Tolerance and Withdrawal Issues with Sedatives in the Intensive Care Unit.

Prolonged use of sedative medications continues to be a concern for critical care practitioners, with potential adverse effects including tolerance and withdrawal. The amount of sedatives required in critically ill patients can be lessened and tolerance delayed with the use of pain and/or sedation scales to reach the desired effect. The current recommendation for prolonged sedation is to wean patients from the medications over several days to reduce the risk of drug withdrawal. It is important to identify patients at risk for iatrogenic withdrawal and create a treatment strategy.

Current Practices in Global/International Advanced Pharmacy Practice Experiences: Preceptor and Student Considerations.

The objective of this article is to describe the key areas of consideration for global/international advanced pharmacy practice experience (G/I APPE) preceptors, students and learning objectives. At the 2013 Annual Meeting of the American Association of Colleges of Pharmacy (AACP), the GPE SIG prepared and presented an initial report on the G/IAPPE initiatives. Round table discussions were conducted at the 2014 AACP Annual Meeting to document GPE SIG member input on key areas in the report. Literature search of PubMed, Google Scholar and EMBASE with keywords was conducted to expand this report. In this paper, considerations related to preceptors and students and learning outcomes are described. Preceptors for G/I APPEs may vary based on the learning outcomes of the experience. Student learning outcomes for G/I APPEs may vary based on the type of experiential site. Recommendations and future directions for development of G/IAPPEs are presented. Development of a successful G/I APPE requires significant planning and consideration of appropriate qualifications for preceptors and students.

Recognition of Advanced Pharmacy Practice Experience Student Participation Within Antimicrobial Stewardship Activities.

Background: Antimicrobial stewardship is important in managing patients with infectious diseases. Limited data exist documenting the extent of pharmacy student involvement within antimicrobial stewardship activities. Objectives: The purpose of this study was to document the types of hospital-based antimicrobial stewardship activities in which Advanced Pharmacy Practice Experience (APPE) students are involved. Methods: A questionnaire was developed using the most current guideline for developing an institutional antimicrobial stewardship program. It was designed to collect preceptor-reported perceptions and APPE student involvement in antimicrobial stewardship activities. Pharmacist preceptors of APPE students from 2 Florida Colleges of Pharmacy were surveyed in October 2011. Questionnaires fully completed by hospital pharmacists currently serving as an APPE preceptor were included. Results: Forty-eight questionnaires met all inclusion criteria, collectively reporting APPE student participation within every element of antimicrobial stewardship. The most common areas of student participation were dose optimization based on patient characteristics (n = 40, 83%), acquiring patient information for prospective audit with feedback (n = 39, 81%), intravenous to oral conversion (n = 37, 77%), and pharmacokinetic services (n = 36, 75%). Anti-infective subcommittee participation (n = 3, 6%) was uncommon. Respondent perceptions were overall favorable regarding student participation in antimicrobial stewardship activities. Conclusion: With supervision from pharmacist preceptors, APPE students from 2 Florida colleges of pharmacy were reported to participate in each element and activity of antimicrobial stewardship as set forth by current guidelines. The role and value of such involvement is not fully understood. Future research investigating activity-specific outcomes and policy creation are needed to guide appropriate use of APPE students as a resource for optimizing antimicrobial use in hospitals.

The FDA Funding Crisis.

The role of the Food and Drug Administration (FDA) is to ensure the safety of prescription and nonprescription drugs, dietary supplements, and the food supply, representing more than 20% of US consumer spending. The increased need to monitor imported drugs, drug products and foods, drug shortages, and compounding pharmacies bring the adequacy of FDA funding into question. Performing even at status quo cannot be accomplished if responsibilities increase without equitable funding increases: both from the federal government and fees imposed on FDA-regulated industries. Additionally, scientific advancement, new legislation, and new industries are continually increasing the FDA workload, necessitating commensurate budget increases.

