Recognition of Advanced Pharmacy Practice Experience Student Participation Within Antimicrobial Stewardship Activities.

Background: Antimicrobial stewardship is important in managing patients with infectious diseases. Limited data exist documenting the extent of pharmacy student involvement within antimicrobial stewardship activities. Objectives: The purpose of this study was to document the types of hospital-based antimicrobial stewardship activities in which Advanced Pharmacy Practice Experience (APPE) students are involved. Methods: A questionnaire was developed using the most current guideline for developing an institutional antimicrobial stewardship program. It was designed to collect preceptor-reported perceptions and APPE student involvement in antimicrobial stewardship activities. Pharmacist preceptors of APPE students from 2 Florida Colleges of Pharmacy were surveyed in October 2011. Questionnaires fully completed by hospital pharmacists currently serving as an APPE preceptor were included. Results: Forty-eight questionnaires met all inclusion criteria, collectively reporting APPE student participation within every element of antimicrobial stewardship. The most common areas of student participation were dose optimization based on patient characteristics (n = 40, 83%), acquiring patient information for prospective audit with feedback (n = 39, 81%), intravenous to oral conversion (n = 37, 77%), and pharmacokinetic services (n = 36, 75%). Anti-infective subcommittee participation (n = 3, 6%) was uncommon. Respondent perceptions were overall favorable regarding student participation in antimicrobial stewardship activities. Conclusion: With supervision from pharmacist preceptors, APPE students from 2 Florida colleges of pharmacy were reported to participate in each element and activity of antimicrobial stewardship as set forth by current guidelines. The role and value of such involvement is not fully understood. Future research investigating activity-specific outcomes and policy creation are needed to guide appropriate use of APPE students as a resource for optimizing antimicrobial use in hospitals.

Assessing Confidence and Competence of Student Pharmacists in a Virtual Medication Adherence Training Program.

OBJECTIVE: To assess the impact of a virtual medication adherence training (VMAT) program on students' perceived confidence and perceived competency in delivering medication adherence services via telehealth. METHODS: This pilot pre-/post-observational study consisted of 2 subsequent sections: (1) 4 asynchronous self-study modules via Canvas (Instructure, Inc.) learning management system, and (2) 2 live application-based sessions involving virtual and telephonic standardized patients. A pre-/post-survey was given to first-, second-, and third-year Doctor of Pharmacy students to assess perceived confidence and perceived competence. Participants completed a 5-question multiple-choice quiz before and after each module to assess knowledge. RESULTS: Students' overall perceived confidence and perceived competency significantly increased upon completing VMAT. Knowledge in each module assessment also significantly improved. During the assessment of performance throughout the live sessions, most participants lost points when resolving issues within the interaction, addressing the need for patient follow-up, and assessing patient knowledge of medication adherence. CONCLUSION: This novel VMAT suggests that this or similar programs would be beneficial to improve pharmacy students' perceived confidence, perceived competence, and knowledge in delivering virtual medication adherence services in the telehealth setting. The incorporation of such training within the didactic curriculum of doctoral pharmacy programs should be considered to improve patient care skills for future medication experts.

Genomic analysis across 53 canine cancer types reveals novel mutations and high clinical actionability potential.

A genomic understanding of the oncogenic processes and individual variability of human cancer has steadily fueled improvement in patient outcomes over the past 20 years. Mutations within tumour tissues are routinely assessed through clinical genomic diagnostic assays by academic and commercial laboratories to facilitate diagnosis, prognosis and effective treatment stratification. The application of genomics has unveiled a wealth of mutation-based biomarkers in canine cancers, suggesting that the transformative principles that have revolutionized human cancer medicine can be brought to bear in veterinary oncology. To advance clinical genomics and genomics-guided medicine in canine oncology, we have developed and validated a canine cancer next-generation sequencing gene panel for the identification of multiple mutation types in clinical specimens. With this panel, we examined the genomic landscapes of 828 tumours from 813 dogs, spanning 53 cancer types. We identified 7856 alterations, encompassing copy number variants, single nucleotide variants, indels and internal tandem duplications. Additionally, we evaluated the clinical utility of these alterations by incorporating a biomarker framework from comprehensive curation of primary canine literature and inferences from human cancer genomic biomarker literature and clinical diagnostics. Remarkably, nearly 90% of the cases exhibited mutations with diagnostic, prognostic or therapeutic implications. Our work represents a thorough assessment of genomic landscapes in a large cohort of canine cancers, the first of its kind for its comprehensive inclusion of multiple mutation types and structured annotation of biomarkers, demonstrating the clinical potential of leveraging mutation-based biomarkers in veterinary oncology.

