Evaluation and revision of an introduction to experiential rotations course

The objectives of this study were to evaluate the perceived student value of topics taught in Butler University’s Introduction to Experiential Rotations (RX500) course, implement course revisions to address any perceived weaknesses, and to reassess the course following implementation of those course revisions. Advanced Pharmacy Practice Experience (APPE) students from Butler University’s 2012 doctorate of pharmacy class were initially surveyed to assess the perceived usefulness and design of RX500. Based on the findings of the initial data, course revisions were developed and implemented for the following semester’s RX500 course. In order to assess for potential changes in the perceived value of the course following implementation, a follow-up survey was sent to students completing the revised course in the fall of 2012. Fifty-eight students completed the initial survey in the fall of 2011, and 34 completed the follow-up survey in the fall of 2012. The majority of students in both groups had completed at least four APPE experiences at the time of survey completion. Both of the study groups rated hands-on activities and visual presentations as their most beneficial learning styles within the classroom setting. Based on the initial survey findings, two topics were removed from the course, two topics were revised within the course, and three topics were added to the course. The follow-up survey results indicated an increased perceived usefulness of the two revised topics; however, the three new topics added to the course had mixed results. Faculty can continue to work on delivery of newer topics being added to the APPE preparation course

Dietary Supplement Education in a Senior Population

Background. Dietary supplements are widely used among United States senior citizens for various indications. Potential dangers with supplement use include the lack of regulation by the Food and Drug Administration (FDA) and the possibility for drug-supplement interactions. Senior focused education may in- crease the safe use of dietary supplements by older adults. Objective. The primary objective of this study was to determine the effectiveness of a pharmacist driven educational seminar in a local senior population. Methods. Participants aged 55 years and older in one of three senior programs were eligible for inclusion. Initially, a needs-assessment interview was con- ducted at a health fair. At that time, interviews focusing on dietary supplement use were delivered to study participants. Following the health fair, inter- view responses were analyzed to determine the most commonly used dietary supplements. During the second phase of the project, an educational seminar focusing on general dietary supplement information and the most commonly used supplements in the phase one population was created and delivered. Pre- and post- surveys were administered at the seminar to gauge baseline knowledge and impact of pharmacist education. Additionally, results were analyzed for any change in attitudes about dietary supplements. Results. Forty-nine participants were interviewed about their use of dietary supplements at the initial health fair. Among these participants, 81.6% were taking at least one supplement. The most commonly used supplements were calcium (n = 23), multivitamins (n = 22), fish oil (n = 13), and vitamin B (n = 12). Approximately 180 participants attended the subsequent educational seminar. Knowledge statistically significantly improved from baseline for all six questions posed to study participants. Overall, the program was well received and attitudes about dietary supplements changed as a result of viewing the seminar. Conclusions. Dietary supplements were commonly used by the study population for various indications. Education by pharmacists is an effective method to in- crease knowledge and awareness about dietary supplements among this population

Lipid Goals: Update on their Status

Goal: The goal of this lesson is to discuss current medical management of dyslipidemias, including available agents and goals of therapy, as well as potential future treatment strategies based on recently published literature

Analysis of a Standardized Perioperative Pain Management Order Set in Highly Opioid-Tolerant Patients

