Antibiotics on Demand: Advances in Asynchronous Telemedicine Call for Increased Antibiotic Surveillance.

The rapid growth of telehealth services has brought about direct-to-consumer telemedicine platforms, enabling patients to request antibiotics online without a virtual or face-to-face consultation. While telemedicine aims to enhance accessibility, this trend raises significant concerns regarding appropriate antimicrobial use and patient safety. In this viewpoint, we share our first-hand experience with 2 direct-to-consumer platforms, where we intentionally sought inappropriate antibiotic prescriptions for nonspecific symptoms strongly indicative of a viral upper respiratory infection. Despite the lack of clear necessity, requested antibiotic prescriptions were readily transmitted to our local pharmacy following a simple monetary transaction. The effortless acquisition of patient-selected antibiotics online, devoid of personal interactions or consultations, underscores the urgent imperative for intensified antimicrobial stewardship initiatives led by state and national public health organizations in telehealth settings. By augmenting oversight and regulation, we can ensure the responsible and judicious use of antibiotics, safeguard patient well-being, and preserve the efficacy of these vital medications.

Prenatal Exposure to Opioids and Neurodevelopmental Disorders in Children: A Bayesian Mediation Analysis.

This study explores natural direct and joint natural indirect effects (JNIE) of prenatal opioid exposure on neurodevelopmental disorders (NDDs) in children mediated through pregnancy complications, major and minor congenital malformations, and adverse neonatal outcomes, using Medicaid claims linked to vital statistics in Rhode Island, United States, 2008-2018. A Bayesian mediation analysis with elastic net shrinkage prior was developed to estimate mean time to NDD diagnosis ratio using posterior mean and 95% credible intervals (CrIs) from Markov chain Monte Carlo algorithms. Simulation studies showed desirable model performance. Of 11,176 eligible pregnancies, 332 had ≥2 dispensations of prescription opioids anytime during pregnancy, including 200 (1.8%) having ≥1 dispensation in the first trimester (T1), 169 (1.5%) in the second (T2), and 153 (1.4%) in the third (T3). A significant JNIE of opioid exposure was observed in each trimester (T1, JNIE = 0.97, 95% CrI: 0.95, 0.99; T2, JNIE = 0.97, 95% CrI: 0.95, 0.99; T3, JNIE = 0.96, 95% CrI: 0.94, 0.99). The proportion of JNIE in each trimester was 17.9% (T1), 22.4% (T2), and 56.3% (T3). In conclusion, adverse pregnancy and birth outcomes jointly mediated the association between prenatal opioid exposure and accelerated time to NDD diagnosis. The proportion of JNIE increased as the timing of opioid exposure approached delivery.

Speech-in-Noise Assessment in the Routine Audiologic Test Battery: Relationship to Perceived Auditory Disability.

OBJECTIVES: Self-assessment of perceived communication difficulty has been used in clinical and research practices for decades. Such questionnaires routinely assess the perceived ability of an individual to understand speech, particularly in background noise. Despite the emphasis on perceived performance in noise, speech recognition in routine audiologic practice is measured by word recognition in quiet (WRQ). Moreover, surprisingly little data exist that compare speech understanding in noise (SIN) abilities to perceived communication difficulty. Here, we address these issues by examining audiometric thresholds, WRQ scores, QuickSIN signal to noise ratio (SNR) loss, and perceived auditory disability as measured by the five questions on the Speech Spatial Questionnaire-12 (SSQ12) devoted to speech understanding (SSQ12-Speech5). DESIGN: We examined data from 1633 patients who underwent audiometric assessment at the Stanford Ear Institute. All individuals completed the SSQ12 questionnaire, pure-tone audiometry, and speech assessment consisting of ear-specific WRQ, and ear-specific QuickSIN. Only individuals with hearing threshold asymmetries ≤10 dB HL in their high-frequency pure-tone average (HFPTA) were included. Our primary objectives were to (1) examine the relationship between audiometric variables and the SSQ12-Speech5 scores, (2) determine the amount of variance in the SSQ12-Speech5 scores which could be predicted from audiometric variables, and (3) predict which patients were likely to report greater perceived auditory disability according to the SSQ12-Speech5. RESULTS: Performance on the SSQ12-Speech5 indicated greater perceived auditory disability with more severe degrees of hearing loss and greater QuickSIN SNR loss. Degree of hearing loss and QuickSIN SNR loss were found to account for modest but significant variance in SSQ12-Speech5 scores after accounting for age. In contrast, WRQ scores did not significantly contribute to the predictive power of the model. Degree of hearing loss and QuickSIN SNR loss were also found to have moderate diagnostic accuracy for determining which patients were likely to report SSQ12-Speech5 scores indicating greater perceived auditory disability. CONCLUSIONS: Taken together, these data indicate that audiometric factors including degree of hearing loss (i.e., HFPTA) and QuickSIN SNR loss are predictive of SSQ12-Speech5 scores, though notable variance remains unaccounted for after considering these factors. HFPTA and QuickSIN SNR loss-but not WRQ scores-accounted for a significant amount of variance in SSQ12-Speech5 scores and were largely effective at predicting which patients are likely to report greater perceived auditory disability on the SSQ12-Speech5. This provides further evidence for the notion that speech-in-noise measures have greater clinical utility than WRQ in most instances as they relate more closely to measures of perceived auditory disability.

