RESUMO
INTRODUCTION: Kratom, an unregulated herbal supplement, has emerged as self-treatment for anxiety/depression. Kratom exhibits inhibition at multiple cytochrome P450 isozymes involved in metabolism of prescription medications, including serotonergic agents. We report a case of possible serotonin syndrome induced by kratom use in combination with prescription psychotropic medications. CASE: A 63-year-old male presented with diaphoresis, flushing, aphasia, confusion, dysarthria, right facial droop, and oral temperature of 39.6oC (103.2oF), lactate 2.7 mmol/L, and creatine phosphokinase of 1507 IU/L. Initial differential diagnoses included acute ischemic stroke and bacterial meningitis. Despite partial treatment with alteplase and broad-spectrum antibiotics, symptoms persisted, and subsequent physical exam noted hyperreflexia, clonus, tremors, and temperature of 41.1oC (106oF). Home medications included a chronic regimen for anxiety/depression with bupropion, buspirone, desvenlafaxine, trazodone, and ziprasidone, in addition to kratom. Clinical suspicion for serotonin syndrome led to initiation of cyproheptadine, lorazepam, and cooling blankets. Aphasia, facial droop, and confusion improved after administration of cyproheptadine. Bupropion was restarted during hospitalization; remaining medications restarted at the discretion of the primary care provider. DISCUSSION: Risk of serotonin syndrome with multiple serotonergic agents is well-known. Kratom is metabolized by cytochrome P40 isozymes 3A4, 2C9, and 2D6, and exhibits inhibition at those enzymes, in addition to 1A2. Pharmacokinetic interactions of kratom with prescription serotonergic agents metabolized through these isozymes has the potential to increase systemic exposure of serotonin, potentially leading to serotonin syndrome. CONCLUSION: Because substances contained in kratom can inhibit metabolism of prescription serotonergic medications, clinicians must be aware of potential development of serotonin syndrome.
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Afasia , AVC Isquêmico , Mitragyna , Síndrome da Serotonina , Humanos , Masculino , Pessoa de Meia-Idade , Afasia/complicações , Afasia/tratamento farmacológico , Bupropiona/efeitos adversos , Ciproeptadina/efeitos adversos , AVC Isquêmico/complicações , AVC Isquêmico/tratamento farmacológico , Isoenzimas , Inibidores Seletivos de Recaptação de Serotonina , Serotoninérgicos/efeitos adversos , Síndrome da Serotonina/induzido quimicamenteRESUMO
BACKGROUND AND PURPOSE: Involvement of pharmacists and trainees in care transitions reduces medication-related problems. Participation in the transitions-of-care (TOC) process may impact self-perceived growth of autonomy within selected entrustable professional activities (EPAs). EDUCATIONAL ACTIVITY AND SETTING: A student-driven TOC documentation process was implemented within an inpatient family medicine advanced pharmacy practice experience. During the month-long rotation, students rounded with an interdisciplinary care team. Responsibilities included ensuring accurate medication reconciliation at care transitions throughout hospitalization and prior to discharge as well as medication optimization during hospitalization. Another responsibility was completing a medication-specific TOC note in the clinic-based electronic health record at discharge for patients receiving primary care from the associated clinic. The note was available to the outpatient interdisciplinary care team during the hospital follow-up appointment. Student-perceived growth in autonomy within selected EPAs was determined through an online anonymous survey. FINDINGS: Ninety percent (n = 18) of eligible students completed the survey. For specific EPA statements (collecting information, establishing patient-centered goals and establishing a care plan, implementing a care plan, collaborating as an interdisciplinary team member, and ensuring immunization), student-perceived autonomy increased after involvement in this student-driven TOC process. During the study period, 215 notes were generated by student pharmacists and included interventions/recommendations within the following themes: evidence-based changes in therapy, patient counseling, and medication access. SUMMARY: The importance of pharmacist and pharmacy trainee involvement in the TOC process has been well-documented. Involving students in student-driven TOC documentation processes serves to facilitate student-perceived growth in autonomy within selected EPAs.
