What is the analgesic ceiling dose of ketorolac for treating acute pain in the ED?

ABSTRACT: Recent research has suggested that ketorolac has an analgesic ceiling effect, meaning that despite increased dosages, the patient obtains no additional pain relief and is more likely to suffer adverse drug reactions. This article describes the outcomes of these studies and the recommendation to use the lowest possible dose for the shortest time when treating patients with acute pain.

Efficacy of Transcutaneous Electrical Nerve Stimulation for Postoperative Pain, Pulmonary Function, and Opioid Consumption Following Cardiothoracic Procedures: A Systematic Review.

OBJECTIVE: Transcutaneous electrical nerve stimulation (TENS) is a minimally invasive method for treating pain. In the most recent review published in 2012, TENS was associated with increased pain relief following cardiothoracic surgery when compared to standard multimodal analgesia. The purpose of this systematic review and meta-analysis is to determine if adding TENS to current pain management practices decreases pain and analgesic use and improves pulmonary function for postcardiothoracic surgery patients. MATERIALS AND METHODS: CINAHL, MEDLINE, Cochrane Database of Systematic Reviews, PubMed, and ClinicalTrials.gov were searched using specific keywords. Covidence was used to screen, select studies, and extract data by two independent reviewers. The Cochrane Risk of Bias tool assessed risk of bias. Visual analog scale (VAS) and pulmonary function data were exported for meta-analysis using a random effects model. RESULTS: The search yielded 38 articles. Eight randomized controlled trials met inclusion criteria for the literature review. Five studies were included in the meta-analysis of pain at 24, 48, and 72 hours postoperatively. Data were analyzed using the standard mean difference (SMD). TENS had a significant impact on VAS at rest (-0.76 SMD [95% confidence interval, CI = -1.06 to -0.49], p < 0.00001) and with coughing (-1.11 SMD [95% CI = -1.64 to -0.56], p < 0.0001). FEV1 improved after 72 hours (1.00 SMD [95% CI = 0.66-1.35], p < 0.00001), as did forced vital capacity (1.16 SMD [95% CI = 0.23-2.10], p = 0.01). CONCLUSION: The addition of TENS therapy to multimodal analgesia significantly decreases pain following cardiothoracic surgery, increases the recovery of pulmonary function, and decreases the use of analgesics.

Problem-Based Learning and Case Scenarios: An Interprofessional Pharmacology Experience.

ABSTRACT: Interprofessional education (IPE) is a required component of the nursing curriculum as it can foster students' abilities to become integral members of the health care team. To facilitate this requirement, an IPE experience focusing on cardiovascular pharmacology was created for nurse practitioner and physician assistant students. The authors developed and utilized a problem-based learning activity and two minicase scenarios. The Student Perceptions of Physician-Pharmacist Interprofessional Clinical Education-Revised was administered before and after the activity to assess students' attitudes toward IPE. This article reviews the planning, development, and implementation of this IPE experience and discusses its challenges.

What is the role of cannabidiol in refractory epilepsy?

The FDA recently approved the first cannabidiol oral medication to treat refractory epilepsy in patients with Dravet syndrome and Lennox-Gastaut syndrome. This article describes the safety and efficacy of cannabidiol treatment in patients with refractory epilepsy.

Brivaracetam (Briviact): A Novel Adjunctive Therapy for Partial-Onset Seizures.

Brivaracetam (Briviact): a novel adjunctive therapy for partial-onset seizures.

Valued characteristics of community pharmacy residency applicants.