Age and Hearing Ability Influence Selective Attention During Childhood.

OBJECTIVES: The purpose of the present study was to determine whether age and hearing ability influence selective attention during childhood. Specifically, we hypothesized that immaturity and disrupted auditory experience impede selective attention during childhood. DESIGN: Seventy-seven school-age children (5 to 12 years of age) participated in this study: 61 children with normal hearing and 16 children with bilateral hearing loss who use hearing aids and/or cochlear implants. Children performed selective attention-based behavioral change detection tasks comprised of target and distractor streams in the auditory and visual modalities. In the auditory modality, children were presented with two streams of single-syllable words spoken by a male and female talker. In the visual modality, children were presented with two streams of grayscale images. In each task, children were instructed to selectively attend to the target stream, inhibit attention to the distractor stream, and press a key as quickly as possible when they detected a frequency (auditory modality) or color (visual modality) deviant stimulus in the target, but not distractor, stream. Performance on the auditory and visual change detection tasks was quantified by response sensitivity, which reflects children's ability to selectively attend to deviants in the target stream and inhibit attention to those in the distractor stream. Children also completed a standardized measure of attention and inhibitory control. RESULTS: Younger children and children with hearing loss demonstrated lower response sensitivity, and therefore poorer selective attention, than older children and children with normal hearing, respectively. The effect of hearing ability on selective attention was observed across the auditory and visual modalities, although the extent of this group difference was greater in the auditory modality than the visual modality due to differences in children's response patterns. Additionally, children's performance on a standardized measure of attention and inhibitory control related to their performance during the auditory and visual change detection tasks. CONCLUSIONS: Overall, the findings from the present study suggest that age and hearing ability influence children's ability to selectively attend to a target stream in both the auditory and visual modalities. The observed differences in response patterns across modalities, however, reveal a complex interplay between hearing ability, task modality, and selective attention during childhood. While the effect of age on selective attention is expected to reflect the immaturity of cognitive and linguistic processes, the effect of hearing ability may reflect altered development of selective attention due to disrupted auditory experience early in life and/or a differential allocation of attentional resources to meet task demands.

Background Speech Disrupts Working Memory Span in 5-Year-Old Children.

OBJECTIVES: The present study tested the effects of background speech and nonspeech noise on 5-year-old children's working memory span. DESIGN: Five-year-old typically developing children (range = 58.6 to 67.6 months; n = 94) completed a modified version of the Missing Scan Task, a missing-item working memory task, in quiet and in the presence of two types of background noise: male two-talker speech and speech-shaped noise. The two types of background noise had similar spectral composition and overall intensity characteristics but differed in whether they contained verbal content. In Experiments 1 and 2, children's memory span (i.e., the largest set size of items children successfully recalled) was subjected to analyses of variance designed to look for an effect of listening condition (within-subjects factor: quiet, background noise) and an effect of background noise type (between-subjects factor: two-talker speech, speech-shaped noise). RESULTS: In Experiment 1, children's memory span declined in the presence of two-talker speech but not in the presence of speech-shaped noise. This result was replicated in Experiment 2 after accounting for a potential effect of proactive interference due to repeated administration of the Missing Scan Task. CONCLUSIONS: Background speech, but not speech-shaped noise, disrupted working memory span in 5-year-old children. These results support the idea that background speech engages domain-general cognitive processes used during the recall of known objects in a way that speech-shaped noise does not.

