Michelle M. Bottenberg

Oral Aloe Vera–Induced Hepatitis

Objective: To report a case of possible oral aloe vera-induced hepatitis. Case Summary: A 73-year-old female was admitted to the hospital for acute hepatitis. Extensive laboratory testing did not reveal the cause of the patients disease. She was asked multiple times whether she was taking any home medications, which she initially denied. It was only after an extensive medication history done by a clinical pharmacist that the patient admitted to using oral aloe vera capsules for constipation. Upon discontinuation of the oral aloe vera, liver markers of hepatotoxicity returned to normal levels. Discussion: Herbal medications pose an increasing problem in patient safety, as the different types of these products and the number of patients who use them continue to grow. In the US, these products are not subject to the same regulatory scrutiny as prescription medications; thus, safety information can be difficult to obtain. In particular, hepatic toxicity due to herbal agents is poorly described in the medical literature. Aloe vera, often used topically for minor burns, can also be used orally as a laxative or an “anti-aging” agent. According to the Naranjo probability scale, the hepatotoxicity in this case was possibly related to ingestion of oral aloe vera. Additionally, using the Roussel Uclaf Causality Assessment Method for determining drug hepatotoxicity, the patients symptoms were scored as probably caused by oral aloe vera. The more conservative designation was used in our report. Conclusions: With the widespread use of oral aloe vera and other herbal products, clinicians faced with a case of acute hepatitis that is not readily diagnosed should question patients about herbal use.

Metronidazole-Induced encephalopathy: a Case Report and Review of the Literature

• J Clin Pharmacol 2011;51:112-116 M is a synthetic nitroimidazole antibiotic that is active against various protozoans as well as most Gram-negative and Gram-positive anaerobic bacteria. Although the mechanism of action for metronidazole is not entirely known, it is believed to exhibit cytotoxic effects by damaging DNA, resulting in inhibition of protein synthesis and ultimately cell death. Since its original use for the treatment of infections caused by Trichomonas vaginalis nearly 5 decades ago, metronidazole has proven useful in the treatment of a variety of conditions, including bacterial vaginosis, Helicobacter pylori infections, giardiasis, amoebiasis, and Clostridium difficile colitis. In addition, the role of metronidazole has been expanded to include surgical prophylaxis and adjunctive therapy for noninfectious conditions, including hepatic encephalopathy, Crohn’s disease, and colitis. When deciding whether patients should be prescribed metronidazole, particularly for extended durations, clinicians must consider the adverse event profile of this agent. The most commonly reported adverse effects include abdominal discomfort, nausea, vomiting, headache, and metallic taste. Although less common, adverse neurological effects such as ataxia, dizziness, peripheral neuropathy, and seizure are possible. Furthermore, several cases of metronidazole-induced encephalopathy have been reported in the medical literature (Table I). We present a case of encephalopathy probably caused by metronidazole as well as a review of the literature regarding this rare but serious adverse event.

A Checklist for the Development of Faculty Mentorship Programs

Mentoring of junior faculty members continues to be a widespread need in academic pharmacy in both new programs and established schools. The American Association of Colleges of Pharmacy (AACP) Joint Council Task Force on Mentoring was charged with gathering information from member colleges and schools and from the literature to determine best practices that could be shared with the academy. The task force summarized their findings regarding the needs and responsibilities for mentors and protégés at all faculty levels; what mentoring pieces are in existence, which need improvement, and which need to be created; and how effective mentoring is defined and could be measured. Based on these findings, the task force developed several recommendations as well as the PAIRS Faculty Mentorship Checklist. Academic institutions can benefit from the checklist whether they are planning to implement a faculty mentorship program or are interested in modifying existing programs.