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Transferência de Pacientes , Farmácia , Adulto , Humanos , Reconciliação de Medicamentos , Farmacêuticos , EstudantesRESUMO
Objective. Team-based learning is widely used in pharmacy education. In this context, students need to be incentivized to do preclass preparation, thus ensuring they are ready for team-based learning, via graded readiness assurance tests (RATs). The purpose of this study was to determine the effect of graded versus ungraded RATs on examination performance in an ambulatory care elective course for third-year student pharmacists.Methods. For the course offered in spring 2020 and 2021, a standard team-based learning framework was employed. In 2020 the RATs were graded and contributed to the overall course grade (graded RAT cohort), but in 2021 RAT grades did not contribute to the course grade (ungraded RAT cohort). For the ungraded RAT cohort, at the end of the course students completed an online anonymous survey regarding class preparation and perceived team accountability.Results. No significant difference was found between the graded RAT (n=47) and ungraded RAT cohorts (n=36) in the overall mean percentage score on individual RATs (76% vs 74%) and individual examinations (82% vs 80%). Most students (69%-91%) in the ungraded RAT cohort reported completing preclass preparation assignments. In the postcourse survey, 94% of students agreed or strongly agreed that RATs contributed to team members' learning, and 86% agreed or strongly agreed that they were proud of their ability to assist in the team's learning.Conclusion. Ungraded RATs did not significantly impact students' examination performance in an elective course. Removing the grading of this test, whereby grading promotes the performance approach to learning, may have shifted the students' motivation to the mastery approach in the context of preclass preparation. This challenges a widely held belief that grades are necessary incentives for preclass preparation within team-based learning.
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Educação em Farmácia , Estudantes de Farmácia , Humanos , Educação em Farmácia/métodos , Estudantes , Aprendizagem , Farmacêuticos , Estudos de Coortes , Aprendizagem Baseada em Problemas/métodos , Avaliação Educacional/métodosRESUMO
BACKGROUND: Consumers are involved more than ever in their health care, with many utilizing the Internet for health information. YouTube is a convenient and vast source of health education videos. Pharmaceutical companies, health organizations, providers, and others post instructional videos for the use of the Respimat® Soft Mist™ Inhaler device on sites like YouTube. Therefore, review of content and quality is important to ensure consumers are directed to the best information available. OBJECTIVE: Assess content and quality of YouTube videos demonstrating Respimat Soft Mist inhaler technique. METHODS: YouTube was queried May 16, 2018 using the term "Respimat inhaler." The first 35 unique videos in English with instructions for use were assessed. Technical quality of each video was evaluated using a validated scale and content assessed using manufacturer/package insert. RESULTS: Of 35 videos reviewed, median duration was 2 minutes 50 seconds (interquartile range [IQR]: 1 minute 23 seconds-4 minutes 22 seconds). Target audience was laypeople for 97% (n = 34) of videos. The source was a professional organization for 70% (n = 24). Most (74%, n = 24) received the maximum quality score of 5. Commonly omitted steps included documentation of the discard date (74%), repetitive dose activation until spray is visible (49%), and pointing inhaler to the back of the throat (43%). CONCLUSIONS: Proper technique is crucial for patients to achieve optimal results from inhaled medications. While many videos are available through YouTube for demonstration of Respimat Soft Mist inhaler technique, some omitted key steps. Thorough and repetitive patient education should be provided, and augmented with reputable online sources.
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Mídias Sociais , Humanos , Nebulizadores e VaporizadoresAssuntos
Aminopiridinas/administração & dosagem , Antibacterianos/administração & dosagem , Impetigo/tratamento farmacológico , Quinolonas/administração & dosagem , Administração Tópica , Aminopiridinas/economia , Antibacterianos/economia , Criança , Pré-Escolar , Humanos , Lactente , Quinolonas/economiaRESUMO
PURPOSE: Attainment of postgraduate year 1 (PGY1) residency positions has become increasingly competitive. Inclusion of clinical knowledge and problem-solving assessments in onsite interviews has increased in recent years. Characterization of these assessments is necessary for applicants to best prepare for interviews and for mentors to provide guidance. METHODS: An online survey was emailed to program directors of PGY1 pharmacy residency programs accredited by the American Society of Health-System Pharmacists (ASHP). Data were analyzed using descriptive statistics. Chi-square and Fisher's exact tests were used to compare categorical data. The Mann-Whitney U test was used to analyze nonparametric continuous data. RESULTS: Of the 221 respondents, most identified their programs as based at community (48%) or academic (39%) medical centers. Ninety percent of programs reported inclusion of clinical knowledge and problem-solving assessments in the onsite interview process. The most common assessments included asking clinical questions (70%), development of a SOAP (subjective, objective, assessment, plan) note or care plan (42%), and formal presentations that applicants prepared prior to arrival (39%). Most programs (71%) reported incorporating multiple assessments, with 2 assessments included most commonly (43%). Clinical assessment performance accounted for 10% to 25% of the overall interview score in approximately half of programs. CONCLUSION: During onsite PGY1 residency interviews, applicants must be prepared to participate in at least 1 clinical knowledge and problem-solving assessment, including answering clinical questions, developing a SOAP note or care plan, and/or delivering a presentation. Applicants should expect that these assessments will account for a substantial portion of the interview evaluation.