A pharmacist-driven academic detailing program to increase adult pneumococcal vaccination.

OBJECTIVES: To describe our statewide, pharmacist-led education campaign to increase knowledge and awareness of pneumococcal immunization recommendations. SETTING: Immunization providers and residents in the state of Rhode Island. PRACTICE DESCRIPTION: A clinical pathway (i.e., decision-support tool) was developed to educate health professionals about appropriate indications, administration schedules, and frequently asked questions for the 2 different adult pneumococcal vaccines. Academic detailing and distribution of the clinical pathway to health professionals was conducted across Rhode Island. Community outreach activities included radio ads as well as distribution of patient handouts and wallet cards at community events. PRACTICE INNOVATION: To our knowledge, this was the first statewide, pharmacist-driven academic detailing and community outreach campaign to promote adult pneumococcal vaccination. EVALUATION: Academically detailed immunization providers received a 6-question survey. Pneumococcal disease rate differences between the study periods were evaluated with the use of Fisher exact tests, whereas changes in vaccination were assessed with the use of chi-square tests. RESULTS: From November 2013 through July 2015, our academic detailers visited and distributed our vaccination pathway materials to more than 400 practice sites across Rhode Island, including 68% of community pharmacies and all adult acute care hospitals. Of the 413 surveys completed, 92% of respondents agreed that their knowledge of the pneumococcal conjugate vaccine, 13-valent and pneumococcal polysaccharide vaccine, 23-valent had improved. Pneumococcal vaccination increased significantly (absolute difference 3.9%, percentage change in proportion 5.4%; P = 0.01), and pneumococcal disease decreased significantly between the preintervention and intervention periods (-2.74/10,000 discharges [95% CI -5.15 to -0.32], P = 0.02). Invasive pneumococcal disease decreased by 21 cases per 1,000,000 population per year between the preintervention and postintervention periods (-42.25 to 0.14, P = 0.05). CONCLUSION: Our statewide, pharmacist-driven pneumococcal vaccination educational outreach program resulted in favorable provider feedback relative to knowledge change and perceptions. Vaccination increased and pneumococcal disease decreased during the study period.

Age-Related Differences in Listening Effort During Degraded Speech Recognition.

OBJECTIVES: The purpose of the present study was to quantify age-related differences in executive control as it relates to dual-task performance, which is thought to represent listening effort, during degraded speech recognition. DESIGN: Twenty-five younger adults (YA; 18-24 years) and 21 older adults (OA; 56-82 years) completed a dual-task paradigm that consisted of a primary speech recognition task and a secondary visual monitoring task. Sentence material in the primary task was either unprocessed or spectrally degraded into 8, 6, or 4 spectral channels using noise-band vocoding. Performance on the visual monitoring task was assessed by the accuracy and reaction time of participants' responses. Performance on the primary and secondary task was quantified in isolation (i.e., single task) and during the dual-task paradigm. Participants also completed a standardized psychometric measure of executive control, including attention and inhibition. Statistical analyses were implemented to evaluate changes in listeners' performance on the primary and secondary tasks (1) per condition (unprocessed vs. vocoded conditions); (2) per task (single task vs. dual task); and (3) per group (YA vs. OA). RESULTS: Speech recognition declined with increasing spectral degradation for both YA and OA when they performed the task in isolation or concurrently with the visual monitoring task. OA were slower and less accurate than YA on the visual monitoring task when performed in isolation, which paralleled age-related differences in standardized scores of executive control. When compared with single-task performance, OA experienced greater declines in secondary-task accuracy, but not reaction time, than YA. Furthermore, results revealed that age-related differences in executive control significantly contributed to age-related differences on the visual monitoring task during the dual-task paradigm. CONCLUSIONS: OA experienced significantly greater declines in secondary-task accuracy during degraded speech recognition than YA. These findings are interpreted as suggesting that OA expended greater listening effort than YA, which may be partially attributed to age-related differences in executive control.

Promoting Safe Use of Medications: Providing Medication Education to Seniors Receiving Meals on Wheels.

