Evaluating the Quality of Exam Items from the Pathophysiology, Drug Action, and Therapeutics Course Series.

OBJECTIVE: To determine the impact of item-writing flaws and cognitive level on student performance metrics in one course series across two semesters at a single institution. METHODS: Four investigators reviewed 928 multiple-choice items from an integrated therapeutics course series. Differences in performance metrics were examined between flawed and standard items, flawed stems and flawed answer choices, and cognitive levels. RESULTS: Reviewers found that 80% of the items were flawed, with the most common types being implausible distractors and unfocused stems. Flawed items were easier than standard ones, with items becoming easier as they accumulate more flaws. These flaws benefited lower-performing students more than higher-performing ones, particularly up to two flaws. Items with flawed stems had the same difficulty as standard items, but those with flawed answer choices were significantly easier. Most items tested lower-level skills and have more flaws than higher-level items. There was no significant difference in difficulty between lower- and higher-level cognitive items, and higher-level items were more likely to have answer flaws than stem flaws. CONCLUSION: Item-writing flaws differently impact student performance. Implausible distractors artificially lower the difficulty of questions, even those designed to assess higher-level skills. This effect contributes to a lack of significant difference in difficulty between higher- and lower-level items. Unfocused stems, on the other hand, likely increase confusion and hinder performance regardless of the question's cognitive complexity.

A Multimedia Evaluation of Pharmacy Faculty PowerPoint Slides in a Critical Care Course.

OBJECTIVES: To conduct a pilot investigation about the alignment between didactic multimedia materials utilized by pharmacy faculty, with Mayer's Principles for Multimedia Learning and faculty characteristics associated with greater alignment. METHODS: An investigatory systematic process was used which included a modified Learning Object Review Instrument (LORI) to evaluate the faculty video-recorded lectures for alignment with Mayer's Principles of Multimedia Learning, hence capturing the number and type of misalignments. Correlations were performed to evaluate the association between faculty characteristics; and ratings and proportions of misalignments. RESULTS: Five hundred fifty-five PowerPoint slides of 13 lectures from 13 faculty members were reviewed. The average (SD) LORI score per slide was 4.44 (0.84) out of 5 with an average score per lecture ranging from 3.83 (0.96) to 4.95 (0.53). Across all lecture slides, misalignments with multimedia principles were captured in 20.2% of slides. For each lecture, the average percentage of misalignments was 27.6% ranging from 0% to 49%. Principal misalignments included violation of the principles of coherence (66.1%), signaling (15.2%), and segmenting (8%). No faculty characteristics were significantly associated with LORI ratings or proportion of misalignments within lectures. CONCLUSIONS: Faculty had high LORI ratings for their multimedia material but these varied significantly between lectures. Misalignments with multimedia principles were identified and were related primarily to extraneous processing. These misalignments, when addressed, have the potential to improve learning, thus suggesting an opportunity for the faculty to develop ways to optimize multimedia educational delivery. Future investigation is needed to clarify how clinical pharmacy faculty can develop multimedia material and the impact of faculty development on the application of multimedia principles and learning outcomes.

Comparison of thrombotic and clinical outcomes in SARS-CoV-2-pneumonia versus other viral pneumonia in an urban academic medical center.