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Competência Clínica/normas , Conhecimentos, Atitudes e Prática em Saúde , Candidatura a Emprego , Residências em Farmácia/normas , Resolução de Problemas , Inquéritos e Questionários , Estudos Transversais , Feminino , Humanos , Masculino , Residências em Farmácia/métodosRESUMO
Apixaban is prescribed for stroke prevention in nonvalvular atrial fibrillation (NVAF) in patients with varying degrees of renal dysfunction. While pharmacokinetic data support apixaban in severe renal impairment, clinical safety outcomes data are limited. This retrospective cohort analysis was conducted to evaluate the safety of apixaban in patients with NVAF and renal impairment. A total of 340 patients with NVAF receiving apixaban 5 mg or 2.5 mg twice daily were included for analysis; 287 preserved renal function (pRF: CrCl ≥ 25 ml/min and SCr ≤ 2.5 mg/dl) and 53 impaired renal function (iRF: CrCl < 25 ml/min and/or SCr > 2.5 mg/dl). The primary endpoint was major bleeding in patients taking apixaban 5 mg. Secondary endpoints included major bleeding with apixaban 2.5 mg and minor bleeding in both groups. There was no difference in major bleeding events in the 5 mg pRF group (4.41%) versus iRF group (3.57%) (P = 0.66). Similar rates occurred between the 2.5 mg pRF and iRF groups. Minor bleeding events were similar regardless of renal function. The incidence of bleeding in the 5 mg group was 11.45% with pRF versus 10.71% with iRF (P = 0.6). In the 2.5 mg group, bleeding incidence was 10% with pRF versus 16% with iRF (P = 0.47). There were no observed differences in bleeding between groups with pRF or iRF, regardless of apixaban dose. Because patients with severe renal impairment were excluded from original trials, this study contributes clinical safety outcomes to the limited data for use of apixaban in this patient population.
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Fibrilação Atrial/tratamento farmacológico , Inibidores do Fator Xa/administração & dosagem , Nefropatias/fisiopatologia , Rim/fisiopatologia , Pirazóis/administração & dosagem , Piridonas/administração & dosagem , Acidente Vascular Cerebral/prevenção & controle , Administração Oral , Idoso , Idoso de 80 Anos ou mais , Fibrilação Atrial/complicações , Fibrilação Atrial/diagnóstico , Esquema de Medicação , Inibidores do Fator Xa/efeitos adversos , Feminino , Hemorragia/induzido quimicamente , Humanos , Nefropatias/complicações , Nefropatias/diagnóstico , Masculino , Pessoa de Meia-Idade , Pirazóis/efeitos adversos , Piridonas/efeitos adversos , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Índice de Gravidade de Doença , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/etiologia , Fatores de Tempo , Resultado do TratamentoRESUMO
OBJECTIVE: To assess the current use of ß-blockers in patients with compelling indications for use, following the acute exacerbation of chronic obstructive pulmonary disease (COPD). METHODS: We performed a multicenter retrospective observational study using data from all of the patients admitted to five institutions for an acute exacerbation of COPD. Patients were included if they were admitted for an acute exacerbation of COPD and had a compelling indication for the use of a ß-blocker, defined as previous myocardial infarction or heart failure with left ventricular ejection fraction ≤40%. RESULTS: There were 396 patients meeting the criteria for inclusion in the study. The population was predominantly white men with myocardial infarction as the most prevalent compelling indication. On admission, 267 (67.4%) patients were receiving ß-blockers, which increased to 278 (70.2%) at discharge. There were 118 (29.8%) patients discharged without ß-blockers. Of the predictors tested, none were significantly predictive of a patient not receiving ß-blockers upon discharge; however, home and in-hospital ß-blockers reduced the likelihood of being discharged without a ß-blocker. Of the 129 patients not receiving ß-blockers prehospitalization, 23 (17.8%) were discharged with a new prescription for a ß-blocker. CONCLUSIONS: Nearly one-third of patients with compelling indications for ß-blockers were not prescribed the therapy at discharge.