OBJECTIVES: To determine the attributes of postgraduate year 1 (PGY1) community pharmacy residency applicants and candidates that are most appealing to community residency program directors (CRPDs). DESIGN: A 22-question online survey, designed to collect residency demographics, desirable characteristics for consideration for interview invitation (applicants), and characteristics that should be displayed during an interview (candidates). SETTING: American Society of Health-System Pharmacists (ASHP)-recognized community pharmacy residency programs (CPRPs). PARTICIPANTS: The CRPDs of 109 ASHP-recognized CPRPs throughout the United States. INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: Minimum applicant requirements; rank order of valued characteristics at application and interview stage of hiring process. RESULTS: The response rate was 71/109 (65.1%). Applicant work experience in chain pharmacy (90.1%) and independent pharmacy (77.5%) was most highly valued by CRPDs, with 85.9% preferring applicants with a minimum of 1 year or more of community pharmacy experience. A large majority of CPRPs (91.4%) indicated a preference for applicants who have been an officer of a student organization. Among CPRPs that required minimum grade point averages (GPAs), a mean GPA of 2.88 ± 0.34 was reported (range 2.0 to 3.5; mode 3.0). Pharmacy work experience (68.1%) and letters of recommendation (59.4%) were most frequently cited as top factors in the decision-making process for selecting candidates to interview. At the interview stage, CRPDs rated interest and knowledge about the residency (62.3%), time management and prioritization (50.7%), and self-awareness and commitment to improvement (43.5%) as the most important skills for candidates to demonstrate. CONCLUSION: Community pharmacy work experience, organizational leadership experience, and positive letters of recommendation appear to be the most valued attributes of a community pharmacy residency applicant. Applicants should consider aligning themselves with these characteristics to successfully match to a community pharmacy residency.

The efficacy of purified pollen extract for reducing vasomotor symptoms in women: a systematic review and meta-analysis.

IMPORTANCE: Menopause impacts the quality of life for women, with symptoms varying from hot flashes to night disturbances. When menopausal hormonal therapy is contraindicated or women refuse menopausal hormonal therapy, many consider alternatives such as pollen extract for treating vasomotor symptoms. OBJECTIVE: This meta-analysis focuses on the impact of using purified pollen extract as a treatment option to reduce vasomotor symptoms in women, specifically focusing on symptoms such as hot flashes, night disturbances, myalgias, and depression. EVIDENCE REVIEW: A comprehensive literature search was conducted using the following Boolean search string "women OR females" AND "purified pollen OR pollen extract OR cytoplasmic pollen OR Bonafide OR Femal OR Estroven OR Serelys" AND "menopausal symptoms OR vasomotor symptoms OR hot flashes OR night sweats OR sleep disturbance." Publications in English from 2003 to the present were included. To assess the risk of bias, authors used the Cochrane Risk-of-Bias 2 for a randomized controlled trial and Risk-of-Bias in Non-Randomized Studies of Interventions (ROBINS-I) for observational studies. Using ReviewManager, a Der Simonian-Laird random-effects model meta-analysis was conducted to determine the standardized mean differences (SMDs) in the outcomes for each study. FINDINGS: Five articles were retained: one randomized controlled trial and four observational studies ( N = 420). An overall decrease in scores from the baseline of studies compared with a 3-month follow-up after purified cytoplasm of pollen (PCP) treatment was recognized when compiling the data. Overall, there was significant improvement across all outcomes at 3 months: hot flashes demonstrated an overall improvement in SMD of -1.66 ( P < 0.00001), night disturbance scores were improved with an SMD of -1.10 ( P < 0.0001), depression scores were improved with an SMD of -1.31 ( P < 0.0001), and myalgia had an improvement in SMD of -0.40 ( P < 0.00001). When controlled studies were pooled for meta-analysis, outcomes, however, were no longer statistically significant. CONCLUSIONS AND RELEVANCE: Evaluating the risk-to-benefit ratio of alternative therapies, such as PCP extract, is important to care for women who cannot take traditional vasomotor symptom therapies. Pooled data from controlled studies evaluating PCP extract suggest that vasomotor symptom improvements seen in noncontrolled studies may have been due to the placebo effect; however, its use was not associated with significant adverse effects.

The efficacy of zuranolone versus placebo in postpartum depression and major depressive disorder: a systematic review and meta-analysis.