Objective: The aim was to assess a standardized order set for perioperative pain management in highly opioid-tolerant patients undergoing elective orthopedic surgery.Methods: This retrospective chart review evaluated a pain order set in highly opioid-tolerant patients undergoing elective total knee or total hip arthroplasty from January 2010 through August 2012. Based on the date of the surgery, patients were allocated into preimplementation or postimplementation order set groups. The primary outcome assessed whether an adjustment in daily opioid dosage was required within the first 48 hours postoperatively. Secondary outcomes included pain scores, length of hospitalization, and safety outcomes.Results: Sixty patients were included in the analysis. An adjustment to postoperative opioid therapy occurred in 62% of the patients in the preimplementation group and in 56% of postimplementation group patients (P = 0.786). There were no differences in median pain scores 48 hours postoperatively (P = 0.348). Cumulative toxicity was increased after order set implementation compared with previous patients (44% versus 5%, P \u3c 0.005); however, opioid doses held for sedation was the only individual toxicity to reach statistical significance (P = 0.011).Conclusions: This study is the first to evaluate a standardized order set for pain management in highly opioid-tolerant patients undergoing elective orthopedic surgery. The order set demonstrated similar efficacy to previous treatment modalities, but opioid-induced sedation was of concern with the order set. After the initial analysis, the order set was modified to minimize opioid-induced sedation. Continual safety analysis is warranted for quality improvement to enhance perioperative pain management in highly opioid-tolerant patients

Simvastatin: A Risk Factor for Angioedema?

Objective. To report a case of simvastatin-induced angioedema in a patient with near nightly episodes of orofacial angioedema. Case Summary. A 75-year-old African American female presented to the emergency department with recurrent face, lip, and tongue swelling. The patient described frequent episodes of orofacial edema, with 4 emergency department visits over the previous 6 months. Her home medications were reviewed and simvastatin was identified as a possible contributing medication. Simvastatin was discontinued with resolution of the symptoms during hospitalization and a significant reduction in episodes. Discussion. Drug-induced angioedema has been documented with several agents, most commonly angiotensin-converting enzyme inhibitors. The association with different drug classes has led to several postulated pathways for the development of angioedema. Notable mechanisms include mediation by bradykinin, inhibition of arachidonic acid metabolism, and complement activation. Each pathway culminates in increasing vascular permeability causing fluid accumulation in subcutaneous tissues. While statin use has been associated with drug-induced angioedema in postmarketing reports, there are no published cases involving simvastatin. Use of the Naranjo probability scale demonstrated a probable relationship between simvastatin use and the patient’s recurrent angioedema. Conclusions. While statin use is not commonly associated with angioedema, clinicians must be aware of this possible adverse reaction. Consideration must also be given to potential drug interactions, increasing the risk of this adverse event

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

GLP-1 Agonists in Type 1 Diabetes Mellitus: A Review of the Literature

Objective: To review the use of GLP-1 agonists in patients with type 1 diabetes mellitus (T1DM). Data Sources: A search using the MEDLINE database, EMBASE, and Cochrane Database was performed through March 2016 using the search terms glucagon-like peptide 1 (GLP-1) agonists, incretin, liraglutide, exenatide, albiglutide, dulaglutide, type 1 diabetes mellitus. Study Selection and Data Extraction: All English-language trials that examined glycemic end points using GLP- 1 agonists in humans with T1DM were included. Data Synthesis: A total of 9 clinical trials examining the use of GLP-1 agonists in T1DM were identified. On average, hemoglobin A1C (A1C) was lower than baseline, with a maximal lowering of 0.6%. This effect was not significant when tested against a control group, with a relative decrease in A1C of 0.1% to 0.2%. In all trials examined, reported hypoglycemia was low, demonstrating no difference when compared with insulin monotherapy. Weight loss was seen in all trials, with a maximum weight loss of 6.4 kg over 24 weeks. Gastrointestinal adverse effects are potentially limiting, with a significant number of patients in trials reporting nausea. Conclusion: The use of GLP-1 agonists should be considered in T1DM patients who are overweight or obese and not at glycemic goals despite aggressive insulin therapy; however, tolerability of these agents is a potential concern. Liraglutide has the strongest evidence for use and would be the agent of choice for use in overweight or obese adult patients with uncontrolled T1DM