Students' Perceptions and Lessons Learned From Virtual APPE Rotations: A Multi-Institutional Perspective.

Objectives: The COVID-19 pandemic caused disruption in pharmacy experiential learning as clinical practice sites restricted student access to onsite rotations. Therefore, colleges of pharmacy across the country likely included virtual advanced pharmacy practice experiences (APPEs) to fulfill experiential education requirements. The objective of this paper is to evaluate students' perceptions of virtual APPEs during the 2020-2021 academic year. Methods: Experiential directors and faculty at 3 colleges of pharmacy in the south Florida region developed a survey to assess students' perceptions of their virtual APPE rotations during the 2020-2021 academic year. Students who took at least one fully virtual APPE rotation were asked about their perceptions of these rotations. Results: A total of 349 students were invited to take the survey and 92 (26.3%) completed the survey. Of these, 77 students (83.7%) completed at least one virtual rotation. These students completed a total of 152 virtual rotations, with elective and ambulatory care rotations being the most frequent. Most students agreed that rotation objectives were clear, and preceptors offered resources needed to be successful during the rotation. Responses regarding engagement during virtual rotations, rotation expectations being met, and rotations expanding students' knowledge were mixed. Conclusions: Virtual rotations may present unique experiential opportunities for students. Colleges of pharmacy and preceptors can benefit from additional guidance regarding how to incorporate virtual rotations into the experiential curriculum. Best practices for virtual rotations include high frequency of interactions with preceptors, clear objectives and responsibilities, and the use of a rotation calendar.

Development and evaluation of physician-precepted advanced pharmacy practice experiences (APPEs) within an accountable care organization (ACO).

BACKGROUND AND PURPOSE: The American Council of Pharmaceutical Education (ACPE) standards emphasize that pharmacy graduates should be "practice- and team-ready," and the American Society for Health-System Pharmacists (ASHP) Task Force on accountable care organizations (ACOs) states that curricula at pharmacy schools should be evaluated and reworked to prepare students to practice effectively as members of the health care team within ACOs. The objective of this study was to describe the development of an ACO-based advanced pharmacy practice experience (APPE) rotation block, clinical activities and interventions completed by students during the experience, and perceptions of students, patients, and physician preceptors regarding the experience. EDUCATIONAL ACTIVITY AND SETTING: The rotation block was within outpatient ACO offices and consisted of a four-week rotation with one pharmacy faculty, immediately followed by a four-week elective experience in a different office with a physician serving as primary preceptor. FINDINGS: Eight students completed the rotation block between August 2017 and April 2018. Students documented a total of 1299 clinical activities and 65 interventions. Medication reconciliation and recommendations to initiate a medication were the most commonly completed activities and interventions documented. The experience was positively perceived among surveyed students, patients, and physician preceptors. SUMMARY: The rotation block was successfully implemented with a positive response from students, patients, and physician preceptors. As a result, the program has expanded in accordance with ACPE Standards to create "practice- and team-readiness" among graduates and expose students to interdisciplinary care within ACOs and other settings.

What is your diagnosis? Cervical mass in a cat.