A Multiyear Analysis of Team-Based Learning in a Pharmacotherapeutics Course

Objectives. To evaluate the impact of team-based learning (TBL) in a pharmacotherapeutics course on pharmacy students’ ratings of faculty instructors and the course, and to assess students’ performance after implementation of team-taught TBL. Design. Teaching methodology in a pharmacotherapeutics course was changed from a lecture with recitation approach in 2 semesters of a 6 credit-hour course to a TBL framework in a 3-semester 3+4+5 credit hour course. The distribution of faculty of instruction was changed from 4 faculty members per week to 1 faculty per 1-credit-hour module. TBL consisted of preclass study preparation, readiness assurance (Individual Readiness Assessment Test and Group Readiness Assessment Test), and in-class application exercises requiring simultaneous team responses. Assessment. Retrospective analysis of student ratings of faculty and instructional methods was conducted for the 2 years pre-TBL and 4 years during TBL. Final course grades were evaluated during the same time period. Student ratings showed progressive improvements over 4 years after the introduction of team-based learning. When aggregated, ratings in the “excellent teacher” category were unchanged with TBL compared to pre-TBL. Improvements in faculty instructor approaches to teaching were noted during TBL. Group grades were consistently higher than individual grades, and aggregate course grades were similar to those prior to TBL implementation. Conclusion. Implementation of TBL in a pharmacotherapeutics course series demonstrated the value of team performance over individual performance, indicated positive student perceptions of teaching approaches by course faculty, and resulted in comparable student performance in final course grades compared to the previous teaching method.

Apparent anaphylactoid reaction after treatment with a single dose of telithromycin

BACKGROUND Telithromycin, the first ketolide antimicrobial agent available in the United States, is related to the macrolide class of antibiotics. Reports of immediate-type hypersensitivity reactions with macrolides or ketolides are rare overall. OBJECTIVE To describe a patient with a severe, apparent mast cell-mediated reaction to telithromycin. METHODS A 54-year-old woman with a history of hypertension was prescribed telithromycin by her primary care physician for presumed bacterial sinusitis. Shortly after ingesting the first dose of telithromycin she developed severe shortness of breath, wheezing, and angioedema. Her allergic history was significant for the development of a maculopapular rash after taking sulfonamide antibiotics, but she had received erythromycin and azithromycin in the past with no adverse effects. She was intubated with difficulty and was treated with epinephrine, diphenhydramine, and corticosteroids. The patient made a full recovery. RESULTS Although not confirmed, the patients severe symptoms were anaphylactoid and were ascribed to an immediate-type hypersensitivity reaction to telithromycin. No other causative agents, including other drugs, foods, and environmental exposures, were implicated in this case. Her history of tolerability to macrolide antibiotics is of interest considering the chemical similarities between these drugs and telithromycin. CONCLUSION To our knowledge, this is the first reported case of a severe, immediate-type hypersensitivity reaction to telithromycin. Physicians prescribing this drug should be aware of this rare but serious effect.

Assessing Pharmacy Students’ Ability to Accurately Measure Blood Pressure Using a Blood Pressure Simulator Arm

Objective. To compare student accuracy in measuring normal and high blood pressures using a simulator arm. Methods. In this prospective, single-blind, study involving third-year pharmacy students, simulator arms were programmed with prespecified normal and high blood pressures. Students measured preset normal and high diastolic and systolic blood pressure using a crossover design. Results. One hundred sixteen students completed both blood pressure measurements. There was a significant difference between the accuracy of high systolic blood pressure (HSBP) measurement and normal systolic blood pressure (NSBP) measurement (mean HSBP difference 8.4 ± 10.9 mmHg vs NSBP 3.6 ± 6.4 mmHg; p<0.001). However, there was no difference between the accuracy of high diastolic blood pressure (HDBP) measurement and normal diastolic blood pressure (NDBP) measurement (mean HDBP difference 6.8 ± 9.6 mmHg vs. mean NDBP difference 4.6 ± 4.5 mmHg; p=0.089). Conclusions. Pharmacy students may need additional instruction and experience with taking high blood pressure measurements to ensure they are able to accurately assess this important vital sign.

Intensive Insulin Therapy in Critical Care Settings

Hyperglycemia in hospitalized patients has been shown to increase both morbidity and mortality, regardless of the presence of preexisting diabetes. In order to achieve recommended glycemic goals, many patients require the use of intravenous insulin therapy in the critical care setting. Following the publication of a landmark trial evaluating the benefits of intensive insulin therapy in critically ill patients, a worldwide increased effort to achieve strict glycemic control has ensued. Maintaining blood glucose levels between 80 and 110 mg/dL has been shown to improve outcomes such as mortality and infectious complications in critically ill patients, while also decreasing length of hospital stay and healthcare expenditures. However, achieving strict glycemic control has proven to be a challenge for many institutions, partly due to the prevalence of hypoglycemia. As demonstrated by studies which have been terminated prematurely due to increased risk for hypoglycemic episodes, the benefits versus risks of intensive insulin therapy must be weighed carefully. Patients receiving continuous infusions of insulin require close monitoring, which may increase workload for intensive care unit staff. In an effort to balance the risks and benefits of intensive insulin therapy, many hospitals are incorporating standardized protocols and using an interdisciplinary approach toward patient care.

