Evaluation of an escape room approach to interprofessional education and the opioid crisis.

BACKGROUND: The use of an escape room in education helps promote communication, teamwork, and leadership amongst interprofessional learners in a unique and engaging manner; however, it is unknown if this method can change clinical knowledge related to the opioid crisis and interprofessional attitudes. Our objective was to evaluate the use of an interprofessional escape room activity to increase clinical knowledge related to the opioid crisis and to change attitudes toward interprofessional collaboration. INTERPROFESSIONAL EDUCATION ACTIVITY: The session was developed as part of an interprofessional program at University of Colorado Anschutz Medical Campus. In this educational escape room activity, teams of interprofessional students solved six puzzles to gain knowledge of the opioid crisis. Knowledge gains were assessed using a pretest and posttest, while changes in interprofessional attitudes were assessed using the Student Perceptions of Interprofessional Clinical Education-Revised (SPICE-R) instrument. DISCUSSION: Of the 88 total participants, 70 students from six different health professions completed both the pretest and posttest and were included in the analysis. Knowledge of the opioid crisis improved, particularly in identifying signs of opioid overdose. Overall, SPICE-R ratings increased, which was driven by improvement in understanding professional roles and responsibilities. IMPLICATIONS: The use of an interprofessional escape room as an educational method was effective in increasing some aspects of opioid crisis related knowledge and enhancing attitudes toward interprofessional collaboration. The educational model is applicable to various topics and interprofessional groups.

Effects of Chronic Proton-Pump Inhibitor Use on Kidney Function in Older Adults.

OBJECTIVE: Proton-pump inhibitors (PPIs) have been associated with adverse renal outcomes in older adults; however, there are little data regarding the magnitude of the change in renal function in this population. The objective of this study was to quantify the change in kidney function associated with chronic PPI therapy at two years in older adults using estimated glomerular filtration rate (eGFR).
DESIGN: The study was a retrospective, pre/post, observational cohort.
SETTING/PATIENTS/INTERVENTIONS/MAIN OUTCOME MEASURE(S): The study included University of Colorado Health primary care patients 60 to 89 years of age who were newly initiated on a PPI between August 1, 2012, and March 1, 2015, and remained on therapy for at least two years. The primary outcome was the change in kidney function, measured by eGFR, two years after starting PPI therapy. Secondary outcomes included change in kidney function and incidence of reduction in eGFR to < 60 mL/min/1.73 m² two years post-index date between patients with and without diabetes mellitus.
RESULTS: Of 877 electronic health records reviewed, 100 patients met inclusion criteria. The mean change in eGFR was -6.15 mL/min/1.73 m² (standard error of the mean = 1.03) at two years compared with baseline
(95% confidence interval -8.20 to -4.10; P < 0.0001). There were no differences in the secondary outcomes based on concomitant diabetes mellitus.
CONCLUSIONS: Chronic PPI use was associated with a significant reduction in eGFR in ambulatory older adults at two years, beyond that expected based on increased age alone. Prescribers should be aware of the potential adverse renal effects of chronic PPI use.

A Review of Clinical Guidelines and Pharmacotherapeutic Management of Hypertension in Older Adults.

OBJECTIVE: To provide an up-to-date review of current hypertension (HTN) guidelines and discuss pharmacotherapeutic management of HTN in the older adult population.
DATA SOURCES: A PubMed search of articles published through June 2018 was performed using a combination of the following words: elderly, older adults, geriatric, and HTN.
STUDY SELECTION/DATA EXTRACTION: Relevant original research, review articles, and guidelines were assessed for the management of HTN in older adults. References from the above literature were also evaluated. Articles were selected for inclusion based on relevance to the topic, detailed methods, complete results, and after a thorough discussion among the authors.
DATA SYNTHESIS: HTN is a common chronic disease state in older adults. Until recently, most guidelines recommended a higher threshold for blood pressure targets in this population, compared with the general adult population. In 2017, two new guidelines for the management of HTN were published, which provided conflicting recommendations for blood pressure goals in the older population. This article reviews current U. S. HTN guidelines published in 2014 to 2017 that most commonly influence patient care, and it specifically addresses the blood pressure targets and pharmacotherapeutic management of HTN in older adults.
CONCLUSION: Management of HTN in older adults is important to avoid further complications and improve outcomes in this population. Blood pressure targets and HTN management should be individualized in older adults based on comorbid conditions, life expectancy, and risk for adverse drug events.

