Implementation of a series of advanced pharmacy practice experience (APPE) preparatory topics into a skills lab curriculum.

BACKGROUND AND PURPOSE: Advanced pharmacy practice experiences (APPEs) play a significant role in readying students for professional practice. Factors beyond traditional knowledge and skills taught in the didactic curriculum may play a role in APPE success. The purpose of this manuscript is to describe an activity implemented within a third-year skills lab focused on APPE preparedness, the methods used, and student feedback related to the series. EDUCATIONAL ACTIVITY AND SETTING: Experiential and skills lab faculty collaborated to generate advice for students regarding common misconceptions or areas of difficulty encountered on APPEs. The advice was developed into short topics that were paired with and presented at the start of most lab sessions with impromptu contributions from faculty and facilitators integrated at the time of delivery. FINDINGS: One hundred twenty-seven third-year pharmacy students (54% of the cohort) consented to complete a follow-up survey and provided feedback on the series. Most students agreed or strongly agreed with the elements evaluated, providing positive feedback for all ranked statements. Feedback from free-text response questions indicated that many students found all topics presented to be beneficial and suggested that topics of interest for the upcoming semester included advice regarding residencies/fellowships/employment, wellness, and communication with preceptors. SUMMARY: Student feedback indicated an overall perception of benefit and value from most respondents. Implementation of a similar series in other courses is a potential area for future study.

Implementing interactive hiring activity in pharmacy management education.

BACKGROUND AND PURPOSE: A major element of management is the process of hiring employees. The purpose of this brief is to describe the implementation of a human resources learning activity asking students to choose an employee to hire, describe student responses, and explore student perspectives of the activity. EDUCATIONAL ACTIVITY AND SETTING: An interactive hiring activity was presented to third-year students (n = 386) at two different institutions, with varied classroom settings. Students were provided with candidates' curricula vitae and then completed a student-led interview using scripted questions presented in a PowerPoint format. The activity asked students to hire one candidate from five qualified candidates of varying backgrounds and traits. A Qualtrics survey collected students' individual hiring choice, hiring rationale, participant demographic information, and activity perceptions. Demographics and candidate choice were assessed using descriptive analysis. Open-ended answers were analyzed for frequency of terms, followed by a latent class analysis. FINDINGS: Over 90% of students (n = 386) completed the post-activity survey. Demographic data between student cohorts varied, with only student age similar. Hired candidates differed by institution with one college expressing preference for a specific candidate and the other demonstrating a greater diversity of candidate preferences. Influencing factors on student choice were numerous. Overall, students reported a favorable experience with the activity. SUMMARY: This management hiring activity allowed students to engage in the practice-ready skills of hiring pharmacy technicians in an interactive classroom activity. This activity allowed the educators involved to develop hypotheses about student preferences in hiring for future study.

Oral Semaglutide: The First-available Noninjectable Glucagon-like Peptide 1 Receptor Agonist.

PURPOSE: There are roughly 30 million Americans diagnosed with diabetes mellitus (DM), with nearly 95% of these cases being type 2 (T2)-DM. The American Diabetes Association continues to recommend metformin as the first-line initial treatment of T2DM, in combination with lifestyle modifications; yet, many require multiple therapies to achieve adequate glycemic control. In patients with atherosclerotic cardiovascular disease, heart failure, or chronic kidney disease, adding a glucagon-like peptide 1 receptor agonist is a preferred treatment option; however, many patients are apprehensive about injecting medications. Semaglutide is the first oral option in this life-saving medication class. The purpose of this article was to review the pharmacology, clinical trials, safety profile, along with recommended dosing and costs, of oral semaglutide used for managing patients with T2DM. METHODS: A search through the PubMed, MEDLINE and Cochrane libraries was conducted for literature published from January 2017 through December 2020, using the key word semaglutide. Articles were selected if they were related to the approval of oral semaglutide or provided novel clinical information regarding this drug entity in its oral dosage formulation. FINDINGS: Three Phase II studies of the pharmacokinetic properties and Phase III trials from the PIONEER series were ultimately selected, as these trials were thought to provide pivotal information to the US Food and Drug Administration for the approval of oral semaglutide. IMPLICATIONS: On review of the literature, it appeared that semaglutide is a viable option in treating T2DM. The use of this medication has been associated with glycosylated hemoglobin lowering similar to that with the injectable medication in its same class. Semaglutide was also showed some potential in preventing cardiovascular events as well as increasing weight loss.