STUDY OBJECTIVES: To assess whether pharmacist-provided medication education and counseling to Meals on Wheels (MOW) participants decreases medication-related preventable harm and improves adherence. DESIGN: Prospective, quasi-experiment. SETTING: Ambulatory congregrate dining centers. PATIENTS: Persons 60 years of age and older participating in MOW receiving prescription, nonprescription, or complementary products were eligible. In total, 42 patients consented. Five patients did not complete the first visit, and 13 patients did not complete the six-month follow-up visit. INTERVENTIONS: Pharmacists provided comprehensive medication education about prescription, nonprescription, and complementary products at baseline. Additional resources to enhance adherence and avoid medication-related preventable harm were provided and discussed. MAIN OUTCOME MEASURES: Medication-related preventable harm and medication adherence were assessed before pharmacist intervention and six months after intervention. Adherence was assessed and compared with baseline using the Morisky scale and pill counts. RESULTS: Women constituted the majority of participants (94.4%) with an average age of 74.5 ± 8.2 years. Mean difference in Morisky score from baseline to six months was 0.28 (-0.11 to 0.56). After adjustment for age and living situation, the change in Morisky score was associated with a 14% improvement in adherence. Mean differences in drug-drug and drug-supplement interactions, and medication-related harm were not significantly reduced from baseline to study end. CONCLUSION: Pharmacist intervention with MOW participants appeared to improve medication adherence rates but had limited effect on medication-related preventable harm. No findings reached statistical significance as the sample size was inadequate. Larger studies are needed to confirm these findings.

The Impact of a Student-Run Journal Club on Pharmacy Students' Self-Assessment of Critical Appraisal Skills.

After attending an educational session on hosting journal clubs at the 2013 Annual Meeting & Exhibition, American Society of Consultant Pharmacists, Seattle, Washington, two third-year professional pharmacy students created a student-run journal club through the University of Rhode Island's ASCP student chapter. Three journal club sessions were held during the spring semester and were open to all pharmacy students. Students completed an anonymous pre- and post-survey to assess confidence in evaluating medical literature. Of the 18 participants, 5 were lost to follow-up. Significant improvements were found among all participants in their confidence in critically evaluating clinical research, interpreting statistical methods, and completing a journal club during Advanced Pharmacy Practice Experience rotations. This activity can be replicated in academic settings as well as workplace environments where pharmacy students are involved.

Assessment and revision of clinical pharmacy practice internet web sites.

BACKGROUND: Health care professionals, trainees, and patients use the Internet extensively. Editable Web sites may contain inaccurate, incomplete, and/or outdated information that may mislead the public's perception of the topic. OBJECTIVE: To evaluate the editable, online descriptions of clinical pharmacy and pharmacist and attempt to improve their accuracy. METHODS: The authors identified key areas within clinical pharmacy to evaluate for accuracy and appropriateness on the Internet. Current descriptions that were reviewed on public domain Web sites included: (1) clinical pharmacy and the clinical pharmacist, (2) pharmacy education, (3) clinical pharmacy and development and provision for reimbursement, (4) clinical pharmacists and advanced specialty certifications/training opportunities, (5) pharmacists and advocacy, and (6) clinical pharmacists and interdisciplinary/interprofessional content. The authors assessed each content area to determine accuracy and prioritized the need for updating, when applicable, to achieve consistency in descriptions and relevancy. The authors found that Wikipedia, a public domain that allows users to update, was consistently the most common Web site produced in search results. RESULTS: The authors' evaluation resulted in the creation or revision of 14 Wikipedia Web pages. However, rejection of 3 proposed newly created Web pages affected the authors' ability to address identified content areas with deficiencies and/or inaccuracies. CONCLUSIONS: Through assessing and updating editable Web sites, the authors strengthened the online representation of clinical pharmacy in a clear, cohesive, and accurate manner. However, ongoing assessments of the Internet are continually needed to ensure accuracy and appropriateness.

Angiotensin Receptor Blockers for Hypertension and Risk of Epilepsy.