BACKGROUND: Infection with viral pneumonia (PNA) is known to offset the coagulation cascade. Recent studies assessing novel SARS-CoV-2 infection observed a high frequency of systemic thrombotic events resulting in ambiguity if severity of infection or specific viral strain drive thrombosis and worsen clinical outcomes. Furthermore, limited data exists addressing SARS-CoV-2 in underrepresented patient populations. OBJECTIVES: Assess clinical outcomes events and death in patients diagnosed with SARS-CoV-2 pneumonia compared to patients with other types of viral pneumonia. METHODS: Retrospective cohort study evaluated electronic medical records in adult patients admitted to University of Illinois Hospital and Health Sciences System (UIHHSS) with primary diagnosis of SARS-CoV-2 PNA or other viral (H1N1 or H3N2) PNA between 10/01/2017 and 09/01/2020. Primary composite outcome was the following event incidence rates: death, ICU admission, infection, thrombotic complications, mechanical ventilation, renal replacement therapy, and major bleeding. RESULTS: Of 257 patient records, 199 and 58 patients had SARS-CoV-2 PNA and other viral PNA, respectively. There was no difference in primary composite outcome. Thrombotic events (n = 6, 3%) occurred solely in SARS-CoV-2 PNA patients in the ICU. A significantly higher incidence of renal replacement therapy (8.5% vs 0%, p=0.016) and mortality (15.6% vs 3.4%, p=0.048) occurred in the SARS-CoV-2 PNA group. Multivariable logistic regression analysis revealed age, presence of SARS-CoV-2, and ICU admission, aOR 1.07, 11.37, and 41.95 respectively, was significantly associated with mortality risk during hospitalization; race and ethnicity were not. CONCLUSION: Low overall incidence of thrombotic events occurred only in the SARS-CoV-2 PNA group. SARS-CoV-2 PNA may lead to higher incidence of clinical events than those observed in H3N2/H1N1 viral pneumonia, and that race/ethnicity does not drive mortality outcomes.

Hypertonic saline use in neurocritical care for treating cerebral edema: A review of optimal formulation, dosing, safety, administration and storage.

PURPOSE: Current Neurocritical Care Society guidelines on the management of cerebral edema recommend hypertonic saline (HTS) over mannitol in some scenarios, but practical questions remain regarding the appropriate administration method, concentration/dose, monitoring to ensure safe use, and storage. The aim of this article is to address these practical concerns based on the evidence currently available. SUMMARY: Many different hypertonic solutions have been studied to define the optimal hyperosmolar substance to relieve acute cerebral edema in patients with conditions such as acute ischemic stroke, intracerebral hemorrhage, subarachnoid hemorrhage, and traumatic brain injury. Mannitol and HTS are the main hyperosmolar therapies in use in contemporary neurocritical care practice. Contemporary use of HTS has followed a circuitous path in regards to the practical aspects of dosing and formulation, with evidence mainly consisting of retrospective or observational data. The effectiveness of bolus doses of HTS to lower acutely elevated intracranial pressure is well accepted. Adverse events with use of HTS are often mild and non-clinically significant if appropriate monitoring of serum sodium and chloride concentrations is performed. Available evidence shows that peripheral administration of HTS is likely safe in certain circumstances. Timely utilization of HTS is complicated by regulatory requirements for safe storage, but with appropriate safeguards HTS can be stored in patient care areas. CONCLUSION: HTS formulations, methods of administration, infusion rate, and storage vary by institution, and no practice standards exist. Central intravenous administration may be preferred for HTS, but peripheral intravenous administration is safe provided measures are undertaken to detect and prevent phlebitis and extravasation. The safe use of HTS is possible with proper protocols, education, and institutional safeguards in place.

A Pilot Study of End-Tidal Carbon Dioxide in Prediction of Inhospital Cardiac Arrests.