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Antagonistas Adrenérgicos beta/uso terapêutico , Prescrições de Medicamentos/estatística & dados numéricos , Doença Pulmonar Obstrutiva Crônica/tratamento farmacológico , Idoso , Alabama/epidemiologia , Feminino , Hospitalização , Humanos , Masculino , Infarto do Miocárdio/tratamento farmacológico , Infarto do Miocárdio/epidemiologia , Alta do Paciente , Doença Pulmonar Obstrutiva Crônica/epidemiologia , Estudos RetrospectivosRESUMO
OBJECTIVES: Outpatient antimicrobial stewardship has become increasingly important. While clinical decision support (CDS) tools have been effective in improving guideline-directed antibiotic prescribing, most notably for upper respiratory tract infections, their use for uncomplicated urinary tract infections (UTIs) has been less extensively studied. The objective of this study was to develop and implement a CDS tool to optimize antimicrobial prescribing for uncomplicated UTIs. SETTING: University-affiliated family medicine resident clinic. PRACTICE DESCRIPTION: This outpatient clinic is the practice site for 24 medical residents, 12 full-time faculty physicians, 1 nurse practitioner, and 1 full-time clinical pharmacist. PRACTICE INNOVATION: An interdisciplinary team including physicians, pharmacists, quality coordinator, and a coding and billing specialist collaborated to develop and implement a CDS tool into the clinic electronic health record to guide diagnosis, documentation, and antibiotic prescribing for uncomplicated UTIs. Prescribing practices were characterized, and a clinic-specific antibiogram was developed to identify focus areas for the CDS tool. EVALUATION: A retrospective chart review was conducted to evaluate empiric antibiotic prescribing before and after implementation of the CDS tool and after implementation when the tool was used or not used. RESULTS: Utilization of the tool clinic-wide was 29%. Overall fluoroquinolone use decreased from 42% to 15% after tool implementation (odds ratio [OR] 0.25; 95% CI 0.13-0.5; P < 0.001). Specifically, when the CDS tool was used, no patients received empiric therapy with fluoroquinolones (P = 0.005). With use of the tool following implementation, trimethoprim/sulfamethoxazole use decreased by 20% (OR 0.21; 95% CI 0.45-0.955; P = 0.003), nitrofurantoin for cystitis increased by 31% (OR 3.83; 95% CI 1.32-11.1; P = 0.01), and guideline-directed duration of therapy increased 32% (OR 4.34; 95% CI 1.48-12.73; P = 0.005). CONCLUSION: In an attempt to optimize empiric antimicrobial treatment for uncomplicated UTIs, we developed and implemented a CDS tool into the electronic health record in a family medicine resident clinic. Despite a 29% usage rate, many benefits were seen after tool implementation.
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Antibacterianos/administração & dosagem , Sistemas de Apoio a Decisões Clínicas , Infecções Urinárias/tratamento farmacológico , Adulto , Idoso , Instituições de Assistência Ambulatorial , Gestão de Antimicrobianos , Registros Eletrônicos de Saúde , Feminino , Humanos , Pessoa de Meia-Idade , Equipe de Assistência ao Paciente , Projetos Piloto , Guias de Prática Clínica como Assunto , Estudos RetrospectivosAssuntos
Enterococcus faecalis/efeitos dos fármacos , Fluoroquinolonas , Pseudomonas aeruginosa/efeitos dos fármacos , Dermatopatias Infecciosas , Staphylococcus aureus/efeitos dos fármacos , Anti-Infecciosos/administração & dosagem , Anti-Infecciosos/efeitos adversos , Anti-Infecciosos/economia , Custos e Análise de Custo , Enterococcus faecalis/isolamento & purificação , Fluoroquinolonas/administração & dosagem , Fluoroquinolonas/efeitos adversos , Fluoroquinolonas/economia , Humanos , Pseudomonas aeruginosa/isolamento & purificação , Índice de Gravidade de Doença , Dermatopatias Infecciosas/diagnóstico , Dermatopatias Infecciosas/tratamento farmacológico , Dermatopatias Infecciosas/microbiologia , Staphylococcus aureus/isolamento & purificação , Resultado do TratamentoRESUMO
BACKGROUND: Given the significant public health burden of pulmonary diseases and the vital role pharmacists play in management across the continuum of care (and within transitions in care), an elective course for pharmacy students focused on pulmonary diseases was developed. EDUCATIONAL ACTIVITY: A month-long elective course for third-year pharmacy students consisting of 12 class sessions delivered in two-hour periods three times per week, was implemented. The course was delivered using the team-based learning (TBL) format in addition to hands-on skills and simulation sessions. Knowledge and skills assessments were administered before and after completion of the course. Student perceptions of self-confidence and ability regarding management of pulmonary diseases pre- and post-course and their perceptions of the course and TBL as a teaching strategy for this course were evaluated upon course completion. CRITICAL ANALYSIS: Nine students completed the course. Mean scores on knowledge and skills assessment significantly improved after completion of the course (54.5% pre-course vs. 79.3% post-course; p < 0.05% and 60.3% pre-course vs. 93.2% post-course; p < 0.05, respectively). Student perceptions of their ability to care for patients with pulmonary diseases significantly increased, compared to pre-assessments, in all areas taught in the course (p< 0.05). Additionally, students' confidence in managing specific disease states significantly improved in all areas (p < 0.05) except for spirometry (p = 0.06). Students' knowledge, skills, and confidence regarding management of common pulmonary disease states improved following this month-long elective course delivered using a combination of TBL activities and hands-on skills sessions.