Patient attitudes toward community pharmacist attire.

The white coat has symbolized professionalism, while representing provider-patient fiduciary relationship. Although well described in the literature for physicians, few studies examine the impact of pharmacist attire on patients' opinions regarding professionalism and trust. Therefore, understanding patient perceptions regarding pharmacist's attire and its influence on comfort, confidence, trust, and professionalism may provide guidance on ways to enhance the quality of the provider-patient relationship. A 43-item Likert-type questionnaire was administered to 347 adults in a community pharmacy setting to determine preferences about the pharmacist's attire, accessories, and body art incorporating 8 photographs depicting a male pharmacist in various degrees of dress formality (ie, casual to professional). Descriptive and inferential statistics were used to summarize and analyze the data. Survey respondents reported it was desirable/strongly desirable that pharmacists be dressed in a shirt and tie, dress shoes, white coat, and name tag (mean 4.21-4.72), whereas they should not be dressed in jeans, casual shoes, or have visible body art (mean 2.17-2.78). Over 86% of the respondents felt that a pharmacist with a white coat instilled feelings of comfort, confidence, trust, and professionalism. In a community pharmacy setting, a pharmacist wearing a white coat appears to be the mainstay in displaying professionalism and inspiring trust in adult patients.

Use of herbals as galactagogues.

With a substantial number of women using herbal products to augment their milk production, this article will review available literature illustrating efficacy and adverse effects of using these products. Embase, PubMed, and EBSCO (all databases) were searched from inception to June 2011 using terms such as ''galactagogue,'' ''galactogogue,'' ''herbal,'' and ''botanical'' and the search was subsequently narrowed to specific herbals by name. Additional articles were obtained from article reference lists. Supplemental information was obtained with Natural Standard. All abstracts retrieved were evaluated for relevance and germane articles were included. Numerous lactation-stimulating herbals have been identified in the literature with varying degrees of evidence,mostly anecdotal. Use of torbangun, milk thistle, and fenugreek may correlate with increased milk supply. Evidence regarding adverse effects, pharmacodynamic properties, and pharmacokinetic effects remains scarce. Despite the fact that postpartum women may turn to herbal galactagogues, scant clinical evidence exists to justify their effectiveness. Further clinical trials are needed in order to substantiate these findings.

Evaluation of nursing-specific drug information PDA databases used as clinical decision support tools.

BACKGROUND: Nursing is arguably the most organizationally diverse healthcare profession. Educational backgrounds may vary, even among similarly credentialed nurses. Drug information databases used as clinical decision support tools can improve access to pharmacologic information at point-of-care when housed on personal digital assistants. They may also help address the disparity in drug information and pharmacology education between nurses. OBJECTIVES: To evaluate nursing-specific drug information database content on personal digital assistants (PDAs). METHODS: Seven nursing-specific PDA databases were evaluated for scope (absence or presence of an answer) and completeness (three-point scale) via the use of 80 general category and 80 subspecialty drug information questions. Erroneous information was also tracked. Individual scope and completeness scores were delineated by rank order and chi square was performed to determine differences in scope and completeness scores between the databases. RESULTS: Davis's Drug Guide for Nurses (DDGN) and Nursing Lexi-Drugs (NLD) tied for the highest scores for scope, including each answering 72.5% of the 160 evaluation questions. No significant differences existed between their scores and those earned by Nursing2008 Drug Handbook (p<0.05). The highest scores for completeness were earned by NLD with 58.1% and DDGN at 57.1%. Saunders Nursing Drug Handbook was the only database that showed a significantly lower score in completeness as compared to the other six databases (p<0.05). A 4.2% overall error rate was found among database answers. DISCUSSION: Significant differences were found among the performances in the databases evaluated in this study for their ability to answer commonly encountered drug information issues in nursing practice. All databases contained some erroneous information and even the top performers failed to provide answers to more than one-fourth of the questions posed. The availability of accurate and timely drug information at point-of-care can play a vital role in patient management and outcomes, but current resources that are available need to be improved.