BACKGROUND: Zuranolone, an oral version of allopregnanolone and neurosteroid, is a novel drug for the treatment of major depressive disorder (MDD) and postpartum depression (PPD). AIM: The purpose of this systematic review and meta-analysis was to assess the efficacy of zuranolone in the treatment of MDD and PPD. METHOD: A systematic search was conducted using EBSCOhost to simultaneously search Academic Search Premier, APA PsycArticles, APA PsycInfo, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, CINAHL Ultimate, and MEDLINE with Full Text. Two independent reviewers screened the articles and completed a full-text review using Covidence. The quality of each study was assessed using the Cochrane Risk of Bias tool for randomized trials (RoB 2). A meta-analysis was then conducted using Review Manager (RevMan v5.4) software. RESULTS: The initial search yielded 127 results, with 6 articles fitting our inclusion and exclusion criteria. All 6 studies, comprising 1707 participants, had an overall low risk of bias. There was a significant decrease in HAM-D scores for MDD at 15 days versus placebo (MD - 2.40, 95% CI - 3.07 to - 1.63; p < .001). When pooling data for PDD, there was an overall significant decrease in HAM-D scores at 15 days versus placebo (MD - 4.06, 95% CI - 4.25 to - 3.87; p < .001). CONCLUSION: The results suggest that zuranolone can improve symptoms of PPD at 15 days; however, results were not clinically significant for MDD. Future research is needed to evaluate the long-term efficacy of zuranolone in PPD and the treatment efficacy in MDD.

Remimazolam: A Novel Option for Procedural Sedation in High Risk Patients.

PURPOSE: The purpose of this drug review was to explore the safety and efficacy of the newly approved benzodiazepine, remimazolam, in order to evaluate its place in therapy. SUMMARY: Remimazolam has a faster onset of action and recovery time than midazolam when given as single IV doses. Additionally, it has no known CYP450 interactions that would contribute to drug-drug interactions. Patients with severe hepatic impairment may require dose titration as well as the elderly who should be closely monitored. Although remimazolam vials should be protected from light and must be reconstituted immediately before use, the reconstituted vial may be stored for later use at room temperature for up to 8 hours. Remimazolam is more expensive than current options used in practice, as such individual institutional formulary and provider preference will require review to see if its advantages are worth the additional cost and to determine its place in therapy. CONCLUSION: Remimazolam is a novel option when choosing a benzodiazepine for procedural sedation that has pharmacokinetic and pharmacodynamic advantages when compared to other commonly prescribed sedatives. Remimazolam has proved superior to midazolam when analyzing drug-drug interactions, onset, and time to alertness. Remimazolam also has a shorter elimination half-life and decreased volume of distribution when compared to midazolam.

Mpox (Formally Known as Monkeypox).

This article reviews Mpox, including its epidemiology, transmission, clinical presentation, diagnosis, prevention, and management and treatment of the virus. This article also investigates the current outbreak of Mpox in nonendemic countries, including the United States. It discusses the high prevalence of Mpox affecting the men who have sex with men community. It examines the social stigma related to disease outbreaks of the past and it provides strategies that should be implemented to prevent stigmatization of the men who have sex with men community with the present-day outbreak of Mpox.

Efficacy of subcutaneous semaglutide compared to placebo for weight loss in obese, non-diabetic adults: a systematic review & meta-analysis.

BACKGROUND: Research on semaglutide's effect on weight loss has been largely focused on Type 2 Diabetics. No meta-analyses of semaglutide's efficacy in non-diabetic individuals have been conducted to date. Expanding the knowledge of semaglutide's outcome in non-diabetics may provide impactful changes at the clinical level. AIM: This systematic review and meta-analysis quantified the efficacy of subcutaneous semaglutide in treating obesity in non-diabetic adult patients compared to placebo. METHOD: Academic Search Premier, Cumulative Index to Nursing and Allied Health Literature (CINAHL) complete, MEDLINE with Full Text, Cochrane Central Register of Controlled Trials, medrxiv.org, and clinicaltrials.gov were systematically investigated using a predetermined search strategy from inception to August 21, 2021. Covidence.org was used to screen, select, and extract data by two independent reviewers. Individual study bias was assessed using the Cochrane Risk of Bias 2 tool. Data were exported to RevMan v5.4, where meta-analysis was conducted using a DerSimonian and Laird random-effects model. RESULTS: The initial search identified 332 relevant articles and ultimately retained four randomized controlled trials encompassing 2,882 participants with a BMI ≥ 27 kg/m2. Patients treated with semaglutide experienced a clinically significant reduction in mean body weight - 11.62 kg (95% CI: -13.03 to -10.21; P < 0.00001). CONCLUSION: This systematic review and meta-analysis validates the clinical efficacy of semaglutide for the treatment of obesity in the adult, non-diabetic population.

