Shaunta' M. Ray

Pharmacy student knowledge retention after completing either a simulated or written patient case

Objective. To determine pharmacy students’ knowledge retention from and comfort level with a patient-case simulation compared with a written patient case. Design. Pharmacy students were randomly assigned to participate in either a written patient case or a simulated patient case in which a high-fidelity mannequin was used to portray a patient experiencing a narcotic and acetaminophen overdose. Assessment. Participants’ responses on a multiple-choice test and a survey instrument administered before the case, immediately after the case, and 25 days later indicated that participation in the simulated patient case did not result in greater knowledge retention or comfort level than participation in the written patient case. Students’ knowledge improved post-intervention regardless of which teaching method was used. Conclusions. Although further research is needed to determine whether the use of simulation in the PharmD curriculum is equivalent or superior to other teaching methods, students’ enthusiasm for learning in a simulated environment where they can safely apply patient care skills make this technology worth exploring.

Indacaterol: A Novel Long-Acting β2-Agonist

Bronchodilator drugs are the foundation for the treatment of chronic obstructive pulmonary disease. The principal inhaled bronchodilator treatments used are β2‐agonists and anticholinergics, either alone or in combination. Currently available β2‐agonists are of either short duration and used multiple times/day, or of long duration, which requires twice‐daily administration. Indacaterol is considered an ultra–long‐acting β2‐agonist and was recently approved for use in the United States. Its duration of action is approximately 24 hours, allowing for once‐daily administration. Cough was the most commonly reported adverse effect with use of indacaterol. Cough usually occurred within 15 seconds of inhalation of the drug, lasted around 6 seconds, was not associated with bronchospasm, and did not cause discontinuation of the drug. Otherwise, the drugs safety profile was similar to that of other bronchodilators. Based on similar improvement in spirometric measurements compared with other bronchodilator drugs and the convenience of its once‐daily dosing, indacaterol may be beneficial in the management of mild‐to‐moderate chronic obstructive pulmonary disease, either alone or in combination with anticholinergic drugs administered once/day.

Tobramycin-Induced Hepatotoxicity

Objective: To report a case of tobramycin-induced hepatotoxicity. Case Summary: A 20-year-old female was hospitalized for treatment of Pseudomonas aeruginosa bacteremia and osteomyelitis. Empiric intravenous antibiotic therapy with piperacillin/tazobactam, vancomycin, and ciprofloxacin was started, and based on the results of culture and sensitivity testing, was changed to intravenous ceftazidime and tobramycin 70 mg every 8 hours on hospital day 3. Liver enzyme levels then increased over days 3–6. Tests for hepatitis A, B, and C were all nonreactive, and HIV testing was negative. On day 8, therapy was changed from ceftazidime to piperacillin/tazobactam and the tobramycin dose was increased to 100 mg every 8 hours. Due to a continued increase in total bilirubin, aspartate aminotransferase, and alanine aminotransferase, piperacillin/tazobactam was discontinued and aztreonam was started on day 10. All antibiotics were stopped on day 12 and the elevated liver parameters began to decrease. Aztreonam and ciprofloxacin were restarted on day 16, and most laboratory test results returned to baseline levels by day 19; total bilirubin and alkaline phosphatase decreased to lower than baseline values. Discussion: This case illustrates a possible occurrence of tobramycin-induced hepatotoxicity. Liver enzymes rose when tobramycin therapy was initiated, markedly increased when the tobramycin dose was increased, then resolved upon discontinuation of therapy. Other medication-related causes were ruled out by temporal relationship or rechallenge (aztreonam). Use of the Naranjo probability scale indicated a possible relationship between hepatotoxicity and tobramycin therapy. Other adverse reaction scales specific for evaluation of drug-induced liver disease were also used. Both the Council for International Organizations of Medical Sciences and Maria and Victorino scales indicated a probable likelihood of tobramycin-induced hepatotoxicity. This patient was not rechallenged with tobramycin due to the highly suggestive timeline present, lack of specific symptoms, and unnecessary risk to the patient. Conclusions: Although no other case reports on this interaction have been published through October 9, 2007, historical data from tertiary sources reveal the possibility of aminoglycoside-induced hepatotoxicity; therefore, tobramycin-induced hepatotoxicity cannot be ruled out in this patient. Clinicians should be aware of this adverse event.

