ARIA pharmacy 2018 "Allergic rhinitis care pathways for community pharmacy": AIRWAYS ICPs initiative (European Innovation Partnership on Active and Healthy Ageing, DG CONNECT and DG Santé) POLLAR (Impact of Air POLLution on Asthma and Rhinitis) GARD Demonstration project.

Pharmacists are trusted health care professionals. Many patients use over-the-counter (OTC) medications and are seen by pharmacists who are the initial point of contact for allergic rhinitis management in most countries. The role of pharmacists in integrated care pathways (ICPs) for allergic diseases is important. This paper builds on existing studies and provides tools intended to help pharmacists provide optimal advice/interventions/strategies to patients with rhinitis. The Allergic Rhinitis and its Impact on Asthma (ARIA)-pharmacy ICP includes a diagnostic questionnaire specifically focusing attention on key symptoms and markers of the disease, a systematic Diagnosis Guide (including differential diagnoses), and a simple flowchart with proposed treatment for rhinitis and asthma multimorbidity. Key prompts for referral within the ICP are included. The use of technology is critical to enhance the management of allergic rhinitis. However, the ARIA-pharmacy ICP should be adapted to local healthcare environments/situations as regional (national) differences exist in pharmacy care.

Antimicrobial stewardship education in US colleges and schools of pharmacy.

Background: Pharmacists are key members of antimicrobial stewardship (AS) teams. It is unknown if and how US colleges and schools of pharmacy incorporate AS into their Doctor of Pharmacy (PharmD) curricula. Methods: This study was a cross-sectional, multicentre, electronic survey distributed to infectious diseases faculty or department chairs of 137 accredited and candidate-status PharmD programmes. Results: One hundred and sixteen programmes participated, representing an 84.7% response rate. AS education was integrated into the required didactic, elective didactic and experiential education components of the curricula in 79 (68.1%), 43 (37.1%) and 97 (83.6%) PharmD programmes, respectively. The most common AS topics in required and elective didactic curricula were AS definitions, principles and purpose (98.7% and 86.0%) and the pharmacist's role in AS (93.7% and 83.7%). In the required and elective didactic curricula, lecture (93.7% and 86.0%) and case-based instruction (57.0% and 83.7%) were the most common instructional methods. For experiential education, the pharmacist's role in AS (96.9%), de-escalation of antimicrobials (96.9%) and antimicrobial dose optimization (95.9%) were the most common AS topics. PharmD programmes employing a faculty member who specializes in AS were more likely to offer AS experiential education than programmes without AS faculty (88.1% versus 71.9%, P = 0.049). Conclusions: Integration of AS education in US PharmD curricula is variable and there are considerable differences in the AS activities and topics delivered. PharmD programmes should attempt to expose students to AS education to prepare future pharmacists for AS practice. Efforts should be made to incorporate interprofessional collaboration into AS education.

The relationship between patient-provider communication and quality of life for children with asthma and their caregivers.

OBJECTIVE: This study examined whether patient-provider communication is associated with asthma-related quality of life (QOL) and asthma outcomes among children with asthma and their caregivers. METHODS: Children ages 8-16 years with asthma and their caregivers (n = 296) were recruited at five pediatric practices in North Carolina. Children and caregivers reported demographic and clinical characteristics immediately after an audio-taped medical visit with their health care provider. During a home visit that took place 1 month after the medical visit, children and caregivers reported asthma-related QOL, and caregivers reported child asthma outcomes, including asthma symptom days and missed school days. Generalized estimating equations were used to determine whether patient-provider communication during the medical visit was associated with child and caregiver QOL and child asthma outcomes 1 month later. RESULTS: On average, providers asked caregivers 4.5 questions and asked children 3 questions per visit, whereas caregivers and children asked less than 1 question per visit. Providers asked children more asthma-related questions, caregivers reported better QOL and fewer asthma symptom days 1 month later. Children and caregivers with higher asthma-management self-efficacy at the office visit reported better QOL 1 month later. CONCLUSIONS: Mirroring national guideline recommendations, our results suggest that providers should ask children about their asthma during medical visits. Future longitudinal studies should conduct mediation analyses to determine whether asking children asthma-related questions during medical visits increases children's asthma management self-efficacy and ultimately improve outcomes, such as QOL, health care utilization, symptom days and missed school days.

Quality of pulmonary function testing in 3 large primary care pediatric clinics in rural North Carolina.