Non-antipsychotic pharmacotherapy of psychogenic polydipsia: A systematic review.

OBJECTIVE: Polydipsia is defined at the intake of excessive fluid (>3 L daily). Psychogenic polydipsia (PPD) presents without an identifiable medical cause and is often seen in patients with diagnoses of schizophrenia, OCD, anxiety, alcohol use disorder, and other psychotic disorders. The purpose of this systematic review is to assess the therapeutic effect of various non-antipsychotic medications on patients with a stable psychotic illness and concurrent PPD. METHODS: A systematic search was conducted using the following databases: PubMed, MEDLINE with Full Text, CINAHL complete, Cochrane database of systematic reviews, Cochrane methodology register, MasterFILE Premier, APA PsychArticles, APA PsychInfo, APA PsycBooks, APA PsycTests, TRIP, Nursing and Allied Health. The quality of each retained study was assessed using appropriate risk of bias tools based on study design. RESULTS: The initial search resulted in 1422 articles from which 22 articles were included for qualitative synthesis. Study designs ranged from case reports to double blind, placebo controlled randomized trials and was interpreted uniquely based on study design. Acetazolamide was effective in improving some PPD outcomes. Fluoxetine at high doses was effective in reducing fluid intake and polydipsia. Other medications included in this review performed equivocally for reduction of numerous parameters evaluating PPD. CONCLUSION: No one drug appeared to be the most efficacious; however, some did show promise in specific populations. Those in need of pharmacotherapeutic options for PPD may consider one of the included agents to assist with co-morbid state. Further high-quality research is needed to provide better treatment guidance for PPD.

Folate as adjunct therapy to SSRI/SNRI for major depressive disorder: Systematic review & meta-analysis.

OBJECTIVE: Evaluate depression scores, response, and remission rates in patients with major depression receiving adjunct therapy with folate (L-Methylfolate or folic acid) compared to selective serotonin reuptake inhibitor or serotonin-norepinephrine reuptake inhibitor (SSRI or SNRI) monotherapy. METHODS: Academic Search Premier, CINAHL Complete, Cochrane Database of Systematic Reviews, Medline with Full Text, PsychInfo, PubMed, ClinicalTrials.org, and Google Scholar were searched utilizing specific key words. Identified studies were independently screened for inclusion by two reviewers, were assessed for risk of bias using the Revised Cochrane risk-of-bias tool (RoB2), then meta-analyzed using a random effects model with Review Manager (5.4) software. RESULTS: The initial search revealed 293 articles with 6 randomized control trials ultimately meeting inclusion criteria. In patients with depression, analysis of 5 studies revealed a significantly lower Hamilton Depression Rating Scale (HAM-D) score in individuals treated with adjunct therapy with l-Methylfolate/folic acid [Mean Difference (MD): -2.16 (95 % CI -3.62 to -0.69), p = 0.004], as well a combined HAM-D and Beck Depression Inventory-II (BDI-II) scores [standardized mean difference (SMD): -0.61 (95 % Confidence Interval {CI} -0.97 to -0.24), p = 0.002]. This adjunct therapy also yielded an improved response rate [Risk Ratio (RR): 1.36 (95 % CI: 1.16-1.59) P = 0.0001], increase in remission rate [RR: 1.39 (95 % CI: 1.00-1.92) P = 0.05], and reduction in depression scores after varying durations of treatment, 4 week: [SMD = -0.38 (95 % CI: -0.55 to -0.22) P ≤ 0.00001]; 6 week: [SMD = -0.94 (95 % CI: -1.85 to -0.03) P = 0.04]; ≥ 8 week: [SMD= -0.57 (95 % CI: -0.91 to -0.23) P = 0.0009]. CONCLUSION: Adjunct therapy with l-Methylfolate or folic acid improves depression scale scores, patient response, and remission rates.

Duloxetine for the reduction of opioid use in elective orthopedic surgery: a systematic review and meta-analysis.