Impact of an educational intervention on steroid prescribing and dosing effect on patient outcomes in COPD exacerbations

The increasing number of patients affected by chronic obstructive pulmonary disease (COPD) and associated exacerbations has led to both rising hospital admissions and significant economic impact. Evidence-based guidelines have been formulated for COPD management recommending the use of low dose, oral corticosteroid therapy in the treatment of exacerbations. However, fewer than 50% of physicians’ prescribing practices appropriately reflect the published clinical guidelines on the use of systemic corticosteroids in these patients. Objective The purpose of this study was to evaluate the impact of a pharmacist-led educational intervention on prescribing practices and patient outcomes when using systemic corticosteroids in patients with COPD exacerbations. Methods This retrospective case-control study included patients admitted to an inpatient family medicine service with a COPD exacerbation who received systemic corticosteroids. Two pharmacist-led educational interventions were delivered to prescribers to review current guidelines for managing COPD exacerbations with systemic corticosteroids. Patients were retrospectively identified over a three month span prior to and following the educational intervention. Data was collected via chart review to evaluate prescribing practices prior to and following the educational sessions. In addition, data was collected to evaluate the effects of an educational intervention on length of stay, adverse events, and cost of treatment. Results A total of 23 pre-intervention patients and 18 post-intervention patients met inclusion criteria. After pharmacist-led interventions, guidelines were not more likely to be adhered to by prescribers when compared to guideline adherence in the pre-intervention patients. Because no statistically significant change in guideline adherence was observed, there was no impact on secondary outcomes. Conclusion Pharmacist-led didactic educational interventions and guideline dissemination do not improve guideline adherence and prescribing practices with respect to systemic corticosteroids in COPD exacerbations.

Case Report - Aripiprazole-Induced Diabetic Ketoacidosis: Remaining Vigilant

Purpose A case of hyperglycemia and subsequent diabetic ketoacidosis (DKA) possibly associated with aripiprazole use in an adult patient with no previous history of diabetes mellitus is reported. Summary A 55-year-old man presented to the emergency department with altered mental status and complaints of nausea, vomiting, and abdominal pain. The patients past medical history was significant only for depression and hyperlipidemia. His home medications included sertraline 200 mg once daily and aripiprazole 10 mg once daily, which was initiated 6 months prior. The patient had no documented history of diabetes mellitus. Laboratory test results at the time of admission revealed hyponatremia, elevated serum creatinine, a blood glucose of 714 mg/dL, elevated amylase and lipase, and ketonuria. The patients hemoglobin A1C was 13.5%. DKA was diagnosed. The patient was admitted to the hospital and given a normal saline bolus and infusion. Home medications were not continued. An insulin infusion was also initiated. On the second day of admission, his blood glucose continued to decrease, the insulin infusion was slowly titrated down, and NPH was started. On hospital day 3, the NPH was increased and the insulin infusion was discontinued. The patient was discharged home following 4 days of hospitalization on insulin therapy and aripiprazole was not restarted. Conclusions Although the glucose dysregulatory effect of aripiprazole is not widely appreciated, our case report emphasizes the importance of monitoring patients who receive any atypical antipsychotic, particularly aripiprazole, for glucose and metabolic abnormalities.