Efficacy and renal outcomes of SGLT2 inhibitors in patients with type 2 diabetes and chronic kidney disease.

OBJECTIVE: To review glucose-lowering efficacy and changes in renal function associated with sodium-glucose co-transporter 2 (SGLT2) inhibitors among patients with chronic kidney disease (CKD) and type 2 diabetes mellitus (T2DM). DATA SOURCES: A literature search of MEDLINE and Cochrane databases was performed from 2000 to August 2018 using search terms: SGLT2 inhibitors, sodium glucose co-transporter 2, canagliflozin, empagliflozin, dapagliflozin, ertugliflozin, and chronic kidney disease. References of identified articles were also reviewed. STUDY SELECTION AND DATA EXTRACTION: English-language studies investigating glucose-lowering endpoints and/or changes in renal function with one of four U.S. approved SGLT2 inhibitors were included. A total of 10 studies met inclusion criteria and are included in this review. RESULTS: In patients with T2DM and CKD, SGLT2 inhibitors are modestly effective in lowering hemoglobin A1C and fasting plasma glucose compared to placebo. Small reductions in eGFR are seen shortly after initiating therapy with SGLT2 inhibitors, but return to baseline levels after discontinuation. SGLT2 inhibitors are associated with a substantial reduction in albuminuria and reduced risk of progression to albuminuria. CONCLUSIONS: In patients with T2DM and CKD, SGLT2 inhibitors have a decreased glucose-lowering effect compared to patients without CKD. Renal benefits among patients with CKD are similar to those without CKD and include a significant reduction in albuminuria and reduced incidence of worsening albuminuria. Given that CKD and T2DM are both associated with increased cardiovascular risk, we believe these agents should considered as preferred add-on agents in most patients with uncontrolled T2DM and eGFR >30 ml/min/1.73 m2. Ongoing studies will provide additional information as to whether these agents should be added to the current standard of care for CKD patients, with and without T2DM.

Hyponatremia after initiation and rechallenge with trimethoprim-sulfamethoxazole in an older adult.

PURPOSE: The purpose of this study is to describe a case report of a patient experiencing hyponatremia from trimethoprim-sulfamethoxazole (TMP-SMX) upon initial use and subsequent rechallenge. SUMMARY: An 82-year-old woman presented to the emergency department with altered mental status thought to be due to complicated cystitis and was treated with TMP-SMX 160 mg/800 mg orally twice daily for 7 days. Her basic metabolic panel prior to initiation of TMP-SMX was within normal limits, with the exception of her serum sodium of 132 mmol/L (range 133-145 mmol/L). The day after completing her 7-day course of TMP-SMX therapy the patient was evaluated by her primary care provider and another basic metabolic panel revealed a reduction in the serum sodium to 121 mmol/L. The patient's serum sodium concentrations increased to baseline 7 days after completion of the TMP-SMX therapy, and remained normal until she was treated in the emergency department several months later for another presumed urinary tract infection. She was again started on TMP-SMX therapy empirically, and within several days her serum sodium concentrations decreased from 138 mmol/L to a low of 129 mmol/L. The TMP-SMX therapy was discontinued upon negative urine culture results and her serum sodium increased to 134 mmol/L upon discharge. Based upon the Naranjo probability scale score of 9, TMP-SMX was the probable cause of the patient's hyponatremia. CONCLUSION: Our patient developed hyponatremia from TMP-SMX therapy upon initial use and rechallenge. Although hyponatremia appears to be rare with TMP-SMX therapy, providers should be aware of this potentially life-threatening adverse event.