APPE unreadiness - The other side of the coin.

INTRODUCTION: Student readiness for Advanced Pharmacy Practice Experiences (APPEs) has not been explicitly defined in literature or standards. Readiness for APPEs is a programmatic requirement of all schools and colleges of pharmacy (schools), leaving schools to determine their own assessments of APPE readiness. Current literature provides no consensus on the definition of APPE readiness nor the assessments or benchmarks used to evaluate APPE readiness. Schools have an opportunity to improve efforts to identify students at risk for poor APPE performance and provide early intervention. COMMENTARY: Due to a lack of consensus, it may be easier to describe students who are not ready for APPEs than it is to describe students who are APPE ready. APPE unreadiness is defined by the authors as those who require significant preceptor instruction on foundational competencies such as knowledge, skills, and/or attitudes and therefore are unable to meaningfully engage in application-based patient care activities. By adding focus to APPE unreadiness within APPE readiness programs, pharmacy schools may be able to more readily identify and remediate students who are at risk of failing one or more APPE rotations. IMPLICATIONS: We provide four recommendations for schools to consider. These are focused on assessing APPE readiness to qualify and quantify APPE unready students. By assessing APPE unreadiness, schools can make continuous quality improvement to ensure that preceptors, sites, students, and faculty can have the ongoing confidence that APPE students are all ready to meaningfully engage on rotation.

Achieving cholesterol goals with low-cost 3-hydroxy-3-methylglutaryl coenzyme-A (HMG Co-A) reductase inhibitors.

OBJECTIVE: The objective of this study was to determine the efficacy of widely available low-cost generic statins in achieving NCEP/ATP III cholesterol goals in diabetic patients seen in an indigent clinic. METHODS: Retrospective chart review of patients seen in the pharmacist managed diabetes clinic between January 1, 2005 and February 10, 2010. 154 patient charts were reviewed, with 12 included for analysis. Patients were age >40, diagnosed with diabetes mellitus, referred to the pharmacy clinic for diabetes management, and treated with a study statin for 6 weeks. Patients were excluded for baseline triglycerides >400 mg/dL, treatment with a non-study lipid lowering therapy ≤6 weeks prior to baseline, or pregnancy. The primary endpoint was the proportion of patients with an LDL <100 mg/dL at 6 weeks. Secondary endpoints included an LDL <70 mg/dL, other cholesterol goals, and a 30% reduction in LDL at 6 weeks. RESULTS: At the first follow-up, 33% (n = 4) of patients achieved an LDL <100 mg/dL, and 66.7% (n = 8) a 30% LDL reduction. Race was a significant predictor, with Caucasians having greater LDL reductions than non-Caucasians at 6 weeks (Pearson Correlation -0.595, p = 0.041). Higher doses were significant predictors of greater change in LDL (Pearson Correlation -0.708, p = 0.01). CONCLUSION: Due to the small sample size, statistical power was not met. Both race and dose were significant predictors of LDL reduction. When controlled for race, dose remained a significant predictor of LDL reduction. Further studies with low-cost statins in a larger patient population are needed.

Identification of previously undiagnosed diabetes and prediabetes in the inpatient setting using risk factor and hemoglobin A1C screening.

BACKGROUND: Identifying diabetes early in its progression can present opportunities to intervene with education and medical management to prevent diabetes-related complications. OBJECTIVE: The primary objective was to determine the incidence of diabetes in hospitalized patients without insurance or routine outpatient care using recommendations by the American Diabetes Association (ADA) Standards of Medical Care in Diabetes for diabetes risk screening and diagnosis. METHODS: This study was conducted at a community hospital in Abilene, Texas. Hospitalized patients were screened if they had self-payer status and did not have a primary care physician. If patients met screening criteria based on risk factors listed in the ADA guidelines, a hemoglobin A1C test and fasting plasma glucose test were completed during hospitalization. Patients found to have diabetes were referred for outpatient education and management of diabetes. Data to determine the incidence of diabetes diagnosis were collected retrospectively. RESULTS: A total of 460 patients were screened for inclusion. Of the 92 patients included in the analysis, 8.7% (n=8) were identified as having diabetes and 39.1% (n=36) with prediabetes. Age and hypertension were independently positively correlated with increased risk for diabetes (P=0.002; P=0.045). CONCLUSIONS: Using risk factor screening based on ADA recommendations in the inpatient setting did not identify a significant number of patients with diabetes. This study found specific risk factors to be correlated with diagnosis of diabetes. Rather than using routine screening based on the number of risk factors, the presence of highly correlated risk factors may be an indication for diabetes screening.

A 7-year case of furosemide-induced immune thrombocytopenia.

Immune thrombocytopenia has been attributed to many causes. Several drugs have been implicated as culprits in causing drug-induced thrombocytopenia. Although the mechanism for this type of thrombocytopenia is not well understood, at least three types of antibodies appear to be involved: drug-dependent antibodies, hapten-dependent antibodies, and drug-induced platelet-reactive autoantibodies. In this report, we describe a case in which furosemide was identified as the probable cause of drug-induced thrombocytopenia in an 84-year-old man with chronic symptomatic idiopathic thrombocytopenia for seven years before discovery. The patient's platelet count and daily furosemide dose, both intravenous and oral, were documented throughout his medical history. A dose-dependent change in platelet count was observed in association with the furosemide dose. His platelet count increased on discontinuation of furosemide and beginning of torsemide. Several months after discontinuation of furosemide, his platelet count increased to a 9-year high of 206 × 10³/mm³ from a low of 36 × 10³/mm³ while receiving furosemide therapy. Based on the observations of this case report, clinicians should more readily consider furosemide as a potential cause of thrombocytopenia.