Do Medication Samples Jeopardize Patient Safety

BACKGROUND Medication samples are commonly dispensed by prescribers. Written consumer medication information (CMI) provided with sample packaging is an important source of patient information. Although one-third of Americans have health literacy deficiencies, previous studies have found that CMI is often too complex for many patients to understand. This may prevent patients from using these medications appropriately. OBJECTIVE To evaluate readability and formatting characteristics of CMI included with nonsolid (ie, topical cream/lotion, inhalation, transdermal) drug samples. METHODS We collected a convenience sample of nonsolid dosage sample medications (N = 55) from several different private and university-affiliated primary care and specialty physician practices at a large academic medical center in the southeastern US. We noted whether CMI was present and, if it was, we assessed it for instruction presentation, reading level, text size, format/layout, and comprehensibility. RESULTS Most (43 of 55) products included CMI, either as a separate leaflet or directly on the packaging. Reading level of CMI leaflets ranged from the 6th- to 14th-grade level, with just 4 (16.0%) written at the recommended 6th-grade level. Text font point size was 9.48 ± 2.14 (mean ± SD; range 5–12). Text printed directly on sample packaging averaged 6.61 point ± 2.62 (4–11) font size. Ninety-two percent of CMI leaflets included a combination of text and pictures; only 11.1% of CMI printed directly on the packaging used pictorial aids. CONCLUSIONS Most CMI accompanying nonsolid medication samples is written at a reading level that exceeds that of many consumers and does not meet recommended standards for readability and comprehensibility of patient education material.

Development and implementation of an interdisciplinary pulmonary care clinic within an existing clinic program.

Asthma and chronic obstructive pulmonary disease (COPD) continue to impose noteworthy public health burdens. In the United States, COPD is the third leading cause of death, claiming approximately 138,000 lives annually, while asthma exacerbations contribute to over 1.8 million emergency room visits

Intractable Epistaxis With Febuxostat

Objective To report a case of serious, intractable epistaxis warranting an emergency department (ED) visit and hospital admission for transfusion following initiation of febuxostat. Case Summary An 86-year-old female presented to the ED after onset of intractable epistaxis for the previous 24 hours. Medications included aspirin, clopidogrel, metoprolol tartrate, valsartan, rosuvastatin, levothyroxine, esomeprazole, and febuxostat. She was treated with prednisone in the ED for a gout flare 3 weeks prior to the current visit, then was started on febuxostat at her follow-up primary care visit. Ten days after starting febuxostat therapy, she had onset of epistaxis. Initial treatment did not provide hemostasis and hemoglobin, and hematocrit values decreased. She was admitted and transfused. Aspirin, clopidogrel, and febuxostat were held during hospitalization. Bleeding subsided following bedside cautery. On hospital day 3, she restarted aspirin and clopidogrel and was discharged with no recurrence of bleeding. Discussion Epistaxis is relatively common and can be caused by multiple etiologies. Patient did not have prior episodes of epistaxis and had been on all medications for more than a year, except for febuxostat. This patient was also taking aspirin and clopidogrel; however, she had been taking these agents concomitantly for at least 4 years with no prior report of bleeding. Epistaxis occurred 10 days after the first dose of febuxostat with no other reported changes. Conclusions Epistaxis due to febuxostat use cannot be ruled out. Clinicians may consider alternate gout therapy in patients at high risk or taking medications that increase their risk for bleeding.

Transforming Health Care Through Interprofessional Graduate Education

PURPOSE We provide an overview of the Recovery-based Interprofessional Distance Education (RIDE) rotation for graduate students in psychiatric mental health (PMH) nursing, pharmacy, nutrition, and exercise physiology, with faculty from the four professions represented. CONCLUSIONS Interprofessional education can enhance team concepts in these professions and is viewed positively by students and faculty. PRACTICE IMPLICATIONS Interprofessional learning opportunities prepare graduates to contribute to team-based care. We urge colleagues to join us in providing meaningful IPE experiences to students at all levels, with the goal of optimizing health care for all persons with mental health treatment needs.