BACKGROUND: Pulmonary function testing (eg, spirometry) is recommended by the National Heart, Lung, and Blood Institute as part of basic asthma management. Previous research has shown that spirometry is feasible in primary care settings. OBJECTIVES: In this retrospective study, we sought to describe the proportion of spirometries meeting American Thoracic Society (ATS) and European Respiratory Society (ERS) quality criteria in children with asthma evaluated in North Carolina primary care pediatric clinics and to characterize predictors of spirometry that meets ATS/ERS quality criteria. METHODS: Medical records and spirometries from January 1, 2001, to August 1, 2009, were reviewed and analyzed from children enrolled in a larger asthma study that focused on communication between physicians, children, and caregivers. Children were eligible for the larger study if they were between the ages of 8 and 16 years and had received a previous diagnosis of persistent asthma. Children were enrolled from primary care pediatric practices. RESULTS: Spirometry was not acceptable, on the basis of ATS/ERS criteria, in 75% of cases. Approximately 19% of spirometries used incorrect or outdated predictive sets. CONCLUSIONS: More than three-quarters of spirometries in these primary care pediatric clinics were unacceptable. Changes or lack of changes in asthma management may be based on unacceptable spirometry. Additional education and training regarding accurate spirometry and interpretation are warranted.

Feedback for Learning in Pharmacy Education: A Scoping Review.

Feedback is an effective pedagogy aimed to create cognitive dissonance and reinforce learning as a key component of clinical training programs. Pharmacy learners receive constant feedback. However, there is limited understanding of how feedback is utilized in pharmacy education. This scoping review sought to summarize the breadth and depth of the use of feedback within pharmacy education and identify areas for future research. PubMed, Embase, Scopus, and Web of Science were searched for English articles since January 2000 to identify studies related to feedback in pharmacy education. Sixty-four articles were included for analysis, stratified by moderate and major theory talk, where moderate theory talk explicitly included feedback into study design and major theory talk included feedback into both study design and analysis. Feedback was provided in Bachelor (14%), Master (15.6%), Doctor of Pharmacy (67.2%) and post-graduate programs (4.7%) on a variety of curricular objectives including communication and patient work up in didactic, objective structured clinical examination (OSCE), and experiential settings, and career/interview preparation in the co-curriculum. Feedback comments were mostly written in didactic courses, and both written and verbal in OSCE, experiential, and co-curricular settings. The pharmacy education feedback literature lacks depth beyond student perceptions, especially with respect to assessing the effectiveness and quality of feedback for learning. While feedback has been utilized throughout pharmacy education across myriad outcomes, several areas for inquiry exist which can inform the design of faculty and preceptor development programs, ensuring provision of effective, quality feedback to pharmacy learners.

Clinical Pharmacology of Corticosteroids.

Corticosteroids have numerous applications in treating inflammation and diseases of immune function based on their significant anti-inflammatory and immunosuppressive effects. Corticosteroids modulate immune function through various effects in the nucleus of numerous cells. When used in pharmacologic doses to suppress allergic responses or inflammation, these agents can cause numerous adverse effects associated with an excess of glucocorticoid activity. Prolonged use (>2 wk) results in suppression of the hypothalamic-pituitary-adrenal axis, which requires tapering of doses. Dosing strategies for systemic corticosteroids are designed to minimize the risk for hypothalamic-pituitary-adrenal axis suppression. Topical administration of corticosteroids, including oral inhalation, is often used to avoid the significant adverse effects associated with chronic use. Inhaled corticosteroids are potent synthetic agents that exert their actions locally in the airways but can cause systemic effects based on several factors that influence systemic bioavailability. Inhaled corticosteroids are the cornerstone of asthma therapy and important options for COPD in patients who experience frequent exacerbations. By the nasal route, they are the most effective therapy for treating moderate-to-severe allergic rhinitis.

Clinical Pharmacology of Bronchodilator Medications.

Obstructive lung diseases, including asthma and COPD, are characterized by air-flow limitation. Bronchodilator therapy can often decrease symptoms of air-flow obstruction by relaxing airway smooth muscle (bronchodilation), decreasing dyspnea, and improving quality of life. In this review, we discuss the pharmacology of the ß agonist and anticholinergic bronchodilators and their use, particularly in asthma and COPD. Expanding knowledge of receptor subtypes and G-protein signaling, agonist and antagonist specificity, and drug delivery have led to the introduction of safer medications with fewer off-target effects, medications with longer duration of action that may improve adherence, and more effective and efficient aerosol delivery devices.