A validated means to predict inhospital cardiac arrest is lacking. The purpose of this study was to evaluate the changes in end-tidal carbon dioxide, as it correlates with the progression to inhospital cardiac arrest in ICU patients. DESIGN SETTING AND PATIENTS: Single-center, retrospective cohort study of mechanically ventilated ICU patients (age > 18 yr old) having inhospital cardiac arrest with advanced cardiac life support and continuous end-tidal carbon dioxide monitoring at a single academic center from 2014 to 2017. Demographics, clinical variables, and outcomes were collected. End-tidal carbon dioxide was collected from 5 to 2,880 minutes before inhospital cardiac arrest. Data were analyzed using descriptive statistics, and model estimates were generated using a repeated-measures categorical model with restricted maximum likelihood estimation and fully specified (autoregressive) covariance to assess the effect of time on changes in end-tidal carbon dioxide. MEASUREMENTS AND MAIN RESULTS: A total of 788 patients were identified and 104 met inclusion criteria, where 62% were male with an average age of 58.5 years. Seventy-four percent required vasopressors and 72% experienced pulseless electrical activity. Mean end-tidal carbon dioxide 5 minutes prior to inhospital cardiac arrest was significantly lower than all evaluated time points except 180 minutes (p < 0.05). One patient survived to hospital discharge. In multivariate logistic regression modeling for return of spontaneous circulation, a greater change in the prearrest end-tidal carbon dioxide maximum to prearrest end-tidal carbon dioxide minimum was associated with a decreased likelihood of return of spontaneous circulation (odds ratio 0.903; 95% CI, 0.832-0.979; p = 0.014). Additionally, a change from prearrest end-tidal carbon dioxide maximum to prearrest end-tidal carbon dioxide minimum greater than 17 mm Hg was associated with a decreased likelihood of return of spontaneous circulation and odds ratio 0.150; 95% CI, 0.036-0.66; p = 0.012). CONCLUSIONS: Mean end-tidal carbon dioxide is significantly lower immediately before inhospital cardiac arrest. The statistical and clinical significance of end-tidal carbon dioxide may highlight its utility for predicting inhospital cardiac arrest in ICU patients. Comparison analysis and modeling explorations in a larger cohort are needed.

Challenges in ICU Care: The Patient With Parkinson's Disease.

Patients with Parkinson's disease (PD) face unique challenges when admitted to the hospital. The nature of the disease, complexity of the pharmacotherapeutic home regimens, and the medication-related policies of institutionalized care all contribute to the challenges patients and providers face. In addition, medication errors are common in this population. Incorrectly ordered or omitted home medications or delayed administration can have significant negative consequences including worsening of PD symptoms, dopamine agonist withdrawal syndrome, or malignant or hyperpyrexia syndrome. Also, this patient population may commonly encounter contraindicated medications ordered during their hospitalizations. These medication misadventures negatively affect patient care, which may lead to increased length of stay and significant adverse sequalae. Nurses, pharmacists, and other health care providers can help ease the anxiety of patients and their families by taking detailed medication histories, restarting home medication regimens, customizing medication administration to fit patients' needs, and screening patient profiles for drug-drug and drug-disease interactions. Education of hospital staff regarding the unique needs of this patient population and seeking the advice of specialists in PD can also promote improved patient care.

Application of Cannabinoids in Neurosciences: Considerations and Implications.

Medicinal cannabinoid use continues to evolve across the United States, although legitimate federal recognition for medicinal purpose is lacking. Variability exists across states within the United States with respect to legislation, and health care institutions encounter challenges when patients present with a history of medicinal cannabinoid use. Emerging evidence in the field of neurosciences suggests a role of cannabinoids for neurologic medical conditions such as Parkinson disease, multiple sclerosis, and epilepsy. We aim to provide an overview of cannabinoids including a historical perspective, pharmacology, applications in neurosciences, and challenges in health care and academia. Knowledge of the appropriate role of cannabinoids in the clinical setting is essential for all health care practitioners including nursing.

Balance of academic responsibilities of clinical track pharmacy faculty in the United States: a survey of select American College of Clinical Pharmacy Practice and Research Network Members.