Book Review: Clinical Handbook of Psychotropic Drugs, 18th Revised Edition

Therapeutic Area: This bookaddresses various areasof medication safetyandapplies themto thepractice of pharmacy within theemergency department (ED). Format: This is a softcover bookcomposed of 22 chapters and 3 appendices. Audience: The intended audience includes alliedhealthprofessional students, residents, andpractitioners. Purpose: This book, intendedto be an introduction to the ED, providesa description of the pharmacists roleor pharmacy services within the ED and provides instructionon how a pharmacist should respond during emergency care. Content: Thisbookis divided into5 sections thatcontain 22 chapters and3 appendices. Thefirstsection discusses howgeneral careis provided in an ED and identifiesbarriersto safe medication use and regulatory compliance. It alsoprovides an introduction to the roleof thepharmacist within the ED and includes a model for safe medication use (the PharmERpyramidmodel).The secondsectionprovidesdiagramsand casestudies to illustrate gapsthatmayexistin theEDmedication usesystemanddescribes howthesegapscontribute to adverse outcomes. It also expands uponthePharmER model by highlighting waysto improve safe medication ordering anddelivery and illustrates how pharmacy services maycontribute to a safersystem. The third section focuses on howto provide high-quality emergency pharmacotherapy. Usingexamplesfrom Maimonides Medical Center, it describes howthe pharmacy department canhelptheinstitution havean impact onquality indicators, antimicrobial stewardship, toxicology, critical careemergencies, clinical decision support,medication reconciliation, andspecial populations suchas geriatric, pediatric, and obesepatients within theED.Thefourth section focuses on preparing pharmacy students, residents, and technicians to providesafe andquality pharmacotherapy in theED byproviding descriptions of variousrolesandactivities. It alsoprovides a blueprint for training pharmacy residents, usingexamples from Maimonides Medical Centerandthe1JYJ7 Emergency Medicine Modelof Practicefor medical residency training andtheeducational goals andlearning objectives of theAmerican Society of Health-System Pharmacists. The fifthsectioncontains3 appendices thatprovide examples of policies and procedures, dosingguidelines, tables,andeducational information aboutemergency medicine. Usability: This book uses a varietyof resources,including primary literature and national initiatives, to provide a goodintroduction to emergencymedicine pharmacy. It willbe mostusefulfor institutions implementing pharmacy services in the ED or those creating emergency medicine training programs forpharmacy students and residents. It may also be useful for institutions withlimitedpharmacy services in the ED, as it may provideexamplesof waysto extendor enhancetheircurrent services. It wi11 be lessuseful for institutions thatalready havededicated, full-time emergency medicine pharmacists. Highlights: The textprovides a general overview of the limiteddata supporting pharmacyservicesfor the ED, and specificcase studiesare used as examples to support safe pharmacotherapy. Using high alert medications as an example,it explains how adverseeventsoccurwhen medication reconciliation is not performed in the ED and patientsafety is impacted. It describes the controversy and resistance to the National PatientSafetyGoal. It also providesgoodexamplesof problems in the medication usesystem thatcan be measured beforeandafterimplementingchanges to pharmacy services or systems. Limitations: This is the firsteditionof thisbook,and it is limited by the amountof published pharmacy literature to supportservices within the ED. Also, the book uses examples mainly from one institution, which maylimitthe number of examples andideasit provides. Comparison with Other Related Booksor Products: This book is similarto othermedication safetybooks,but it provides moreexamples andcasestudiesof pharmacy interventions andpolicies and procedures thatareunique to emergency medicine. Reviewers Summary: Overall,the authorhas provided a reviewof howpharmacyservices can positively impactsafepharmacotherapy in theED. Since this is uncharted territory for manyinstitutions, the book can serveas a tool for pharmacy departments implementing emergency medicine services, clerkships, or residency rotations. The text is limited by its description of services at a smallnumberof sitesand also by the limited dataavailable in thisunique practice area. It canchallenge institutionsthatalready havetheseservices to evaluate theircurrent practice and publish literature to support the future ofemergency medicine pharmacy. Reviewer: NancyC MacDonald PharmDBCPS,Clinical Coordinator,Department of Pharmacy Services, HenryFordHospital, Detroit, MI