An 8-year-old female spayed domestic shorthair cat was presented for several months of weight loss, decreased appetite, and 2 bilateral, ventral cervical masses. Initial cytologic samples were interpreted as reactive lymphoid hyperplasia. Evaluation of subsequent mass aspirates revealed small numbers of large binucleated and multinucleated cells resembling Reed-Sternberg cells admixed with more numerous small and intermediate-sized lymphocytes. In histopathologic sections, the normal architecture of the lymph node was largely effaced by a slightly heterogeneous mass composed of round cells arranged in densely cellular sheets with a minor population of large (25-microm diameter) mononuclear cells and a few very large (30-40-microm diameter) binucleated or multinucleated cells interpreted as Reed-Sternberg-like cells. Immunohistochemically, the large neoplastic (Reed-Sternberg-like) cells were negative for CD18, CD3, CD20, and CD79a while the background population consisted of about 70% T cells and 30% B cells. This pattern of immunohistochemical staining along with cytologic and histopathologic findings supported a diagnosis of Hodgkin's-like lymphoma, specifically, the lymphocyte-rich subtype. Hodgkin's-like lymphoma has been reported previously in cats and should be suspected when Reed-Sternberg-like cells are observed in cytologic preparations of lymph node aspirates. Histopathology and immunohistochemistry are necessary for a definitive diagnosis.

Acute myeloid leukemia with multilineage dysplasia in an alpaca.

An 18-year-old female alpaca was presented to the Colorado State University Veterinary Teaching Hospital for chronic ill thrift over a 1-year period. Six weeks previously, an infected left mandibular cheek tooth was removed by oral extraction. On physical examination the patient was cachectic, lethargic, and weak. Abnormalities on the CBC included neutropenia, thrombocytosis, and severe nonregenerative, macrocytic, hypochromic anemia. Dysplastic nucleated erythrocytes and micromegakaryocytes were observed on the peripheral blood smear. Neutrophils, bands, and metamyelocytes appeared markedly toxic. Numerous blasts containing variable numbers of fine azurophilic granules were also observed. Based on their morphology, the cells were interpreted to be progranulocytes and myeloblasts, and a presumptive diagnosis of acute myeloid leukemia (AML) was made. The blast cells accounted for 60% of the nucleated cell population on bone marrow aspirates, further supporting a diagnosis of AML with multilineage dysplasia. Post mortem examination showed infiltration of the neoplastic cells into spleen, liver, kidney, and lymph nodes. Based on histologic findings, the morphologic diagnoses were disseminated myeloid neoplasia, chronic regionally extensive tooth root abscess, and membranous glomerulonephritis. The neoplastic cells were CD172a-positive on flow cytometry, chloroacetate esterase-positive by cytochemistry, and myeloperoxidase-positive by immunohistochemistry, confirming myeloid origin. To our knowledge, this is the first case of AML with multilineage dysplasia in an alpaca, with only one other case of myelodysplasia described previously in this species.

Midwestern Farm Widows: Adaptation Following Spousal Loss.

The purpose of this descriptive study was to co-create oral histories of Midwestern farm widows. Rural widows constitute a vulnerable population due to issues of bereavement and depression compounded by emotional and geographical isolation. A farm widow is often forced to maintain viability of the farm for the family's livelihood. Oral history interviews with nine Midwest farm widows were conducted and analyzed. Three overarching themes emerged: competence, industriousness, and inner strength. Women shared stories of overcoming insurmountable obstacles. This study contributes to the literature on grief and expanding inner strength among rural widows. Further research could inform theory related to inner strength following a challenging life event.

Role of Residency Interview Preparatory Activities as a Determinant on Pharmacy Residency Match Rates.

PURPOSE: Different strategies have been implemented to assist students in securing residency positions. The purpose of this study was to explore the impact of student participation in residency preparation activities on match rates. METHODS: A retrospective observational study was conducted to explore the effect of participation in residency preparation activities and grade point average (GPA) on residency match rate. Match rates for students participating in the Residency Interview Preparation Seminar (RIPS) or mock interviews (ie, intervention group) were compared with students who participated in neither activity (ie, control group). RESULTS: A total of 118 individuals were included in the comparison. Forty-eight students participated in RIPS (n = 29) or mock interviews (n = 19), while 70 students were in the control group. The intervention group had a statistically larger proportion of students securing residency than the control group (81% vs 57%; P = .009). Match rates between students enrolled in RIPS versus those in the mock interview group were not significant. No statistically significant differences were observed based on GPA. CONCLUSION: Students receiving additional preparation prior to interviews when seeking postdoctoral training were significantly more likely to obtain a residency position. In academic settings with limited resources, mock interviews may be preferred over comprehensive preparatory courses.