Importance: Animal and human studies have suggested that the use of angiotensin receptor blockers (ARBs) may be associated with a lower risk of incident epilepsy compared with other antihypertensive medications. However, observational data from the US are lacking. Objective: To evaluate the association between ARB use and epilepsy incidence in subgroups of US patients with hypertension. Design, Setting, and Participants: This retrospective cohort study used data from a national health administrative database from January 2010 to December 2017 with propensity score (PS) matching. The eligible cohort included privately insured individuals aged 18 years or older with diagnosis of primary hypertension and dispensed at least 1 ARB, angiotensin-converting enzyme inhibitor (ACEI), ß-blocker, or calcium channel blocker (CCB) from 2010 to 2017. Patients with a diagnosis of epilepsy at or before the index date or dispensed an antiseizure medication 12 months before or 90 days after initiating the study medications were excluded. The data analysis for this project was conducted from April 2022 to April 2024. Exposures: Propensity scores were generated based on baseline covariates and used to match patients who received ARBs with those who received either ACEIs, ß-blockers, CCBs, or a combination of these antihypertensive medications. Main Outcomes and Measures: Cox regression analyses were used to evaluate epilepsy incidence during follow-up comparing the ARB cohort with other antihypertensive classes. Subgroup and sensitivity analyses were conducted to examine the association between ARB use and epilepsy incidence in various subgroups. Results: Of 2 261 964 patients (mean [SD] age, 61.7 [13.9] years; 1 120 630 [49.5%] female) included, 309 978 received ARBs, 807 510 received ACEIs, 695 887 received ß-blockers, and 448 589 received CCBs. Demographic and clinical characteristics differed across the 4 comparison groups prior to PS matching. Compared with ARB users, patients receiving ACEIs were predominantly male and had diabetes, CCB users were generally older (eg, >65 years), and ß-blocker users had more comorbidities and concurrent medications. The 1:1 PS-matched subgroups included 619 858 patients for ARB vs ACEI, 619 828 patients for ARB vs ß-blocker, and 601 002 patients for ARB vs CCB. Baseline characteristics were equally distributed between comparison groups after matching with propensity scores. Use of ARBs was associated with a decreased incidence of epilepsy compared with ACEIs (adjusted hazard ratio [aHR], 0.75; 95% CI, 0.58-0.96), ß-blockers (aHR, 0.70; 95% CI, 0.54-0.90), and a combination of other antihypertensive classes (aHR, 0.72; 95% CI, 0.56-0.95). Subgroup analyses revealed a significant association between ARB use (primarily losartan) and epilepsy incidence in patients with no preexisting history of stroke or cardiovascular disease. Conclusions and Relevance: This cohort study found that ARBs, mainly losartan, were associated with a lower incidence of epilepsy compared with other antihypertensive agents in hypertensive patients with no preexisting stroke or cardiovascular disease. Further studies, such as randomized clinical trials, are warranted to confirm the comparative antiepileptogenic properties of antihypertensive medications.

Microstructural Changes in the Brainstem Auditory Pathway in Children With Hearing Loss.

OBJECTIVE: To assess the utility of diffusion tensor imaging of the auditory pathway in children with sensorineural hearing loss (SNHL). STUDY DESIGN: Retrospective cohort study. SETTING: A single academic tertiary children's hospital. PATIENTS: Sixteen pediatric patients with bilateral SNHL of at least moderate severity in the poorer ear (eight male; mean age, 5.3 ± 4.9 yrs). Controls consisted of age- and sex-matched children with normal hearing who were imaged for nonotologic, non-neurologic medical concerns and found to have normal magnetic resonance imaging (MRI). INTERVENTIONS: Three Tesla MRI scanners were used for diffusion tensor imaging. MAIN OUTCOME MEASURES: Quantitative diffusion tensor metrics were extracted from the superior olivary nucleus (SON), inferior colliculus (IC), and ipsilateral fiber tracts between the SON and IC delineated by tractography. RESULTS: We identified differences in fractional anisotropy of the SON between the SNHL cohort and controls (0.377 ± 0.056 vs. 0.422 ± 0.052; p = 0.009), but not in the IC. There were no differences in the mean diffusivity (MD) values in the IC and SON. Among younger children (≤5 yrs), MD was decreased in the SNHL cohort compared with controls in the IC (0.918 ± 0.051 vs. 1.120 ± 0.142; p < 0.001). However, among older children (>5 yrs), there were no differences in MD (1.124 ± 0.198 vs. 0.997 ± 0.103; p = 0.119). There were no differences in MD or fractional anisotropy in the white matter fibers of the IC-SON tract. CONCLUSIONS: Our results suggest abnormal neural tracts along the central auditory pathway among children with SNHL. Longitudinal studies should assess the prognostic value of these MRI-based findings for assessing long-term outcomes and determining intervention efficacy.

An Integrative Review of Micro-Credentials and Digital Badges for Pharmacy Educators.

