Acute Asthma Exacerbations: Management Strategies.

Asthma exacerbations, defined as a deterioration in baseline symptoms or lung function, cause significant morbidity and mortality. Asthma action plans help patients triage and manage symptoms at home. In patients 12 years and older, home management includes an inhaled corticosteroid/formoterol combination for those who are not using an inhaled corticosteroid/long-acting beta2 agonist inhaler for maintenance, or a short-acting beta2 agonist for those using an inhaled corticosteroid/long-acting beta2 agonist inhaler that does not include formoterol. In children four to 11 years of age, an inhaled corticosteroid/formoterol inhaler, up to eight puffs daily, can be used to reduce the risk of exacerbations and need for oral corticosteroids. In the office setting, it is important to assess exacerbation severity and begin a short-acting beta2 agonist and oxygen to maintain oxygen saturations, with repeated doses of the short-acting beta2 agonist every 20 minutes for one hour and oral corticosteroids. Patients with severe exacerbations should be transferred to an acute care facility and treated with oxygen, frequent administration of a short-acting beta2 agonist, and corticosteroids. The addition of a short-acting muscarinic antagonist and magnesium sulfate infusion has been associated with fewer hospitalizations. Patients needing admission to the hospital require continued monitoring and systemic therapy similar to treatments used in the emergency department. Improvement in symptoms and forced expiratory volume in one second or peak expiratory flow to 60% to 80% of predicted values helps determine appropriateness for discharge. The addition of inhaled corticosteroids, consideration of stepping up asthma maintenance therapy, close follow-up, and education on asthma action plans are important next steps to prevent future exacerbations.

Pharmacologic Management of Chronic Pain.

Pharmacologic management of chronic pain is one component of a patient-centered care plan. Multiple classes of medications are available and can be used individually or in combination. Choice of medication is determined by the type and cause of pain, safety profile of the medication, patient values and preferences, comorbid conditions, cost, and availability. Incorporating shared decision making is critical when implementing a pharmacologic pain management regimen.

Evaluation of student-perceived growth in entrustable professional activities after involvement in a transitions-of-care process within an adult medicine advanced pharmacy practice experience.

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.

YouTube as a Guide for Respimat® Soft Mist™ Inhaler Technique.

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.

Comparison of traditional anesthesia method and jet injector anesthesia method (MadaJet XL®) for Nexplanon® insertion and removal.

BACKGROUND: This study compared a needle-free anesthesia method with traditional local anesthesia for insertion and removal of Nexplanon® long-acting removable contraceptive device. In our clinic, patients often avoid this highly effective form of contraception due to fear of needles. We sought to determine if patients perceived a difference in pain with the injection, anxiety level or pain with the procedure when local anesthesia was given with a needle v/s a needle-free jet injector device. METHODS: Patients were randomly assigned to one of two groups: jet injector or needle lidocaine delivery. Outcomes were ease of use, patient anxiety level, painfulness, and efficacy of anesthesia method. RESULTS: Patient pain perception with administration of jet injector lidocaine was statistically lower than traditional needle with no difference in anxiety or ease of use, or efficacy of the anesthesia. CONCLUSION: The jet injector device is a reasonable alternative to needle injection delivery of anesthesia prior to insertion/removal of Nexplanon® device. Further studies may determine whether this needle-free alternative for administration of local anesthetic would result in more women choosing Nexplanon® as a contraceptive method.

Rapunzel Syndrome in a Postpartum Patient after Caesarian Delivery.

A trichobezoar is an immobile, indigestible collection of hair or hair-like fibers that accumulates within the GI tract. Rapunzel syndrome is a rare variant in which a trichobezoar extends into the small intestine, potentially causing obstruction. We describe the first case, to our knowledge, of Rapunzel syndrome occurring in a postpartum patient after delivery by Caesarian section.