STUDY OBJECTIVES: To characterize the balance of clinical and academic responsibilities of clinical track pharmacy faculty in the United States and evaluate organizational structures that promote satisfactory balance between these responsibilities. DESIGN: Prospective cross-sectional survey. SETTING: A 22-item online survey was developed and distributed via Qualtrics software. PARTICIPANTS: Clinical faculty members of the American College of Clinical Pharmacy Adult Medicine, Ambulatory Care, Cardiology, Critical Care, Gastrointestinal/Liver/Nutrition, Immunology/Transplantation, Infectious Disease, and Pediatrics Practice and Research Networks (PRNs) were invited to participate via the PRN electronic mailing list. MEASUREMENTS AND MAIN RESULTS: The survey comprised questions related to demographics, organizational structure, and balance of clinical and academic responsibilities. A total of 344 participants responded to some or all of the survey questions. The demographics were relatively equally balanced between faculty at state and private academic institutions, academic rank, and practice setting. Expected and actual effort allocations were similar for each of the clinical and academic responsibilities, with direct patient care and clinical teaching representing more than 50% effort allocation cumulatively. Clinical faculty at state institutions devoted a larger proportion of time to clinical service, whereas clinical faculty at private institutions devoted a greater proportion of time to didactic teaching. When asked about time constraints, 157 (69.8%) of the 225 survey participants responding to this question did not believe they had sufficient time to fulfill their nonclinical academic needs. Clinical faculty who were provided "protected time" away from clinical service had a significantly more favorable opinion of this question. CONCLUSION: Most of the clinical track pharmacy faculty indicated that they have insufficient time to fulfill their nonclinical academic responsibilities. Provision of protected time may alleviate some of these time constraints.

Treatment outcomes of heparin-induced thrombocytopenia in subarachnoid hemorrhage patients: a 4-year, retrospective single-center review.

INTRODUCTION: The treatment and outcomes of heparin-induced thrombocytopenia (HIT) are not well described in neurosurgery patients. This study reviewed the treatment for HIT in subarachnoid hemorrhage (SAH) patients, and compared outcomes in patients with isolated HIT (iHIT) and HIT with thrombotic syndrome (HITTS). METHODS: Adult patients with SAH discharged from the University of Illinois Hospital & Health Sciences System from 2006 to 2009 were included if they had at least one positive HIT antibody test. Patients were categorized with either iHIT or HITTS based on documented evidence of thrombosis. The primary outcome was the incidence of new thromboses prior to discharge. Secondary outcomes included the incidence of major bleeding, new thromboses up to 3 months after discharge, or hospice/death. Patients having any secondary outcome were defined as having a "poor treatment-related effect". RESULTS: A total of 176 patients were screened and 30 patients met inclusion criteria. Eighteen patients (60 %) were categorized with iHIT and 12 (40 %) with HITTS. Twelve patients (67 %) with iHIT received prophylaxis with fondaparinux and nine patients (75 %) with HITTS were treated with argatroban. There were no differences in the primary (11 vs. 25 %, p = 0.364) or secondary outcomes in the iHIT group versus the HITTS group. Patients with iHIT had a 5.5 % incidence of "poor treatment-related effects" compared to a 33.3 % incidence in patients with HITTS (p = 0.024). CONCLUSIONS: SAH patients with iHIT and HITTS did not differ in the incidence of new thromboses, incidence of hemorrhage, or hospice/death. Patients with iHIT had fewer "poor treatment-related effects" than HITTS patients.

Outcomes associated with transdermal nicotine replacement therapy in a neurosurgery intensive care unit.

PURPOSE: The outcomes associated with transdermal nicotine replacement therapy (NRT) in a neurosurgery intensive care unit (ICU) were studied. METHODS: Data from pharmacy records, neurosurgery ICU admission logs, and computerized patient charts at the University of Illinois Medical Center at Chicago from January 2001 through August 2008 were reviewed for patients older than 18 years who were admitted to the neurosurgery ICU for neurologic insults. Patients were categorized into three groups: smokers who received transdermal NRT (n = 114), smokers who did not receive transdermal NRT (n = 113), and nonsmokers (n = 113). The primary outcome of this study was unfavorable disposition at discharge from the hospital. Secondary outcomes measured included overall mortality; lengths of hospital and neurosurgery ICU stays; and rates of subarachnoid hemorrhage (SAH) rebleeding, angiographic vasospasm, intracerebral hemorrhage rebleeding, and ischemic stroke. RESULTS: Overall, there was no difference in unfavorable discharge disposition among the three groups (p = 0.17). However, the group who received NRT had higher admission rates of SAH, smoked more cigarettes for a longer period of time, and had longer stays in the neurosurgery ICU and hospital compared with the other groups. All patients who received NRT had prolonged hospital (p = 0.014) and neurosurgery ICU (p = 0.006) stays compared with those who did not receive NRT. There were no differences in other secondary outcomes among the groups. CONCLUSION: There was no significant difference in unfavorable discharge disposition among neurosurgery ICU patients who were smokers treated with NRT, smokers not treated with NRT, and nonsmokers not treated with NRT.