Background Duloxetine is currently approved for chronic pain management; however, despite some evidence, its utility in acute, postoperative pain remains unclear Aim of the review This systematic review and meta-analysis is to determine if duloxetine 60 mg given perioperatively, is safe and effective at reducing postoperative opioid consumption and reported pain following elective orthopedic surgery. Method CINAHL, Medline, Cochrane Central Registry for Clinical Trials, Google Scholar, and Clinicaltrials.gov were searched using a predetermined search strategy from inception to January 15, 2019. Covidence.org was used to screen, select, and extract data by two independent reviewers. Individual study bias was assessed using the Cochrane Risk of Bias tool. Opioid consumption data were converted to oral morphine milligram equivalents (MME) and exported to RevMan where meta-analysis was conducted using a DerSimonian and Laird random effects model. Results Six randomized-controlled trials were included in the literature review of postoperative pain and adverse effects. Five studies were utilized for the meta-analysis of postoperative opioid consumption; totaling 314 patients. Postoperative pain analysis showed variable statistical significance with overall lower pain scores with duloxetine. Adverse effects included an increase in insomnia with duloxetine but lower rates of nausea and vomiting. Meta-analysis revealed statistically significant [mean difference (95% CI)] lower total opioid use with duloxetine postoperatively at 24 h [- 31.9 MME (- 54.22 to - 9.6), p = 0.005], 48 h [- 30.90 MME (- 59.66 to - 2.15), p = 0.04] and overall [- 31.68 MME (- 46.62 to - 16.74), p < 0.0001]. Conclusion These results suggest that adding perioperative administration duloxetine 60 mg to a multimodal analgesia regimen within the orthopedic surgery setting significantly lowers total postoperative opioid consumption and reduces pain without significant adverse effects.

Examining the Relationship Between Biometric Indicators and Pharmacy Students' Academic Performance.

Objective. To use a fitness tracking device to track student wellness habits, specifically number of steps, activity, and sleep duration, in an attempt to identify relationships between these variables and academic performance outcomes such as examination scores and course grades. Methods. A fitness tracker was issued to second professional year Doctor of Pharmacy (PharmD) students to track their daily number of steps, activity levels, and minutes of sleep. Individual data from these devices were collected using a cloud-based data aggregation platform. The outcome variables of interest were student grade point average (GPA) in core courses, as well as examination grades for 17 examinations administered across eight required courses during the study period. After exploratory analyses, the primary research questions relating steps and sleep to academic performance were addressed with a series of linear regression models. Results. No significant, identifiable relationships were found between examination grades or course GPA and the variables of interest. There was a significant negative relationship between the number of steps students took 72-hours before an examination and performance on the examination where students in the low activity group significantly outperformed those in the high activity group by an average of two points. Participants took an average of 1,466 fewer steps prior to an examination. Conclusion. Sleep and physical activity were not robust predictors of examination scores and course grades in this cohort of PharmD students. While the fitness tracker served as an impetus for the students to be more cognizant of their activity, the capital expenditure for the devices did not result in improved academic performance.

Gamifying the memorization of brand/generic drug names.

BACKGROUND AND PURPOSE: The objective of this study was to determine how the implementation of Quizlet, an electronic flashcard/quiz/gaming platform, affected the doctor of pharmacy candidate's ability to successfully complete quizzes based on brand and generic names of the most commonly used medications. EDUCATIONAL ACTIVITY AND SETTING: Brand name, generic name, and class of Top 300 Prescription Medications were uploaded into the program in four different study sets. Students were encouraged to utilize the provided games to prepare for quizzes. Quiz results were compared to results from the previous year. A survey was administered to measure the student's perception of the efficacy of and engagement in the program in comparison to traditional printed text-based materials. FINDINGS: Students who played the games in spring 2017 scored significantly higher than the spring 2016 cohort who did not utilize gaming (average 94.1% vs. 86.9%). Most (61.2%) of the students in the 2017 course reported that they primarily utilized the games to study vs. other methods. SUMMARY: The use of gaming could be a resource that increases student motivation to independently memorize material for quizzes in didactic courses.

Development of valid and reliable tools for student evaluation of teaching.