Recommendations for integration of foundational and clinical sciences throughout the pharmacy curriculum.

INTRODUCTION: Pharmacy faculty have the often difficult task of translating and incorporating existing concepts and advances from the foundational sciences into the clinical sciences and practice. This commentary focuses on content integration as a curricular and educational strategy, outcomes data from integration, and recommendations for programs employing or considering curricular integration. COMMENTARY: Integration of foundational and clinical sciences across the curriculum has been emphasized in accreditation standards but met with mixed reactions by faculty across different disciplines in the academy. Many pharmacy programs have already incorporated some level of integration in didactic courses. However, most report coordination of curricular delivery rather than higher levels of integration in which different disciplines work together to design and deliver instructional materials across the entire curriculum. IMPLICATIONS: Curricular integration models should be optimized to minimize or eliminate the risks of marginalization of foundational sciences in pharmacy curricula. A significant problem in implementing curricular integration is determining the appropriate balance between foundational and clinical sciences. Well-designed curricular integration with ongoing reinforcement that builds in complexity over time could enhance knowledge retention, critical thinking abilities, and clinical decision making. Further research is needed into the outcomes achieved from various integrated curricular approaches in pharmacy education.

Ambulatory care elective: Introduction to core practice concepts.

BACKGROUND AND PURPOSE: Introduction to various pharmacy practice environments is effectively accomplished through concentrated elective courses. The ambulatory care elective utilized innovative active learning strategies to enhance chronic disease management, foster empathy, and introduce strategic planning in an ambulatory care center. EDUCATIONAL ACTIVITY AND SETTING: A new two-credit hour ambulatory elective course was offered to third-year pharmacy students in a four-year doctor of pharmacy program. This 30-hour, 2-week long course, ran simultaneously between three campuses, and included six modules. The course employed lectures, active learning activities, shadowing, role playing, and a simulation. FINDINGS: Course evaluations and student reflections indicate high satisfaction with the course and reveal value in the simulation. SUMMARY: Active learning sessions in this third-year pharmacy elective allowed application of lecture materials to explore the focused practice of ambulatory care. Discussion topics were varied, allowing students to gauge the breadth of opportunities offered in ambulatory pharmacy, while also appreciating the scope of skills required for successful and sustainable practice. Students valued the chronic disease state simulation, which provided a unique approach to foster personal attributes.

A framework for the development of a global standardised marine taxon reference image database (SMarTaR-ID) to support image-based analyses.

Video and image data are regularly used in the field of benthic ecology to document biodiversity. However, their use is subject to a number of challenges, principally the identification of taxa within the images without associated physical specimens. The challenge of applying traditional taxonomic keys to the identification of fauna from images has led to the development of personal, group, or institution level reference image catalogues of operational taxonomic units (OTUs) or morphospecies. Lack of standardisation among these reference catalogues has led to problems with observer bias and the inability to combine datasets across studies. In addition, lack of a common reference standard is stifling efforts in the application of artificial intelligence to taxon identification. Using the North Atlantic deep sea as a case study, we propose a database structure to facilitate standardisation of morphospecies image catalogues between research groups and support future use in multiple front-end applications. We also propose a framework for coordination of international efforts to develop reference guides for the identification of marine species from images. The proposed structure maps to the Darwin Core standard to allow integration with existing databases. We suggest a management framework where high-level taxonomic groups are curated by a regional team, consisting of both end users and taxonomic experts. We identify a mechanism by which overall quality of data within a common reference guide could be raised over the next decade. Finally, we discuss the role of a common reference standard in advancing marine ecology and supporting sustainable use of this ecosystem.

easySLM-STED: Stimulated emission depletion microscopy with aberration correction, extended field of view and multiple beam scanning.