Role of the pharmacist in pre-exposure chemoprophylaxis (PrEP) therapyfor HIV prevention / Papel del farmacéutico en la quimioprofilaxis pre-exposición para prevención del VIH

With a global estimate of 2.5 million new infections of HIV occurring yearly, discovering novel methods to help stem the spread of the virus is critical. The use of antiretroviral chemoprophylaxis for preventing HIV after accidental or occupational exposure and in maternal to fetal transmission has become a widely accepted method to combat HIV. Based on this success, pre-exposure chemoprophylaxis (PrEP) is being explored in at-risk patient populations such as injecting drug users, female sex workers and men who have sex with men. This off-label and unmonitored use has created a need for education and intervention by pharmacists and other healthcare professionals. Pharmacists should educate themselves on PrEP and be prepared to counsel patients about their means of obtaining it (e.g. borrowing or sharing medications and ordering from disreputable Internet pharmacies). They should also be proactive about medication therapy management in these patients due to clinically important drug interactions with PrEP medications. Only one trial exploring the safety and efficacy of tenofovir as PrEP has been completed thus far. However, five ongoing trials are in various stages and two additional studies are scheduled for the near future. Unfortunately, studies in this arena have met with many challenges that have threatened to derail progress. Ethical controversy surrounding post-trial care of participants who seroconvert during studies, as well as concerns over emerging viral resistance and logistical site problems, have already halted several PrEP trials. Information about these early trials has already filtered down to affected individuals who are experimenting with this unproven therapy as an 'evening before pill'. The potential for PrEP is promising; however, more extensive trials are necessary to establish its safety and efficacy. Pharmacists are well-positioned to play a key role in helping patients make choices about PrEP, managing their therapy, and developing policy with an eye towards the future (AU)

Con una estimación global de 2,5 millones de nuevas infecciones de VIH cada año, es crítico descubrir nuevos métodos para ayudar a detener la extensión del virus. El uso de quimioprofilaxis antirretroviral para prevención del VIH después de una exposición accidental u ocupacional y en transmisión materno-fetal se ha convertido en un método comúnmente aceptado para combatir el VIH. Basando en este éxito, se está explorando la quimioprofilaxis pre-exposición (PrEP) en poblaciones de riesgo tales como drogadictos intravenosos, trabajadoras sexuales, y hombres que tiene sexo con hombres. Este uso no autorizado y no vigilado ha creado la necesidad de educación e intervención de farmacéuticos y otros profesionales de la salud. Los farmacéuticos deberían formarse sobre la PrEP y estar preparados para aconsejar a los pacientes sobre los medios de obtenerla (p.e. prestándose o compartiendo medicaciones y comprándola en farmacias de confianza en Internet). También deberían ser proactivos en el seguimiento de estos pacientes debido a las importantes interacciones de los medicamentos PrEP. Solo se ha completado un ensayo que exploró la seguridad y la eficacia del tenofovir como PrEP. Sin embargo, están programados 5 ensayos en marcha en diversos estadios, y dos estudios adicionales en un futuro próximo. Desafortunadamente, los estudios en este campo se han encontrado con muchos obstáculos que han amenazado interrumpir su progreso. La controversia ética sobre la atención post-ensayo de los pacientes que se seroconvierten durante el estudio, así como las preocupaciones sobre la emergente resistencia viral y los problemas logísticos, ya han interrumpido varios ensayos de PrEP. La información de estos primeros ensayos se ha filtrado e los individuos afectados que están experimentando con este tratamiento no probado como una 'píldora de la tarde anterior'. El potencial de la PrEP es prometedor, sin embargo se necesitan ensayos más extensos para establecer su seguridad y eficacia. Los farmacéuticos están bien posicionaos para jugar un papel importante ayudando a los pacientes a tomar mejores decisiones sobre la PrEP, gestionando su tratamiento, y desarrollando políticas con un ojo en el futuro (AU)

Role of the pharmacist in pre-exposure chemoprophylaxis (PrEP) therapy for HIV prevention.