Human recombinant factor VII for emergency reversal of coagulopathy in neurosurgical patients: a retrospective comparative study.

OBJECTIVE: Severe coagulopathy in a neurosurgical patient with intracranial hemorrhage is a common and serious problem. Current therapy with vitamin K and fresh-frozen plasma (FFP) may be too slow in certain situations. There are reports of rapid reversal of coagulopathy using human recombinant factor VII. We present a retrospective controlled study of our experience with factor VII. METHODS: We used factor VII as a second-line therapy after initial attempts at reversal with FFP had failed. Factor VII was given to 29 patients in the neurosurgical intensive care unit; 24 patients treated before the introduction of factor VII were control subjects. The groups were matched by age, sex, cause of coagulopathy, and presence of intracranial hemorrhage. RESULTS: After initial FFP administration, the international normalized ratio (INR) changed from a mean of 2.57 to 1.67 in the factor VII group and from 2.17 to 1.85 in control subjects. In all patients, INR tended to rebound. Before administration of factor VII, the mean INR was 2.206. After 1.4 mg of factor VII, mean INR decreased to 1.12 (P < 0.05). Measured from admission, INR in the factor VII group normalized within 6.78 +/- 2.68 hours, and in control subjects, within 47.44 +/- 9.88 hours (P < 0.0005). Six factor VII patients and six control subjects died. The number of patients with good functional outcome (Glasgow Outcome Scale score of 5) was greater among patients treated with factor VII compared with those who received only vitamin K and FFP (nine versus two, P = 0.04). None of the deaths were the result of a thrombotic complication. There were no thrombotic complications in the factor VII group. CONCLUSION: Factor VII is safe and highly effective when emergency reversal of coagulopathy is desired and may improve the functional outcome. We speculate that the use of factor VII as first choice may result in decreased use of FFP and thus increase patient safety.

The treatment of cancer pain.

Pain is probably one of the most common cancer symptoms. In addition to being a major source of suffering and disability, cancer pain is extremely frightening for patients and their families. This review discusses the current options for treating cancer pain, focusing on the pharmacological agents currently available and briefly exploring some of the surgical options for pain management. The authors propose to adjust the World Health Organization (WHO) pain management ladder from its current three-step approach to a more sophisticated five-step algorithm that includes physical and psychological modalities along the entire continuum of care and adds two more steps related to neuromodulative and neurodestructive procedures once the opioids fail.

Cyclooxygenase-2 inhibitor-associated acute renal failure: case report with rofecoxib and review of the literature.

Cyclooxygenase (COX)-2 inhibitors are widely prescribed for their antiinflammatory and analgesic effects. The potential for COX-2 inhibitors to exert deleterious effects on renal function similar to those of traditional nonsteroidal antiinflammatory drugs is not well defined. Until recently, COX-1 was considered responsible for the synthesis of renal prostaglandins. However, COX-2 is also constitutively expressed in the human kidney Clinical studies have reported a significant decrease in glomerular filtration rate in young and elderly sodium-depleted volunteers given COX-2 inhibitors. We describe the case of a 71-year-old woman who developed acute renal failure after receiving a 50-mg dose of the selective COX-2 inhibitor rofecoxib.