We demonstrate a simplified set-up for STED microscopy with a straightforward alignment procedure that uses a single spatial light modulator (SLM) with collinear incident excitation and depletion beams to provide phase modulation of the beam profiles and correction of optical aberrations. We show that this approach can be used to extend the field of view for STED microscopy by correcting chromatic aberration that otherwise leads to walk-off between the focused excitation and depletion beams. We further show how this arrangement can be adapted to increase the imaging speed through multibeam excitation and depletion. Fine adjustments to the alignment can be accomplished using the SLM only, conferring the potential for automation.

Effect of Balloon-Expandable Transcatheter Aortic Valve Replacement Positioning: A Patient-Specific Numerical Model.

Transcatheter aortic valve replacement (TAVR) has emerged as a life-saving and effective alternative to surgical valve replacement in high-risk, elderly patients with severe calcific aortic stenosis. Despite its early promise, certain limitations and adverse events, such as suboptimal placement and valve migration, have been reported. In the present study, it was aimed to evaluate the effect of various TAVR deployment locations on the procedural outcome by assessing the risk for valve migration. The deployment of a balloon-expandable Edwards SAPIEN valve was simulated via finite element analysis in a patient-specific calcified aortic root, which was reconstructed from CT scans of a retrospective case of valve migration. The deployment location was parametrized in three configurations and the anchorage was quantitatively assessed based on the contact between the stent and the native valve during the deployment and recoil phases. The proximal deployment led to lower contact area between the native leaflets and the stent which poses higher risk for valve migration. The distal and midway positions resulted in comparable outcomes, with the former providing a slightly better anchorage. The approach presented might be used as a predictive tool for procedural planning in order to prevent prosthesis migration and achieve better clinical outcomes.

Tutorial on fiber-based sources for biophotonic applications.

Fiber-based lasers and master oscillator power fiber amplifier configurations are described. These allow spectral versatility coupled with pulse width and pulse repetition rate selection in compact and efficient packages. This is enhanced through the use of nonlinear optical conversion in fibers and fiber-coupled nonlinear crystals, which can be integrated to provide all-fiber pump sources for diverse application. The advantages and disadvantages of sources based upon supercontinuum generation, stimulated Raman conversion, four-wave mixing, parametric generation and difference frequency generation, allowing spectral coverage from the UV to the mid-infrared, are considered.

Patient satisfaction with extended-interval warfarin monitoring.

Extended-interval monitoring of warfarin has been proposed to reduce follow-up burden and improve patient satisfaction. We aimed to make an initial assessment of anticoagulation satisfaction before and after an extended-interval warfarin monitoring intervention. We conducted a translational prospective single-arm pilot study of extended-interval warfarin monitoring in five pharmacist-managed anticoagulation clinics. Patients meeting CHEST guideline criteria for extended-interval warfarin monitoring began progressive extended-interval follow-up (6, 8, and 12 weeks thereafter). The Duke Anticoagulation Satisfaction Scale (DASS) was administered at baseline and at end-of-study or study removal (in patients no longer appropriate for extended interval follow-up). Forty-six patients had evaluable pre- and post-intervention DASS survey data. Mean age of patients was 66.5 years, 74 % were non-Hispanic whites, and 48 % were men. Patients completed a mean ± SD of 34 ± 22 weeks of follow-up. Mean ± SD total DASS score at baseline was 45.2 ± 14.2 versus 49.1 ± 14.9 at end-of-study (mean change, +3.9 [95 % CI -0.6-8.4; p = 0.09]), indicating no benefit-and trending toward decrement-to anticoagulation satisfaction. Change in anticoagulation satisfaction varied substantially following extended-interval monitoring, with no evidence of improved satisfaction. Plausible reasons for patients not preferring extended-interval monitoring include increased anxiety and disengagement from self-management activities, both potentially related to less frequent feedback and reassurance during extended interval-monitoring. Additional research is needed to identify who is likely to benefit most from extended-interval monitoring. Anticoagulation satisfaction should be considered with clinical factors and shared-decision making when implementing extended-interval warfarin monitoring.

