NTD) and frequency of multivitamin use. Methods A health promotion program was developed by a pharmacy student and two pharmacy faculty members that included an oral presentation and reminder messages. A multiple-choice test assessing knowledge of folic acid and NTD and frequency of multivitamin use was given to participants before and immediately after the presentation. Participants then received a reminder message regarding folic acid once a week for three weeks. Knowledge and multivitamin use were reassessed four weeks post-intervention. Results Thirty-two college women voluntarily attended the oral presentation. Twenty-five women (78.2%) completed the four-week post-test. Compared to the pre-test, there were statistically significant increases in average test score (p<0.0001) and correct responses to questions regarding folic acid and NTD (p<0.05 for each question). Participants reported a statistically significant increase in regular (≥4 times/week) multivitamin use (p=0.023). Conclusion Participants in the pilot health promotion program demonstrated a statistically significant increase in knowledge about folic acid and frequency of multivitamin use. A similarly-modeled health promotion program may be an effective way of increasing folic acid and NTD knowledge and changing behaviors of multivitamin use in college women.

Design and implementation of a pharmacist-directed preventive care program

PURPOSE The design and implementation of pharmacist-directed preventive care services within a university-based, employee health and wellness clinic are described. SUMMARY Ohio Northern University (ONU) HealthWise is a multidisciplinary employee health and wellness clinic located on the campus of ONU that offers medication therapy management, disease management, nutrition counseling, and physical wellness coaching services. A pharmacist-directed preventive care program based on recommendations from the U.S. Preventive Services Task Force (USPSTF) was designed for incorporation into the clinic. Using an electronic search tool provided by USPSTF, pharmacists are able to provide a review of recommended preventive services that are appropriate for each individual patient. Whenever possible, pharmacists within the clinic perform the screenings and other interventions that are recommended by USP-STF; when necessary, patients are referred to other health care providers to receive recommended interventions. To date, nine patients have participated in the preventive care program. For these nine patients 112 recommendations have been reviewed by pharmacists in the clinic. Of these, 16 were found to be inappropriate after further discussion with the patients and 36 were verified as already completed by the patient, resulting in a total of 60 unmet recommendations. Of these 60, 52 recommendations were met through interventions by the pharmacist in the clinic, while 5 possible screenings were declined by patients and 3 unmet recommendations required referral to a provider outside of the clinic. CONCLUSION A pharmacist-directed preventive care service offered within an employee health clinic helped ensure that employees receive appropriate screenings and preventive care according to current guidelines.

Impact of a 12-week, pharmacist-directed walking program in an established employee preventive care clinic

PURPOSE The impact on physical activity and health of a 12-week, pharmacist-directed walking program incorporated into an employee health and wellness clinic was evaluated. METHODS Clinic participants were eligible for study inclusion if they or their spouse was a current or retired employee of Ohio Northern University. Participants received a pedometer, a calendar with specific daily walking goals for the 12-week period, and maps with walking routes. Participants also met with a pharmacist and a student pharmacist for point-of-care tests measuring lipid and fasting glucose concentrations and blood pressure. Participants reported to weekly pedometer checks where steps were recorded and medications were reassessed by the pharmacist or student pharmacist. As an incentive to meet the walking goals, the participants received a raffle ticket each week their goal had been achieved. After 12 weeks, participants reported for a final appointment when all baseline variables were reassessed by a team of health care professionals. RESULTS A total of 144 participants were screened at baseline and included in the study, 65 of whom completed the program. At baseline, there were 240 abnormal laboratory test values found in participants with no prior history of dyslipidemia, hyperglycemia, or hypertension. After 12 weeks, significant changes in high-density-lipoprotein (HDL) cholesterol concentrations (p = 0.0012), fasting blood glucose concentrations (p = 0.0017), and blood pressure (p = 0.021) were noted. CONCLUSION A pharmacist-directed walking program that included clinical assessments, walking goals, and weekly pedometer checks was an effective approach to increase employee activity levels, identify previously unknown health conditions, lower blood glucose concentrations and blood pressure values, and increase HDL cholesterol concentrations.

Biostatistical Applications in Epidemiology

Understanding the application of statistical methods is an essential component in the process of evaluating the medical literature. Statistical methods can differ when evaluating randomized controlled clinical trials (experimental design) compared with observational study designs such as cohort or case‐control. A review of common statistical concepts includes variables, measures of central tendency, and measures of dispersion. Other methods include sensitivity, specificity, and predictive value. Observational study designs often include relative risk, odds ratios, relative risk reduction, attributable risk, number needed to treat, and forest plots. A critical component of drug literature evaluation is the understanding of the proper use of parametric and nonparametric statistical tests. Common parametric tests and their nonparametric equivalents are discussed.

Analysis of pharmacy student motivators and deterrents for professional organization involvement

INTRODUCTION The purpose of this study was to determine motivators and deterrents impacting a student pharmacists decision to join professional organizations. The goal was to create a list of meaningful factors that organizations can use for membership recruitment. METHODS This descriptive study utilized a blinded electronic survey sent to eight accredited pharmacy schools in Ohio, Michigan, Wisconsin, Indiana, Illinois, and Kentucky. The survey assessed motivating and hindering factors, as well as demographic data. RESULTS Eight-hundred fifty-six students completed the survey, a 15.05% participation rate. Professional development and networking were the top two endorsed motivational factors, selected as significant by 88.0% and 87.5% respectively. Upon chi-square analysis, networking (p<0.001), involvement opportunities (p=0.01), and scholarships (p=0.02) were motivating factors with which membership was found to be significantly influenced. Networking and involvement opportunities were more significant for members while scholarships were a greater motivator among nonmembers. Time required for involvement and cost were the most commonly selected hindrances with 78% and 76% respectively identifying these as significant barriers. The hindering factor found to be significantly different between active members and nonmembers was bylaws/rules of the organization (p=0.032), with non-members rating this as a greater consideration than current members. DISCUSSION AND CONCLUSIONS Multiple factors contribute to a students decision to join a professional organization. Those active members find greater significance in networking involvement opportunities. Non-member students found scholarships more motivating and recognize bylaws as a consideration for membership more than current members. These results emphasize the multifactorial nature of membership and may direct future membership initiatives.