Micro-credentials (MCs) and digital badges (DBs) have gained popularity in recent years as a means to supplement traditional degrees and certifications. MCs and DBs can play a significant role in supporting student-centered learning by offering personalized and flexible learning pathways, emphasizing real-world relevance and practical skills, and fostering a culture of continuous learning and growth. However, barriers currently exist within health professions education, including pharmacy education, that could limit the full adoption and implementation of MCs and DBs. Research on the use of MCs and DBs in Doctor of Pharmacy degree programs is sparse. In this integrative review, literature on the use of MCs and DBs in health professions education is reviewed, and perspectives on the benefits, issues, and potential future uses within Doctor of Pharmacy degree programs are presented.

Comparative Safety Analysis of Opioid Agonist Treatment in Pregnant Women with Opioid Use Disorder: A Population-Based Study.

INTRODUCTION AND OBJECTIVE: Receipt of opioid agonist treatment during early and late pregnancy for opioid use disorder may relate to varying perinatal risks. We aimed to assess the effect of time-varying prenatal exposure to opioid agonist treatment using buprenorphine or methadone on adverse neonatal and pregnancy outcomes. METHODS: We conducted a retrospective cohort study of pregnant women with opioid use disorder using Rhode Island Medicaid claims data and vital statistics during 2008-16. Time-varying exposure was evaluated in early (0-20 weeks) and late (≥ 21 weeks) pregnancy. Marginal structural models with inverse probability of treatment weighting were applied. RESULTS: Of 400 eligible pregnancies, 85 and 137 individuals received buprenorphine and methadone, respectively, during early pregnancy. Compared with 152 untreated pregnancies with opioid use disorders, methadone exposure in both periods was associated with an increased risk of preterm birth (adjusted odds ratio [aOR]: 2.52; 95% confidence interval [CI] 1.07-5.95), low birth weight (aOR: 2.99; 95% CI 1.34-6.66), neonatal intensive care unit admission (aOR, 5.04; 95% CI 2.49-10.21), neonatal abstinence syndrome (aOR: 11.36; 95% CI 5.65-22.82), respiratory symptoms (aOR, 2.71; 95% CI 1.17-6.24), and maternal hospital stay > 7 days (aOR, 14.51; 95% CI 7.23-29.12). Similar patterns emerged for buprenorphine regarding neonatal abstinence syndrome (aOR: 10.27; 95% CI 4.91-21.47) and extended maternal hospital stay (aOR: 3.84; 95% CI 1.83-8.07). However, differences were found favoring the use of buprenorphine for preterm birth versus untreated pregnancies (aOR: 0.17; 95% CI 0.04-0.77), and for several outcomes versus methadone. CONCLUSIONS: Methadone and buprenorphine prescribed for the treatment of opioid use disorder during pregnancy are associated with varying perinatal risks. However, buprenorphine may be preferred in the setting of pregnancy opioid agonist treatment. Further research is necessary to confirm our findings and minimize residual confounding.

Prevalence of Cochlear Nerve Deficiency and Hearing Device Use in Children With Single-Sided Deafness.

OBJECTIVE: This study aimed to assess the prevalence of cochlear nerve deficiency (CND) in a cohort of pediatric patients with single-sided deafness (SSD). A secondary objective was to investigate trends in intervention and hearing device use in these children. STUDY DESIGN: Case series with chart review. SETTING: Pediatric tertiary care center. METHODS: Children ages 0 to 21 years with SSD (N = 190) who underwent computerized tomography (CT) and/or magnetic resonance imaging (MRI) were included. Diagnostic criteria for SSD included unilateral severe-to-profound sensorineural hearing loss with normal hearing sensitivity in the contralateral ear. Diagnostic criteria for CND included neuroradiologist report of an "aplastic or hypoplastic nerve" on MRI or a "stenotic cochlear aperture" on CT. RESULTS: The prevalence of CND was 42% for children with CT only, 76% for children with MRI only, and 63% for children with both MRI and CT. Of the children with MRI and CT, there was a 90% concordance across imaging modalities. About 36% of children with SSD had hearing devices that routed sound to the normal hearing ear (ie, bone conduction hearing device/contralateral routing of signal), while only 3% received a cochlear implant. Approximately 40% did not have a hearing device. Hearing device wear time averaged 2.9 hours per day and did not differ based on cochlear nerve status. CONCLUSION: There is a high prevalence of CND in children with SSD. Cochlear nerve status should be confirmed via MRI in children with SSD. The limited implementation and use of hearing devices observed for children with SSD reinforce the need for increased support for early and continuous intervention.

