Vincent C. Dennis

A Review of Pharmacist Contributions to Diabetes Care in the United States

This paper summarizes the outcomes associated with pharmacist involvement in diabetes care in all pharmacy practice settings. Published literature was identified through a search of MEDLINE (1960 to September, week 1, 2008) and International Pharmaceutical Abstracts using the search terms “pharmacist,” “pharmaceutical care,” and “diabetes mellitus.” Only articles reporting clinical or behavior change outcomes were selected for review; papers written outside the United States and citations only in abstract form were not reviewed. The specific data extracted included the following: practice setting, model of care, roles of the pharmacist, study design, number of patients studied, duration of the evaluation, and documented outcomes such as changes in hemoglobin A1c values, adherence to standards of care (lipids, blood pressure, eye exams, foot exams, aspirin use), and changes in quality of life. The greatest improvements in hemoglobin A1c values tend to be observed when pharmacists work in collaborative practice models. Growing evidence demonstrates that pharmacists, working as educators, consultants, or clinicians in partnership with other health care professionals, are able to contribute to improved patient outcomes.

The Use of Alternate-Day Lovastatin in Hypercholesterolemic Men

OBJECTIVE: To quantitate the therapeutic effects of alternate-day lovastatin on serum lipoprotein values in a small group of men with primary hypercholesterolemia. DESIGN: Retrospective review of medical, pharmacy, and laboratory records. A paired Students t-test was performed on absolute changes in lipoprotein values with an a priori p value less than or equal to 0.05 being statistically significant. SETTING: A lipid clinic within a tertiary care Department of Veterans Affairs Medical Center. PATIENTS: Twenty men (mean age 62.5 ± 8.3 y) with mean ± SD baseline low-density lipoprotein cholesterol (LDL-C) concentration of 161.3 ± 21.9 mg/dL and triglyceride concentrations below 400 mg/dL. INTERVENTION: All patients had been prescribed lovastatin 20 mg every other day. MAIN OUTCOME MEASURES: The mean absolute and percent changes in lipoprotein values from baseline for patients receiving lovastatin 20 mg every other day and the percentage of patients attaining a target mean LDL-C concentration as defined by the National Cholesterol Education Panel Adult Treatment Panel II guidelines. RESULTS: Mean ± SD total cholesterol and LDL-C were significantly reduced by 32.4 ± 17.8 (14.0% ± 7.8%) and 34.1 ± 14.6 mg/dL (21.5% ± 9.7%), respectively. No significant changes were seen in high- density lipoprotein cholesterol or triglycerides. Four of 20 patients (20%) attained a goal LDL-C concentration. CONCLUSIONS: Lovastatin 20 mg every other day may effectively lower LDL-C in some elderly men, and target LDL-C concentrations may be obtained in some patients.

Doxercalciferol Treatment of Secondary Hyperparathyroidism

Objective: To review the pharmacology, pharmacokinetics, effectiveness, safety, and therapeutic considerations related to the use of doxercalciferol in the treatment of secondary hyperparathyroidism. Data Sources: A MEDLINE search (1966–June 2006) was conducted using the key words vitamin D, ergocalciferols, and secondary hyperparathyroidism. Text word searches were also performed for the terms 1-ά-hydroxy-vitamin D2,1-ά-hydroxyergocalciferol, Hectorol, and doxercalciferol. Searches were limited to studies published in English and conducted in human subjects. Study Selection and Data Extraction: All published clinical studies evaluating the safety and effectiveness of doxercalciferol in secondary hyperparathyroidism were reviewed, and anecdotal patient reports were also evaluated. Selected clinical studies involving the use of calcitriol and/or paricalcitol in the treatment of secondary hyperparathyroidism were also included. Data Synthesis: Doxercalciferol effectively reduces parathyroid hormone levels in patients with chronic kidney disease (CKD). Both oral and intravenous administration can significantly increase serum calcium and/or phosphorus levels as evidenced by placebo-controlled clinical trials. This agent has not been studied comparatively with calcitriol or paricalcitol to assess relative safety. Conclusions: Doxercalciferol is approved for and effective in the treatment of secondary hyperparathyroidism related to CKD, both before and during dialysis, but has not demonstrated a lower incidence of hypercalcemia and/or hyperphosphatemia in relation to other vitamin D therapies. The drug is available in both oral and intravenous dosage forms. Doxercalciferol should be maintained as a formulary alternative for patients unresponsive to or intolerant of other vitamin D therapies, but comparative randomized studies are needed to differentiate its place in therapy.