With a global estimate of 2.5 million new infections of HIV occurring yearly, discovering novel methods to help stem the spread of the virus is critical. The use of antiretroviral chemoprophylaxis for preventing HIV after accidental or occupational exposure and in maternal to fetal transmission has become a widely accepted method to combat HIV. Based on this success, pre-exposure chemoprophylaxis (PrEP) is being explored in at-risk patient populations such as injecting drug users, female sex workers and men who have sex with men. This off-label and unmonitored use has created a need for education and intervention by pharmacists and other healthcare professionals. Pharmacists should educate themselves on PrEP and be prepared to counsel patients about their means of obtaining it (e.g. borrowing or sharing medications and ordering from disreputable Internet pharmacies). They should also be proactive about medication therapy management in these patients due to clinically important drug interactions with PrEP medications. Only one trial exploring the safety and efficacy of tenofovir as PrEP has been completed thus far. However, five ongoing trials are in various stages and two additional studies are scheduled for the near future. Unfortunately, studies in this arena have met with many challenges that have threatened to derail progress. Ethical controversy surrounding post-trial care of participants who seroconvert during studies, as well as concerns over emerging viral resistance and logistical site problems, have already halted several PrEP trials. Information about these early trials has already filtered down to affected individuals who are experimenting with this unproven therapy as an "evening before pill". The potential for PrEP is promising; however, more extensive trials are necessary to establish its safety and efficacy. Pharmacists are well-positioned to play a key role in helping patients make choices about PrEP, managing their therapy, and developing policy with an eye towards the future.

Ability of online drug databases to assist in clinical decision-making with infectious disease therapies.

BACKGROUND: Infectious disease (ID) is a dynamic field with new guidelines being adopted at a rapid rate. Clinical decision support tools (CDSTs) have proven beneficial in selecting treatment options to improve outcomes. However, there is a dearth of information on the abilities of CDSTs, such as drug information databases. This study evaluated online drug information databases when answering infectious disease-specific queries. METHODS: Eight subscription drug information databases: American Hospital Formulary Service Drug Information (AHFS), Clinical Pharmacology (CP), Epocrates Online Premium (EOP), Facts & Comparisons 4.0 Online (FC), Lexi-Comp (LC), Lexi-Comp with AHFS (LC-AHFS), Micromedex (MM), and PEPID PDC (PPDC) and six freely accessible: DailyMed (DM), DIOne (DIO), Epocrates Online Free (EOF), Internet Drug Index (IDI), Johns Hopkins ABX Guide (JHAG), and Medscape Drug Reference (MDR) were evaluated for their scope (presence of an answer) and completeness (on a 3-point scale) in answering 147 infectious disease-specific questions. Questions were divided among five classifications: antibacterial, antiviral, antifungal, antiparasitic, and vaccination/immunization. Classifications were further divided into categories (e.g., dosage, administration, emerging resistance, synergy, and spectrum of activity). Databases were ranked based on scope and completeness scores. ANOVA and Chi-square were used to determine differences between individual databases and between subscription and free databases. RESULTS: Scope scores revealed three discrete tiers of database performance: Tier 1 (82-77%), Tier 2 (73-65%) and Tier 3 (56-41%) which were significantly different from each other (p < 0.05). The top tier performers: MM (82%), MDR (81%), LC-AHFS (81%), AHFS (78%), and CP (77%) answered significantly more questions compared to other databases (p < 0.05). Top databases for completeness were: MM (97%), DM (96%), IDI (95%), and MDR (95%). Subscription databases performed better than free databases in all categories (p = 0.03). Databases suffered from 37 erroneous answers for an overall error rate of 1.8%. CONCLUSION: Drug information databases used in ID practice as CDSTs can be valuable resources. MM, MDR, LC-AHFS, AHFS, and CP were shown to be superior in their scope and completeness of information, and MM, AHFS, and MDR provided no erroneous answers. There is room for improvement in all evaluated databases.