Curriculum and instructional methods for drug information, literature evaluation, and biostatistics: survey of US pharmacy schools.

BACKGROUND: The drug information curriculum in US colleges of pharmacy continues to evolve. The American College of Clinical Pharmacy (ACCP) Drug Information Practice and Research Network (DI PRN) published an opinion paper with specific recommendations regarding drug information education in 2009. Adoption of these recommendations has not been evaluated. OBJECTIVE: To assess which recommendations made in the ACCP DI PRN opinion paper are included in US pharmacy school curricula and characterize faculty qualifications, educational methods, and recent changes in drug information education. METHODS: An electronic survey was designed using the ACCP DI PRN opinion paper and the Accreditation Council for Pharmacy Education standards and guidelines for accreditation of PharmD programs in the US. Survey questions addressed curricular content within the following categories: drug information, literature evaluation, and biostatistics. A letter including the online survey link was sent via email to the dean of each US college/school of pharmacy (N = 128). Recipients were instructed to forward the email to the individual at their institution who was the most knowledgeable about the content and methodology used for didactic drug information education. RESULTS: Sixty-four responses were included in the final analysis. Of the 19 ACCP DI PRN minimum core concepts, 9 (47%) were included in curricula of all responding institutions; 14 of 19 (74%) were included in curricula for all but 1 institution. In contrast, 5 of 16 concepts (31%) were not formally taught by a number of institutions. Many respondents noted an increased focus on evidence-based medicine, medication safety, and informatics. CONCLUSIONS: Although a survey of drug information curricula documented substantial inclusion of the essential concepts presented in the ACCP DI PRN opinion paper, room for improvement remains in drug information curricula in US colleges of pharmacy.

Intranasal Ketamine for Acute Pain.

OBJECTIVES: The aim was to review current evidence regarding the off-label use of intranasal ketamine for acute pain presenting in the setting of the emergency department, and secondary to pediatric limb injuries, renal colic, digital nerve block, and migraines. RESULTS: In all 5 indications reviewed, ketamine demonstrated efficacy in reducing pain. However, when compared with other agents, ketamine did not demonstrate superiority over opioids in pediatric limb injuries or renal colic and was not as efficacious as standard therapy for migraine relief. Ketamine was also associated with a greater incidence of transient adverse reactions, such as dizziness, bitter aftertaste, fatigue, and vomiting than opioid therapies. DISCUSSION: The current body of evidence is insufficient to support the use of intranasal ketamine over other standard therapies for acute pain. However, current evidence can be used when developing dosing strategies, preparing for adverse reactions, and generating hypotheses for future, more robust research.

A systematic review of integrative medicine for opioid withdrawal.

INTRODUCTION: The United States has been battling an opioid epidemic for decades. As substance use disorders have grown, so too has investigation into treatment options, including integrative medicine approaches, for managing opioid withdrawal symptoms (OWS). OBJECTIVES: This systematic review sought to assess the use of integrative medicine approaches for the alleviation of OWS in patients dependent on opioids and to summarize the available data. METHODS: The authors searched using synonyms for opioids, substance use disorder, and integrative medicine and standardized searches in Embase, PubMed, and Cochrane Library. We also hand searched references for systematic reviews. This review did not include articles that could not be obtained as full-text publications via interlibrary loan. The review also excluded studies with interventions involving acupuncture because multiple systematic reviews on this approach already exist. In addition, we also excluded studies of therapy for opioid maintenance. We evaluated studies for inclusion based on the Jadad criteria. We compared opioid withdrawal outcomes of the studies to determine the efficacy of integrative medicine approaches. RESULTS: The authors identified a total of 382 unique publications initially for possible inclusion through systematic searches. After applying inclusion and exclusion criteria, five studies met Jadad criteria. The authors identified an additional two studies for inclusion via hand searching. A total of seven studies included interventions consisting of passionflower, weinicom, fu-yuan pellet, jinniu capsules, tai-kang-ning, dynorphin, and l-tetrahydropalmatine. Analyzing the articles was difficult given the varied scoring methods they used to quantify opioid withdrawal symptoms and the small sample sizes in the trials. Most showed evidence that supported integrative medicine approaches for OWS, although the strength of evidence was limited because of sample sizes. CONCLUSIONS: This review found evidence of multiple integrative medicine approaches for opioid withdrawal symptoms. Well-designed randomized controlled trials should assess the efficacy of integrative medicine for improvement in OWS.