Integration of an Introductory Pharmacy Practice Experience With an Advanced Pharmacy Practice Experience in Adult Internal Medicine

Objective. To describe the development, implementation, and assessment of an internal medicine introductory pharmacy practice experience (IPPE) that was integrated with an existing advanced pharmacy practice experience (APPE) in internal medicine. Design. A structured IPPE was designed for first-, second-, and third-year pharmacy (P1, P2, and P3) students. Activities for the IPPE were based on the established APPE and the individual learners educational level. Assessment. Students reported a greater understanding of clinical pharmacists’ roles, increased confidence in their clinical skills, and better preparation for APPEs. Peers viewed the approach as innovative and transferable to other practice settings. Participating faculty members provided a greater number of contact hours compared to traditional one-time site visits. Conclusions. Integrating an IPPE with an existing APPE is an effective and efficient way to provide patient care experiences for students in the P1-P3 years in accordance with accreditation standards.

Potentiation of oral anticoagulation and hemarthrosis associated with nabumetone.

Concomitant therapy with warfarin and nonsteroidal antiinflammatory drugs (NSAIDs) is of concern due to the potential for increased bleeding. Nonsteroidal antiinflammatory drugs may alter patient response to warfarin by pharmacodynamic or pharmacokinetic interactions. A man receiving long‐term, stable warfarin therapy experienced a significant increase in international normalized ratio 1 week after nabumetone was added to his regimen. Despite prompt reduction of the warfarin dosage, he experienced hemarthrosis of his right knee. Previous reports suggested lack of interaction between nabumetone and warfarin. Caution and close monitoring are advisable when the two agents are administered concomitantly.

Pharmacy Preceptors' Views on the Value and Optimal Frequency of Quality Assurance Visits to Advanced Pharmacy Practice Experience Sites

Objective. To determine volunteer preceptors’ perceived value and desired frequency of quality assurance visits by experiential education faculty members. Methods. An electronic survey instrument was sent to 235 volunteer preceptors. Results. A 71.5% response rate was achieved. Nearly 90% of respondents indicated that onsite visits met their needs. Approximately 50% of respondents preferred monthly onsite visits, 17% preferred every other month, and 32% preferred once per year. Conclusions. A quality assurance program for preceptors and experiential sites that includes onsite visits from experiential education faculty members meets multiple needs of the college and the preceptors. More research is needed to determine the impact of this method of quality assurance on experiential education.

Practice Experiences at a Single Institutional Practice Site to Improve Advanced Pharmacy Practice Examination Performance

Objective. To determine whether sequential assignment of students to the same facility for institutional practice experiences improves their advanced pharmacy practice experience (APPE) examination scores. Design. Student volunteers were assigned to the same healthcare facility for all institutional introductory pharmacy practice experiences (IPPEs) and advanced pharmacy practice experiences (APPEs). Other students completed institutional IPPEs and APPEs at separate healthcare facilities, ranging from 2 to 4 different facilities per student. APPE examination scores of students assigned to the same facility for all institutional learning experiences were compared with those of students assigned to more than 1 institutional practice site. Assessment. Holding grade point average constant, students assigned to the same facility for institutional IPPEs and APPEs scored 3 percentage points higher on the APPE institutional examination compared with students assigned to separate facilities for these experiences. Conclusion. Assigning students to the same facility for both institutional IPPEs and APPEs positively influenced knowledge-based APPE examination performance.

Comparison of Aseptic Compounding Errors before and after Modified Laboratory and Introductory Pharmacy Practice Experiences

Objective. To determine whether aseptic compounding errors were reduced at the end of the third professional year after modifying pharmacy practice laboratories and implementing an institutional introductory pharmacy practice experience (IPPE). Design. An aseptic compounding laboratory, previously occurring during the third-year spring semester, was added to the second-year spring semester. An 80-hour institutional IPPE was also added in the summer between the second and third years. Instructors recorded aseptic compounding errors using a grading checklist for second-year and third-year student assessments. Third-year student aseptic compounding errors were assessed prior to the curricular changes and for 2 subsequent years for students on the Oklahoma City and Tulsa campuses of the University of Oklahoma. Assessment. Both third-year cohorts committed fewer aseptic technique errors than they did during their second years, and the probability was significantly lower for students on the Oklahoma City campus. The probability of committing major aseptic technique errors was significantly lower for 2 consecutive third-year cohorts after the curricular changes. Conclusion. The addition of second-year aseptic compounding laboratory experiences and third-year institutional IPPE content reduced instructor-assessed errors at the end of the third year.