Performance of online drug information databases as clinical decision support tools in infectious disease medication management.

Infectious disease (ID) medication management is complex and clinical decision support tools (CDSTs) can provide valuable assistance. This study evaluated scope and completeness of ID drug information found in online databases by evaluating their ability to answer 147 question/answer pairs. Scope scores produced highest rankings (%) for: Micromedex (82.3), Lexi-Comp/American Hospital Formulary Service (81.0), and Medscape Drug Reference (81.0); lowest includes: Epocrates Online Premium (47.0), Johns Hopkins ABX Guide (45.6), and PEPID PDC (40.8).

Effect of faculty-mediated interventions on pharmacy students' pursuit of postgraduate training.

PURPOSE: The influence of faculty-mediated interventions on the pursuit of postgraduate training (PGT) by pharmacy students was studied. METHODS: Three weeks before graduation, members of the class of 2005 (control group) at a Florida pharmacy school completed a questionnaire assessing their understanding of PGT opportunities. Members of the class of 2006 (intervention group) were exposed to faculty-mediated interventions during their final academic year of pharmacy school. The interventions consisted of informational pamphlets, a PGT booth during the school's career day, and PGT-related dinner programs. These students were surveyed before and after the interventions. RESULTS: Seventy-three percent (120/165) of control-group students and 63% (132/211) of intervention-group students completed the survey. Of the control students, 14% (15/108) reported plans to enter PGT after graduation. Sixteen percent (21/132) of intervention-group students reported such plans; the difference was not significant. All faculty-mediated interventions were reported to be helpful to students in making their postgraduation plans. Analysis of the combined groups suggested that students' interaction with faculty and residents during advance practice experiences positively affected pursuit of PGT. CONCLUSION: Students who received faculty- mediated interventions designed to inform them about PGT were not significantly more likely to pursue such training than students who did not receive the interventions. However, students reported the information to be helpful.

An elective course in adult acute care medicine using a hybrid delivery system.

OBJECTIVE: To develop and assess the effectiveness of an elective course modeled after activities students encounter on internal medicine advanced pharmacy practice experiences (APPEs). DESIGN: This hybrid elective course used a Web-based course management system linking pre-class lectures and assignments, classroom discussions, and projects to promote active student learning. ASSESSMENT: Assessment of student performance was based on assignments, quizzes, and participation in classroom discussions. Students were surveyed to ascertain their opinion of the elective. CONCLUSION: This elective in adult acute care medicine increased student exposure to inpatient settings and provided students additional opportunities to communicate effectively, evaluate medical literature, and think critically.

Tolerance and withdrawal issues with sedation.

The stay in an ICU is a complex mixture of providing optimal care while keeping the patient safe. Means of reducing the anxiety associated with the ICU stay include frequent reorientation and maintenance of patient comfort with sedation supplemented by analgesia as needed. The most common agents used to provide sedation include benzodiazepines, propofol, and the newer dexmedetomidine. Others include barbiturate agents, neuroleptics, clonidine, etomidate, ketamine, and supplemental opioid analgesics for pain control. A common complication of sedation is tolerance, which can lead to withdrawal if the sedation is discontinued hastily. This article evaluates the occurrence of tolerance and withdrawal in the most commonly used sedatives in critically ill patients.

Nationwide antibiogram analysis using NCCLS M39-A guidelines.