Association of Gestational Opioid Exposure and Risk of Major and Minor Congenital Malformations.

Importance: The rapid increase of opioid-related overdoses and deaths has become a public health concern in the US. Use of prescription opioids in pregnant women has increased; results from teratogenicity studies remain controversial. Objective: To evaluate the association between maternal prescription opioid use (excluding opioid use disorders) during pregnancy and the incidence of congenital malformations. Design, Setting, and Participants: This retrospective population-based cohort study evaluated linked Rhode Island Medicaid claims and vital statistics data of live births from January 1, 2008, to December 31, 2016. Data analysis was conducted from May 1, 2019, to May 31, 2020. Women who had a live birth during the study period, but no cancer or opioid use disorder, were followed up from 3 months before pregnancy to the end of pregnancy. Exposures: Data on the mother's prescription opioid exposure were obtained through pharmacy claims and exposure was defined as dispensing of at least 1 prescription opioid during the first, second, or third trimester. Main Outcomes and Measures: The primary outcome was overall major or minor congenital malformations, defined as 1 or more major or minor congenital malformation. Secondary outcomes were defined as 10 specific categories of congenital malformations classified by organ systems using International Classification of Diseases diagnosis codes. Results: Of 12 424 included pregnancies, 891 mothers (7.2%) received prescription opioids during pregnancy and 3153 infants (25.4%) were diagnosed with major or minor congenital malformations. Comparing prescription opioid exposure vs nonexposure, no excess risk was observed for major birth defects in infants with opioid exposure in trimester 1 (adjusted relative risk [aRR], 1.40; 95% CI, 0.84-2.34), and higher risks were found for overall minor birth defects in trimester 3 (aRR, 1.26; 95% CI, 1.04-1.53) and minor birth defects in the musculoskeletal system in trimester 2 (aRR, 1.50; 95% CI, 1.10-2.03) and trimester 3 (aRR, 1.65; 95% CI, 1.23-2.22). Significant dose responses in selected minor malformations and effects of specific opioids were also identified. Hydrocodone in trimester 2 (aRR, 3.01; 95% CI, 1.80-5.03) and oxycodone in trimester 3 (aRR, 2.43; 95% CI, 1.37-4.02) were associated with plagiocephaly, polydactyly, and other specified congenital deformities of the hip. Conclusions and Relevance: The findings of this study suggest a higher risk of minor congenital malformations associated with use of prenatal prescription opioids in trimester 3, which seems to be dose-dependent. Further investigation is needed to establish causality and explore the physiologic plausibility of the association.

Maternal Complications and Prescription Opioid Exposure During Pregnancy: Using Marginal Structural Models.

INTRODUCTION: Prescription opioids are frequently used for pain management in pregnancy. Studies examining perinatal complications in mothers who received prescription opioids during pregnancy are still limited. OBJECTIVES: The aim of this study was to assess the association of prescription opioid use and maternal pregnancy and obstetric complications. METHODS: This retrospective cohort study with the Rhode Island (RI) Medicaid claims data linked to vital statistics throughout 2008-2015 included pregnant women aged 12-55 years with one or multiple live births. Women were excluded if they had cancer, opioid use disorder, or opioid dispensing prior to but not during pregnancy. Main outcomes included adverse pregnancy and obstetric complications. Marginal Structural Cox Models with time-varying exposure and covariates were applied to control for baseline and time-varying covariates. Analyses were conducted for outcomes that occurred 1 week after opioid exposure (primary) or within the same week as exposure (secondary). Sensitivity studies were conducted to assess the effects of different doses and individual opioids. RESULTS: Of 9823 eligible mothers, 545 (5.5%) filled one or more prescription opioid during pregnancy. Compared with those unexposed, no significant risk was observed in primary analyses, while in secondary analyses opioid-exposed mothers were associated with an increased risk of cesarean antepartum depression (HR 3.19; 95% CI 1.22-8.33), and cardiac events (HR 9.44; 95% CI 1.19-74.83). In sensitivity analyses, results are more prominent in high dose exposure and are consistent for individual opioids. CONCLUSIONS: Prescription opioid use during pregnancy is associated with an increased risk of maternal complications.