Feasibility of Extended-interval Follow-up for Patients Receiving Warfarin.

AIMS: The 2012 American College of Chest Physician Evidence-Based Management of Anticoagulant Therapy guidelines suggest an international normalized ratio (INR) testing interval of up to 12 weeks, rather than every 4 weeks, for patients with consistently stable INRs while taking vitamin K antagonists. We aimed to examine the feasibility of extended-interval follow-up in a real-world setting. METHODS: Patients receiving stable warfarin therapy for ≥ 12 weeks at baseline began extended-interval follow-up with visits occurring at 6 weeks, 14 weeks, and every 12 weeks thereafter to a maximum of 68 weeks or until they were no longer suitable for extended-interval follow-up. A single INR excursion >0.3 from goal was permitted if a reversible precipitating factor was identified and the INR was expected to return to goal without dose adjustment. The primary outcome was the proportion of patients completing all study follow-up visits. RESULTS: Of 48 patients enrolled, 47 had evaluable data. The most common indication for anticoagulation was atrial fibrillation/flutter (53.2%). At baseline, mean prior warfarin treatment duration was 6.7 ± 6 years and median number of weeks on a stable regimen was 24 weeks (IQR, 19-37.5). Eleven patients (23%) completed all study follow-up visits, whereas 17 (36%) did not maintain a stable INR past the 14-week follow-up. CONCLUSION: A large proportion of patients with previously stable (≥ 3 months) INRs were not able to maintain stable INRs during extended-interval follow-up. More research is needed to identify patient characteristics predictive of success with extended-interval follow-up prior to broad implementation.

Emerging new therapies for the treatment of type 2 diabetes mellitus: glucagon-like peptide-1 receptor agonists.

PURPOSE: The goal of this article was to review the safety, efficacy, and potential for utilization of the newly approved once-weekly glucagon-like peptide-1 (GLP-1) receptor agonists in the treatment of type 2 diabetes. METHODS: Published articles for Phase III trials were found by performing a MEDLINE search using the search terms exenatide, exenatide once weekly, DURATION, albiglutide, and HARMONY as key terms. Search results were restricted by using filters to include clinical trials in humans. A search of relevant diabetes journals (including Diabetes Care and Diabetologia) was also performed to find abstracts for studies that did not have complete published articles at the time of this review. FINDINGS: Exenatide once weekly reduced glycosylated hemoglobin (HbA1c) by -1.0% to -2.0% when used as monotherapy and add-on therapy; it also provided significant weight loss ranging from 2 to 4 kg and maintained a relatively low risk of hypoglycemia. Albiglutide was able to reduce glycosylated hemoglobin levels between -0.5% and -0.84% when used as monotherapy and in combination with other antidiabetic medications. The newest once-weekly GLP-1 receptor agonist, dulaglutide, reduced glycosylated hemoglobin levels between -0.78% and -1.51% and demonstrated noninferiority to once-daily liraglutide. IMPLICATIONS: The GLP-1 receptor agonists have proven efficacy in the treatment of type 2 diabetes and may provide patients with additional nonglycemic benefits, including significant weight loss and decreased systolic blood pressure. The newer once-weekly formulations are more convenient than the BID and once-daily medications, which could improve adherence and may be more attractive to providers and patients.

Sodium-glucose cotransporter 2 inhibitors: the new option for diabetes mellitus management.