Improved Organizational Outcomes Associated With Incorporation of Early Clinical Experiences for Second-Year Student Pharmacists at an Academic Medical Center.

PURPOSE: To assess the feasibility of engaging second professional year student pharmacists in the medication reconciliation process on hospital and health system pharmacy practice outcomes. METHODS: Student pharmacists in their second professional year in the Doctor of Pharmacy degree program at our institution were randomly selected from volunteers to participate. Each participant completed training prior to completing three 5-hour evening shifts. Organizational metrics, student pharmacist perception regarding quality of interactions with health care professionals, and pharmacist perceptions were collected. RESULTS: A total of 83 medication histories were performed on complex medical patients (57.0 ± 19.2 years, 51% female, 65% Caucasian, 12 ± 6 medications); of those, 93% were completed within 24 hours of hospital admission. Second professional student pharmacists completed on average 1.9 ± 0.6 medication histories per shift (range 1-3). Student pharmacists identified 0.9 medication-related problems per patient in collaboration with a pharmacist preceptor. Student pharmacists believed the quality of their interactions with health care professionals in the Student Medication and Reconciliation Team (SMART) program was good or excellent. The program has been well received by clinical pharmacists involved in its design and implementation. CONCLUSION: This study provides evidence that second professional year student pharmacists can assist pharmacy departments in the care of medically complex patients upon hospital admission.

Considerations in the long-term management of asthma in ambulatory patients.

PURPOSE: The goals of treatment and drug therapies used for long-term asthma control, classification of the disease by severity, and treatment based on severity are reviewed, with an emphasis on recent controversies in treatment approach and safety concerns. SUMMARY: Patient education and written asthma self-management and action plans are essential components of asthma treatment because of the need for patients to acquire substantial knowledge and skills in self-care. Inhaled corticosteroids are the most effective long-term-control therapy and usually suffice as monotherapy for mild persistent asthma. Adding a long-acting, inhaled beta2 agonist to the inhaled corticosteroid is preferred for moderate and severe persistent disease despite safety concerns. Omalizumab use is limited to selected patients with moderate-to-severe allergic asthma and an inadequate response to inhaled corticosteroids. CONCLUSION: The long-term control of asthma requires substantial patient knowledge and skill. Persistent disease is best managed by inhaled corticosteroids and if it is moderate or severe, long-acting, inhaled beta2 agonists in combination with inhaled corticosteroids.

Case studies illustrating the implementation of treatment strategies for acute and chronic asthma.

PURPOSE: Considerations that enter into decisions about treatment strategies for acute and chronic asthma are illustrated in two case studies. SUMMARY: A patient's signs, symptoms, vital signs, laboratory test results, recent history of illness or exposure to substances that can provoke asthma symptoms, and response to recently used asthma medications as well as efficacy, safety, and cost are important considerations in choosing drug therapy in the emergency department to treat an acute exacerbation. The need for a rapid onset of action and patient limitations may influence the choice of a dosage form, delivery device, and route of administration. Treatment strategies for patients with chronic asthma may require resolution of problems with adherence to the treatment plan or inhaler technique. Long-term control of asthma symptoms involves the use of preventive measures, including long-term-control medications, efforts to control asthma triggers, and self-monitoring of pulmonary function. Patient education and a written action plan are important elements of the treatment strategy. CONCLUSION: An individualized approach to treating patients with acute or chronic asthma that takes into consideration patient-specific factors as well as efficacy, safety, and cost of drug therapy is needed when devising and implementing a treatment strategy to optimize patient outcomes.

Early Clinical Experiences for Second-Year Student Pharmacists at an Academic Medical Center.

OBJECTIVE: To examine student outcomes associated with the Student Medication and Reconciliation Team (SMART) program, which was designed to provide second-year student pharmacists at the University of North Carolina (UNC) Eshelman School of Pharmacy direct patient care experience at UNC Medical Center. DESIGN: Twenty-two second-year student pharmacists were randomly selected from volunteers, given program training, and scheduled for three 5-hour evening shifts in 2013-2014. Pre/post surveys and reflection statements were collected from 19 students. Data were analyzed with a mixed methods approach. ASSESSMENT: Survey results revealed an increase in student self-efficacy (p<0.05) and positive perceptions of SMART. Qualitative findings suggest the program provided opportunities for students to develop strategies for practice, promoted an appreciation for the various roles pharmacists play in health care, and fostered an appreciation for the complexity of real-world practice. CONCLUSION: Early clinical experiences can enhance student learning and development while fostering an appreciation for pharmacy practice.