Lack of standardization in antibiogram (ABGM) preparation (the overall profile of antimicrobial susceptibility results of a microbial species to a battery of antimicrobial agents) has not been addressed until recently. The objective of this study was to analyze current antibiograms using the recently published NCCLS M39-A guidelines for preparation of antibiograms to identify areas for improvement in the reporting of antibiogram susceptibility data. Antibiograms from across the United States were obtained by various methods, including direct mailings, Internet searches, and professional contacts. Each ABGM collected was analyzed using prospectively defined elements from the M39-A guidelines. Additionally, seven quality indicators were also evaluated to look for the reporting of any atypical or inappropriate susceptibility data. The 209 antibiograms collected from 149 institutions showed at least 85% compliance to 5 of the 10 M39-A elements analyzed. Clinically relevant elements not met included annual analysis, duplicate isolate notation, and the exclusion of organisms with fewer than 10 isolates. As for the quality indicators evaluated, unexpected results included the 7% of antibiograms that reported <100% vancomycin susceptibility for Staphylococcus aureus, 24% that had inconsistent beta-lactam susceptibility for Staphylococcus aureus, 20% that reported <100% imipenem susceptibility for Escherichia coli, and 37% that reported >0% ampicillin susceptibility for Klebsiella pneumoniae. These findings suggest that antibiograms should be reviewed thoroughly by infectious disease specialists (physicians and pharmacists), clinical microbiologists, and infection control personnel for identification of abnormal findings prior to distribution.

Trospium chloride for the treatment of overactive bladder with urge incontinence.

BACKGROUND: Urinary incontinence is caused by an overactive bladder, leading to symptoms of urgency, frequency, and incontinence. Urge incontinence occurs predominantly in women as they age. OBJECTIVES: This article reviews the current primary literature concerning the efficacy and tolerability of the anticholinergic agent trospium chloride (TCl) in the treatment of overactive bladder with symptoms of urge incontinence, urgency, and frequency. The pharmacokinetics of TCl are also reviewed. METHODS: Pertinent articles in English were identified through a search of MEDLINE (1966-present), EMBASE Drugs & Pharmacology (1980-third quarter 2004), Current Contents/Clinical Medicine (week 42, 2003-week 41, 2004), Cochrane Database of Systematic Reviews, MICROMEDEX Healthcare Series, and International Pharmaceutical Abstracts (1970-present). The search terms were overactive bladder, urinary incontinence, trospium, randomized controlled clinical trial, oxybutynin, tolterodine, scopolamine, imipramine, desipramine, and propantheline. RESULTS: TCl, a quaternary amine, exhibits high solubility in water but low oral bioavailability (9.6%) and poor central nervous system penetration. Approximately 80% of the absorbed fraction is renally eliminated as unchanged drug via active tubular secretion, with approximately 15% hepatically metabolized into a spiroalcohol and hydrolysis/oxidation products. In 3 placebo-controlled studies, patients who received TCl had an increase in maximum bladder filling capacity and bladder compliance, with a reduction in maximum cystometric capacity (P < 0.005); however, only 1 of these studies showed an increase in bladder compliance, with reductions in maximum detrusor pressure (P < 0.001), number of voids/d (P < or = 0.001), and incontinence episodes/d (P < or = 0.001). In another placebo-controlled study, TCl reduced the number of voids/d and incontinence episodes/d (both, P < or = 0.001). In 2 double-blind studies, TCl and oxybutynin were similarly effective in significantly increasing maximum cystometric capacity and bladder compliance, and in significantly reducing maximum detrusor pressure compared with baseline (all, P < 0.001); there were no significant differences between the 2 treatments at end point. In a third double-blind study comparing TCl and tolterodine with placebo, only TCl significantly reduced the frequency of micturitions/d (P = 0.01). Commonly reported adverse effects in patients receiving TCl included dry mouth, constipation, and headache. CONCLUSIONS: In the 7 studies reviewed, TCl was effective and well tolerated in patients with urge incontinence caused by idiopathic detrusor muscle overactivity or neurogenic detrusor overactivity resulting from spinal cord injury. However, this agent was associated with anticholinergic adverse effects similar to those of other anticholinergic agents; careful monitoring of tolerability is required.