Type 2 diabetes mellitus continues to be a challenging disease to manage successfully. Beyond the first-line option metformin, there are a number of classes of medications from which to select. This article reviews the new sodium-glucose cotransporter 2 inhibitors canagliflozin and dapagliflozin, including their benefits, adverse effects, and potential place in therapy. Upon review, the use of these medications has led to an A1c reduction between -0.37% and -1.16%. These medications also have been shown to reduce A1c when used with insulin. Some adverse effects were noted when using canagliflozin and dapagliflozin, with the most frequent being urinary tract infections and genital mycotic infections. We review the sodium-glucose cotransporter 2 inhibitors approved by the US Food and Drug Administration and their potential roles in the management of type 2 diabetes mellitus.

Combining a GLP-1 receptor agonist and basal insulin: study evidence and practical considerations.

Most patients with diabetes mellitus require multiple medications to achieve glycemic goals. Considering this and the increasing incidence of type 2 diabetes worldwide, the need for effective combination therapy is pressing. Basal insulin and glucagon-like peptide 1 (GLP-1) receptor agonists are frequently used to treat type 2 diabetes. Though both classes of medication are exclusively injectable, which may cause initial hesitation from providers, evidence for their combined use is substantial. This review summarizes the theoretical benefit, supporting evidence, and implementation of a combined basal insulin-GLP-1 receptor agonist regimen. Basal insulin added to a GLP-1 receptor agonist reduces hemoglobin A1c (HbA1c) without weight gain or significantly increased hypoglycemia. A GLP-1 receptor agonist added to basal insulin reduces HbA1c and body weight. Compared with the addition of meal-time insulin to basal insulin, a GLP-1 receptor agonist produces similar or greater reduction in HbA1c, weight loss instead of weight gain, and less hypoglycemia. Gastrointestinal adverse events are common with GLP-1 receptor agonists, especially during initiation and titration. However, combination with basal insulin is not expected to augment expected adverse events that come with using a GLP-1 receptor agonist. Basal insulin can be added to a GLP-1 receptor agonist with a slow titration to target goal fasting plasma glucose. In patients starting a GLP-1 receptor agonist, the dose of basal insulin should be decreased by 20 % in patients with an HbA1c ≤8 %. The evidence from 15 randomized prospective studies supports the combined use of a GLP-1 receptor agonist with basal insulin in a broad range of patients with uncontrolled type 2 diabetes.

Optimal management of type 2 diabetes in patients with increased risk of hypoglycemia.

With the number of individuals diagnosed with type 2 diabetes on the rise, it has become more important to ensure these patients are effectively treated. The Centers for Disease Control and Prevention estimated that 8.3% of all Americans were diagnosed with diabetes in 2011 and this number will likely continue to rise. With lifestyle interventions, such as proper diet and exercise, continuing to be an essential component of diabetes treatment, more patients are requiring medication therapy to help them reach their therapeutic goals. It is important for the clinician, when determining the treatment strategy for these individuals, to find a balance between reaching treatment goals and limiting the adverse effects of the treatments themselves. Of all the adverse events associated with treatment of diabetes, the risk of hypoglycemia is one that most therapies have in common. This risk is often a limiting factor when attempting to aggressively treat diabetic patients. This manuscript will review how hypoglycemia is defined and categorized, as well as discuss the prevalence of hypoglycemia among the many different treatment options.

Canagliflozin: a novel treatment option for type 2 diabetes.

Type 2 diabetes continues to be a challenging disease to manage. The addition of new agents with a positive risk-benefit ratio could potentially assist clinicians and patients in achieving adequate diabetes control. Canagliflozin, the first sodium-glucose cotransporter 2 inhibitor presently available on the market, offers a unique mechanism of action: it inhibits renal reabsorption of glucose, thereby increasing urinary glucose excretion. It reduces hemoglobin A1c by approximately 0.37%-1.16%; it also reduces the patient's weight and systolic blood pressure and has a low risk for hypoglycemia. Adverse effects include an increased risk of urinary tract infections and genital mycotic infections. In this manuscript we review canagliflozin and its potential role in management of type 2 diabetes mellitus.