Continuing-education programs in pharmacogenomics for pharmacists.

The Notes section welcomes the following types of contributions: (1) practical innovations or solutions to everyday practice problems, (2) substantial updates or elaborations on work previously published by the same authors, (3) important confirmations of research findings previously published by others, and (4) short research reports, including practice surveys, of modest scope or interest. Notes should be submitted with AJHP's manuscript checklist. The text should be concise, and the number of references, tables, and figures should be limited.

How often do providers discuss asthma action plans with children? Analysis of transcripts of medical visits.

OBJECTIVE: To examine how often providers discussed asthma action plans with children and their caregivers and child, clinical, and provider characteristics that were associated with those discussions. METHOD: This was a cross-sectional analysis of audio-recorded visits between 35 general pediatric providers and 260 children (8-16 years old) with asthma and their caregivers. The visits were transcribed into text. The transcripts were coded for discussions about written asthma action plans. RESULTS: Providers discussed written asthma action plans with 21.0% of children and caregivers. Providers were significantly more likely to discuss asthma action plans when the child was enrolled in Medicaid, the visit was asthma related, the visit was longer, the provider was not White, or more provider education. CONCLUSION: In our sample, providers rarely discussed action plans with children and their caregivers. Providers should discuss asthma action plans with every child with persistent asthma and their caregivers and revise them regularly.

Preparing pharmacy students and pharmacists to provide tobacco cessation counselling.

ISSUES: Tobacco use and abuse is a major health risk for people across the world and is responsible for nearly 500 000 deaths in the USA annually. Currently, the accepted role of pharmacists is the provision of pharmaceutical care, which includes health promotion and prevention of disease. Pharmacists should work collaboratively with other health-care professionals to provide tobacco-cessation counselling to smokers. APPROACH: Recently, in the USA, a curriculum has been developed by faculty at a school of pharmacy and distributed to pharmacy schools across the nation in a train-the-trainer format. This curriculum has been implemented in varying degrees in schools across the USA. In addition, there are national efforts to increase the involvement of practising pharmacists in promoting tobacco cessation by offering comprehensive programs or by increasing awareness and referrals. KEY FINDINGS: The acceptance of the Rx for Change programs by schools of pharmacy has been high and the education and skills are being taught to most current pharmacy graduates. There is an increased emphasis on the role of pharmacists to assist in meeting national health goals including reducing tobacco-related risks. IMPLICATIONS: Numerous opportunities exist for pharmacists to provide tobacco cessation counselling. Barriers to implementation of programs include lack of confidence by pharmacists and a perceived lack of demand by patients. CONCLUSION: The consequences of tobacco use are well known. Pharmacists should enhance their involvement in health promotion and disease prevention and actively develop tobacco cessation counselling programs using available resources for the benefit of their patients.

Accuracy of float testing for metered-dose inhaler canisters.

OBJECTIVE: To characterize and evaluate canister floating patterns of three commercially available metered-dose inhalers (MDIs) with varying amounts of medication remaining. DESIGN: Four canisters each of three asthma medications were studied. MDIs were actuated every 30 seconds to 60 seconds, and canisters were weighed and floated at 100%, 75%, 66%, 50%, 33%, 25%, 10%, and 0% of remaining labeled actuations. Position of the canisters and percentage submersion in water were recorded. SETTING: Controlled laboratory. RESULTS: We observed differences among the products with regard to canister floating behavior at varying levels of fullness. All canisters were completely submerged with the nozzle up at two-thirds full and greater. The canisters remained nozzle-up and were submerged to varying levels at the half-full point. When observed at less than half full, canisters inverted and floated nozzle down. Positions of the canisters varied among products at less than half full. No canister was fully tilted when all labeled actuations were used. CONCLUSION: Float characteristics are product-specific and a function of canister size, design, content, and method of testing. Clinicians and asthma educators should not advise patients to use a float test to assess the amount of medication remaining in an MDI. Recommendations from the National Asthma Education and Prevention Program of the National Heart, Lung, and Blood Institute suggest that the only reliable method for determining the number of doses remaining in a canister is to subtract the number of doses used from the number available.