Retrospective Evaluation of ASCVD Risk and Statin Therapy Need in Nondiabetic Patients Based on the 2013 ACC/AHA Cholesterol Guidelines.

Purpose: Study goal was to assess the impact of the 2013 American College of Cardiology and the American Heart Association (ACC/AHA) Cholesterol Guidelines on patients in the fourth statin benefit group which included patients aged 40 to 75 years, without diabetes or clinical atherosclerotic cardiovascular disease (ASCVD), and have an ASCVD score ≥7.5%. These patients could benefit from treatment interventions by a pharmacist. Methods: Patients were identified from electronic health records. A sample of 3503 patients was ascertained from having a lipid panel performed within the 12 months before November 1, 2013. Patients were excluded if we were unable to calculate 10-year ASCVD risk. Results: A total of 3203 patients were included, with 2008 not on statin therapy. Of those, 1507 (75%) had a 10-year ASCVD risk score <7.5% and 501 (25%) had a score > 7.5%. Patient characteristics leading to an increase in risk included advanced age, smoker, male, and hypertension treatment. Of 2008 nonstatin patients, there were 466 (23.2%) who fit criteria for initiation of moderate- or high-intensity statin. Conclusion: Widespread adoption of the 2013 ACC/AHA Cholesterol Guidelines will expand prescribing rates of statins. Implementing screening strategies may help identify patients who require treatment in this fourth statin benefit group. A pharmacist can be vital in screening patients, educating patients regarding the need for medication therapy, and monitoring for adherence in these new regimens.

Comparison of electronic versus paper rubrics to assess patient counseling experiences in a skills-based lab course

BACKGROUND AND PURPOSE To evaluate an electronic counseling rubric to facilitate timely student feedback and explore differences in student performance, student anxiety, and self-perceived preparedness in a high stakes practical exam when using a paper rubric versus an electronic rubric. EDUCATIONAL ACTIVITY AND SETTING Two cohorts of students in the third professional year were evaluated using the same rubric criteria: cohort 1 (n = 97) used traditional paper rubrics and cohort 2 (n = 104) used electronic rubrics. Cohorts were surveyed to measure anxiety and perceived preparedness in patient counseling skills one week prior to a practical exam, and cohort responses were compared. Student practical exam performance was also compared between the two cohorts. FINDINGS Results showed no significant relationship between electronic rubric use and student anxiety (p = 0.07) or student exam performance [average score 53.42 points (SD 3.65) and 53.93 points (SD 3.78) in Cohort 1 and Cohort 2, respectively]. Perceived exam preparedness was higher among students using electronic rubrics, with timing of feedback being the mediating process in increasing preparedness (p < 0.01). DISCUSSION AND SUMMARY Electronic rubrics resulted in more timely feedback on patient counseling skills, and students felt more prepared for their practical exam. This did not result in a significant difference in practical exam performance between the two cohorts. Additional methods to incorporate electronic rubrics into the course will be explored.

Comparison of faculty and student self-assessment scores of aseptic technique skills and the impact of video review on self-awareness for second-year pharmacy students

BACKGROUND AND PURPOSE Educating students about aseptic technique presents many challenges. Students at Drake University have limited exposure to this skill outside of the classroom setting, and students have previously shown a lack of awareness related to their own aseptic technique skills. One approach to developing self-awareness in this area may be the incorporation of activities involving video viewing and self-reflection. EDUCATIONAL ACTIVITY AND SETTING Second-year pharmacy students in the Intermediate Pharmacy Skills and Applications 2 course completed four total aseptic technique activities, each of which was assessed by faculty using a standardized assessment tool. Each student was video-recorded during one of these aseptic technique activities. Students were asked to self-reflect on their performance immediately after the activity and again after viewing the video recording of their performance (using the same criteria included in a standardized faculty assessment tool). Student self-reflection scores before and after video viewing were then compared to faculty scores. FINDINGS One-hundred six students participated in the video recording and self-reflection activity. Compared to faculty assessment scores, there was no significant difference between the self-reflections before or after video viewing (p = 0.571). DISCUSSION Video self-reflection had no significant impact on the ability to accurately self-assess aseptic technique skills, but this study did reveal several other opportunities for future teaching and research. SUMMARY Future efforts to impact student self-awareness should include additional self-reflection instruction, repeated self-reflection activities conducted over the course of a semester, and improved video recording technology.