Widely tunable polarization maintaining photonic crystal fiber based parametric wavelength conversion.

We report a near-visible parametric wavelength converter comprising a polarization-maintaining photonic crystal fiber (PM-PCF) pumped by a highly versatile diode-seeded master-oscillator power amplifier system based around 1.06 µm. The device is broadly tunable in wavelength (0.74-0.81 µm), pulse duration (0.2-1.5 ns) and repetition rate (1-30 MHz). A maximum anti-Stokes slope conversion efficiency of 14.9% is achieved with corresponding anti-Stokes average output powers of 845 mW, at a wavelength of 0.775 µm.

Lorcaserin for weight management.

Type 2 diabetes and obesity commonly occur together. Obesity contributes to insulin resistance, a main cause of type 2 diabetes. Modest weight loss reduces glucose, lipids, blood pressure, need for medications, and cardiovascular risk. A number of approaches can be used to achieve weight loss, including lifestyle modification, surgery, and medication. Lorcaserin, a novel antiobesity agent, affects central serotonin subtype 2A receptors, resulting in decreased food intake and increased satiety. It has been studied in obese patients with type 2 diabetes and results in an approximately 5.5 kg weight loss, on average, when used for one year. Headache, back pain, nasopharyngitis, and nausea were the most common adverse effects noted with lorcaserin. Hypoglycemia was more common in the lorcaserin groups in the clinical trials, but none of the episodes were categorized as severe. Based on the results of these studies, lorcaserin was approved at a dose of 10 mg twice daily in patients with a body mass index ≥30 kg/m(2) or ≥27 kg/m(2) with at least one weight-related comorbidity, such as hypertension, type 2 diabetes mellitus, or dyslipidemia, in addition to a reduced calorie diet and increased physical activity. Lorcaserin is effective for weight loss in obese patients with and without type 2 diabetes, although its specific role in the management of obesity is unclear at this time. This paper reviews the clinical trials of lorcaserin, its use from the patient perspective, and its potential role in the treatment of obesity.

Probing the ability of presynaptic tyrosine kinase receptors to regulate striatal dopamine dynamics.

Brain-derived neurotrophic factor (BDNF) modulates the synaptic transmission of several monoaminergic neuronal systems. Molecular techniques using synapatosomes in previous studies have suggested that BDNF's receptor, tyrosine kinases (Trk), can quickly regulate dopamine release and transporter dynamics. Our main objective in this study is to determine whether slice fast scan cyclic voltammetry can be used to investigate the role of the TrkB receptor on dopamine release and uptake processes in the caudate-putamen. Fast scan cyclic voltammetry measured dopamine release and uptake rates in the presence of BDNF, or its agonist 7,8-dihydroxyflavone, or a TrkB inhibitor K252a. Superfusion of BDNF led to partial recovery of the electrically stimulated dopamine release response in BDNF(+/-) mice which is blunted compared to wildtype mice, with no effect in wildtype mice. Conversely, infusion of 7,8-dihydroxyflavone increased electrically stimulated dopamine release in wildtype mice with no difference in BDNF(+/-) mice. Overall, BDNF and 7,8-dihydroxyflavone had no effect on dopamine uptake rates. Concentrations greater than 3 µM 7,8-dihydroxyflavone affected dopamine uptake rates in BDNF(+/-) mice only. To demonstrate that BDNF and 7,8-dihydroxyflavone modulate dopamine release by activating the TrkB receptor, both genotypes were pretreated with K252a. K252a was able to block BDNF and 7,8-DHF induced increases during stimulated dopamine release in BDNF(+/-) and wildtype mice, respectively. Fast scan cyclic voltammetry demonstrates that acute TrkB activation potentiates dopamine release in both genotypes.