INTRODUCTION: The objective of this project was to develop valid and reliable course and instructor student evaluation tools (SETs) of teaching for utilization by a college of pharmacy. METHODS: A collection of 119 course and instructor evaluation items was compiled from a review of the primary literature and grouped into six different themes (subscales): organization, communication, motivation, rapport, fairness, and learning. Input was sought from the college of pharmacy faculty to reduce the list of items to a more manageable pilot tool (27 for course evaluations; 29 for instructor evaluations) for developing pilot SETs. The results were analyzed for internal consistency and reliability using Cronbach's alpha, and whether factor structures aligned with the content structure using Confirmatory Factor Analysis (CFA). RESULTS: The Cronbach's alpha for all six subscales in the designed instructor evaluation and for three of the six subscales in the designed course evaluation were above 0.9, indicating high internal consistency and reliability. The CFA results indicated a moderate model fit with factor loadings for all items above 0.6. The correlation coefficients between each dimension were about 0.8, indicating high correlations among dimensions. Those data items found to be valid were then used to construct new course and instructor evaluation instruments, both consisting of three validated items in each of the six themes (subscales). CONCLUSION: This report describes the process that one college of pharmacy employed to develop a valid and reliable SET. The methodology can inform other colleges and schools of pharmacy who wish to design, revise, or develop their own SETs.

Specialization within pharmacy education: A survey of curricular track or concentration offerings.

INTRODUCTION: The purpose of this national survey was to determine what constitutes a curricular track or concentration within colleges and schools of pharmacy. Additionally, for programs not currently offering curricular tracks or concentrations, this survey sought to identify barriers to implementation. METHODS: A survey instrument was developed and piloted. It was distributed electronically via SurveyMonkey to members of the American Association of Colleges of Pharmacy (AACP) Curriculum Special Interest Group (SIG) contact list, along with academic affairs contacts for the balance of programs not included on the SIG contact list, as obtained via a targeted website search. RESULTS: Sixty-five of 134 programs responded to the survey (48.5%). Sixteen programs currently offer 38 curricular tracks or concentrations. On average, tracks or concentrations contained 10.6 didactic credits, with 4.6 elective and six required didactic credits; 0.7 introductory pharmacy practice experience (IPPE) credits; and 5.3 advanced pharmacy practice experience (APPE) credits, with 2.8 elective and 2.5 required APPE credits. Most tracks did not require a summative project (n = 13), while some required completion of a project individualized by interest/needs (n = 7). Forty-nine programs do not currently offer curricular tracks, most frequently due to logistics of faculty, oversight, or the curriculum structure. Of these programs not currently offering curricular tracks or concentrations, 38.8% are currently considering implementation. CONCLUSION: Existing tracks or concentrations are highly variable in their composition. Many colleges and schools of pharmacy are considering implementation of curricular tracks or concentrations; this report provides guidance for appropriate rigor and development considerations.

Integration of transgender care into a pharmacy therapeutics curriculum.

BACKGROUND AND PURPOSE: To examine the impact of a lecture on transgender health given during a special populations therapeutics course on third-year (P3) pharmacy students' knowledge and confidence of transgender care. EDUCATIONAL ACTIVITY AND SETTING: A two-hour lecture that included both cultural sensitivity and pharmacotherapy aspects of care for transgender individuals was added to a required two-credit therapeutics series offered at the end of the P3 year of a doctor of pharmacy curriculum. Following the lecture, students completed a 17-item knowledge-based survey and ranked their confidence with each answer on a 5-point scale. Students in the fourth-year (P4) class, who had not been given the lecture, also completed the survey. FINDINGS: Students who attended the lecture had a significantly higher mean knowledge score and mean confidence score than students who did not attend. The P3 class had a mean knowledge score of 72.5% while the mean knowledge score for the P4 class was 63.4% (P < 0.01). The P3's mean confidence score was 76.8% and the P4's mean confidence score was 60.6% (P < 0.01). DISCUSSION: To the authors' knowledge, this is the first report on incorporating the topic of transgender care to a required disease and therapeutics series in a college of pharmacy curriculum. SUMMARY: Students who attended a lecture on care of transgender individuals performed significantly better on a knowledge-based assessment and reported having greater confidence in their answers than students who did not attend the lecture.