Hematologic and biochemical abnormalities indicating iron deficiency are associated with decreased reticulocyte hemoglobin content (CHr) and reticulocyte volume (rMCV) in dogs.

BACKGROUND: The ADVIA 120 automated hematology system uses low- and high-angle light scatter to determine individual RBC and reticulocyte volume and hemoglobin (Hgb) concentration. Current hematologic and biochemical markers of iron status in the dog are insensitive, and results may be highly variable, especially in the presence of concurrent disease (ie, inflammation, neoplasia). Reticulocyte Hgb content (CHr) has proven useful in detecting early iron deficiency and iron deficiency masked by concurrent disease in human patients. OBJECTIVES: The purpose of this study was to retrospectively investigate the association of low CHr and reticulocyte MCV (rMCV) with hematologic and biochemical abnormalities indicative of iron deficiency in canine patients. METHODS: Reference intervals for CHr and rMCV were established on a population of 362 hematologically-normal dogs using standard methods. CBC and serum biochemical results from 833 dogs at Colorado State University Veterinary Teaching Hospital were retrospectively evaluated. The prevalence of decreased CHr and rMCV values was determined based on the reference intervals. Hematologic (HCT, MCV) and biochemical (serum Fe concentration, percent saturation of transferrin [% sat]) values were compared among dogs with low CHr (n=58), low rMCV (n=50), and control dogs (cohort groups from the initial population) using a Fisher exact test. RESULTS: Reference intervals were 22.3-27.9 pg for CHr and 77.8-100.2 fL for rMCV. Seven percent (n=58) of dogs in the hospital population had low CHr and 6% (n=50) had low rMCV based on the reference values. Dogs with low CHr had significantly lower HCT, MCV, serum Fe, and % sat values than did control dogs. In addition, dogs with low CHr or low rMCV values had a higher frequency of microcytosis, anemia, low serum Fe concentration, and low % sat than did control dogs. CONCLUSION: Low CHr and low rMCV are associated with hematologic and serum biochemical abnormalities indicative of iron deficiency. CHr and rMCV hold promise as noninvasive, cost-effective measures of iron status in the dog.

External validation of aminoglycoside models used in web calculators and clinical decision support systems after laboratory conversion to serum creatinine isotope dilution mass spectrometry assay.

BACKGROUND: Models to predict gentamicin t(½) from serum creatinine (SCr) estimated creatinine clearance (CrCl) are currently being incorporated into smart-device applications and clinical decision support modules without external validation. OBJECTIVE: The aim of this study was to determine whether such models remain viable after conversion to isotope dilution mass spectrometry (IDMS) SCr assay. METHODS: This study analyzed data from retrospective reviews of the medical records of nonobese adults receiving the aminoglycoside gentamicin and having ≥2 evaluable serum gentamicin concentrations after laboratory IDMS SCr conversion, from January 2008 to August 2009, at a tertiary care hospital in Florida. A literature search found a number of cited aminoglycoside models. This group of models was classified as group 1. The World Wide Web was also searched for the term aminoglycoside dosing calculators, with 6 models found and referred to as group 2. Predictive performance measures were used to compare the model results with the t(½) calculated from gentamicin concentrations using the Nelder-Mead algorithm. RESULTS: The records of 39 patients met the inclusion criteria (23 men, 16 women; age range, 18-86 years; range of estimated CrCl, 55-115 mL/min) and provided the "gold standard" aminoglycoside t(½). A gentamicin t(½) was predicted from several published models (group 1) and from other models used in online smart-device applications (group 2) and clinical decision modules. The median (interquartile range) root mean square errors were 0.48 (0.44 to 0.65) and 0.48 (0.45 to 0.70) hours from group-1 and -2 models, respectively. The median mean relative prediction errors were 9% (-14% to +13%) and 11% (+1% to +21%) from groups 1 and 2. The median mean absolute prediction errors were 21% (19% to 28%) and 21% (20% to 30%) from groups 1 and 2. Adjusting SCr by +20% improved the predictive ability in 3 of 12 cited models and in 5 of 6 models used in applications. CONCLUSIONS: Models to predict gentamicin t(½) should be externally validated at one's institution before use. The findings from the present study provide a framework for conducting external validation.