Geriatric and Student Perceptions following Student-led Educational Sessions

Objective: The objective of this study was to measure the effect of student-led educational events on geriatric patient and student participant perceptions in a community setting. Methods: Students led three events at a senior community center, focusing on learning and memory, sleep hygiene, and arthritis pain. The participants were geriatric patients who themselves were providers of support to homebound peers (“clients”) through an independently organized program. Geriatric participants completed pre- and post-event surveys to measure changes in familiarity with the topics. Student participants also completed pre- and post-event surveys that tracked changes in their comfort in working with the geriatric population. Results: Each event demonstrated at least one positive finding for geriatric patients and/or their clients. Students reported increased comfort in working with and teaching the geriatric population following the first and third events, but not the second. Conclusion: Student-led educational sessions can improve perceived health-related knowledge of geriatric participants while simultaneously exposing students to the geriatric patient population. Overall, both students and geriatric participants benefited from these events. Practice Implications: Incorporation of single, student-led educational events could be mutually beneficial to students and the elderly population in the community and easily incorporated into any healthcare curriculum. Funding:This work was supported by a Butler University Innovation Fund Grant. Treatment of Human Subjects: IRB review/approval required and obtained   Type: Original Researc

Prescriptions for Bedtime Sedatives After the Introduction of a General Admission Order Set at an Academic Health Center: The Potential and Pitfalls of Order Sets.

OBJECTIVE: This study describes the impact of modifications to a general admission order set on physician prescribing of 2 as-needed or pro re nata (PRN) bedtime sedatives. METHODS: The hospitalists at our institution have used a general medical admission order set since 2005. Zolpidem was the only as-needed (PRN) bedtime sedative option on the order set until trazodone was added in December 2008. Trazodone is preferred over zolpidem in the geriatric population. We identified patients admitted by the hospitalists between January 2007 and August 2013 who were prescribed with either zolpidem or trazodone as a PRN sedative. Patient demographics, date and time of the order, and number of sedative doses administered during the hospitalization were recorded. Orders placed within 12 hours of admission were attributed to admission orders. RESULTS: Between 2007 and 2013, the number of patients admitted by the hospitalists with an order for PRN trazodone on admission increased by 18-fold. During the same period, the number of admissions by the hospitalists increased by 2.3 times. Zolpidem orders exceeded those for trazodone in all age groups until 2008. After the addition of trazodone, its use exceeded that of zolpidem. Almost half (48%) of all patients did not have a dose of the PRN trazodone administered. CONCLUSIONS: Although order sets can be leveraged to align practitioners with established guidelines, the expediency of using medications on an order set may overcome physicians\u27 clinical judgment. The content of an order set therefore deserves careful scrutiny before implementation

Strategies for the Management of Postoperative Anemia in Elective Orthopedic Surgery

Objective: To assess the use of oral iron, intravenous (IV) iron, and erythropoiesis-stimulating agents (ESAs) for the prevention and management of perioperative anemia in elective orthopedic surgery patients, and to provide a clinical algorithm for use. Data Sources: A PubMed and MEDLINE search was conducted from 1964 through March 2016 using the following search terms alone or in combination: orthopedic, surgery, elective, anemia, blood transfusion, iron, erythropoiesisstimulating agents, and erythropoietin. Study Selection and Data Extraction: All English-language prospective and retrospective human studies and meta-analyses evaluating oral iron, IV iron, or ESA alone or in combination in elective orthopedic surgery patients were evaluated, provided they reported blood transfusion outcomes. Data Synthesis: A total of 9 prospective and retrospective studies and 1 meta-analysis were identified and included. In the preoperative setting, administration of oral iron, IV iron, or ESA alone or in combination to correct underlying anemia led to significantly reduced transfusion rates. Transfusion requirements were generally less with combination therapy (ESA + oral or IV iron). In the short-term perioperative or postoperative period, use of oral or IV iron led to conflicting results, with some reporting a statistically significant reduction in blood transfusions, whereas others reported none. Conclusions: In elective orthopedic surgery, IV or oral iron with or without an ESA may provide benefit in prevention of postoperative anemia and results in blood transfusion reduction without significantly increasing the risk of adverse events. These agents should be considered at the lowest effective dose with emphasis on administration prior to planned surgery