Use of herbals as galactagogues.

With a substantial number of women using herbal products to augment their milk production, this article will review available literature illustrating efficacy and adverse effects of using these products. Embase, PubMed, and EBSCO (all databases) were searched from inception to June 2011 using terms such as ''galactagogue,'' ''galactogogue,'' ''herbal,'' and ''botanical'' and the search was subsequently narrowed to specific herbals by name. Additional articles were obtained from article reference lists. Supplemental information was obtained with Natural Standard. All abstracts retrieved were evaluated for relevance and germane articles were included. Numerous lactation-stimulating herbals have been identified in the literature with varying degrees of evidence,mostly anecdotal. Use of torbangun, milk thistle, and fenugreek may correlate with increased milk supply. Evidence regarding adverse effects, pharmacodynamic properties, and pharmacokinetic effects remains scarce. Despite the fact that postpartum women may turn to herbal galactagogues, scant clinical evidence exists to justify their effectiveness. Further clinical trials are needed in order to substantiate these findings.

Development of a residency interviewing preparatory seminar.

PURPOSE: The development of a residency interviewing preparatory seminar (RIPS) is described. SUMMARY: The RIPS elective at Nova Southeastern University College of Pharmacy was designed to assist pharmacy students during their last professional year in preparing for the residency application process. The learning objectives of the course focused on improving students' interviewing and presentation skills, professionalism, and developing their curriculum vitae (CV) and personal statement. Course and instructor evaluations and demographic data collected via anonymous surveys were used to ascertain students' perspectives about the course. The class was purposely scheduled to begin in October and end in November, right before the ASHP Midyear Clinical Meeting in early December. Due to limited faculty availability on the scheduled evenings and the desire to provide tailored, in-depth feedback, enrollment was limited. The RIPS was an intensive eight-week elective completed by 10 fourth-year pharmacy students. The course began with an overview of the residency application process, and students submitted their CVs and personal statements to faculty mentors for critique. To simulate residency interview components, students completed several timed activities in class and participated in mock interviews. Students stated that the course improved their application materials, interview skills, and confidence in their ability to obtain a residency. Overall, 78% of RIPS participants matched with a residency program. CONCLUSION: The RIPS elective was successful in improving residency candidate confidence at the ASHP Midyear Clinical Meeting. Students reported that the course was helpful and improved their confidence and ability to interview.

Heat-stable ritonavir tablets: a new formulation of a pharmacokinetic enhancer for HIV.

IMPORTANCE OF THE FIELD: HIV is a worldwide epidemic that can be managed by combination antiretroviral therapy. Effective regimens commonly include the use of a ritonavir-boosted protease inhibitor (PI). In February 2010, the FDA approved heat-stable ritonavir tablets for management of HIV; these do not require refrigeration and may improve patient access. AREAS COVERED IN THIS REVIEW: The goal of this article is to review the ritonavir 100 mg heat-stable tablet formulation for the treatment of HIV, focusing on recent pharmacokinetic studies, safety and tolerability data, administration, and storage. WHAT THE READER WILL GAIN: With recent FDA approval, it is important that clinicians and pharmacists are knowledgeable about the differences between heat-stable ritonavir tablets and the previous soft-gel-capsule (SGC) formulation. TAKE HOME MESSAGE: Heat-stable ritonavir tablets are not bioequivalent to previous SGC and differ in regards to storage requirements. Despite this, ritonavir tablets appear to be well tolerated and may provide additional options for selected patients with HIV.