Years of Rampant Expansion Have Imposed Darwinian Survival-of-the-Fittest Conditions on US Pharmacy Schools.

The number of applicants to US pharmacy schools has been declining since 2013, leading to a national enrollment crisis. Enrollment challenges threaten the viability of many pharmacy programs. Some schools are better equipped than others to confront the risk of having to downsize or close, creating survival-of-the-fittest conditions. Four potential risk factors have been identified based on how applicants might perceive the comparable value of respective programs. Schools with lower risk are public, established before 2000, located within an academic health center, and traditional (ie, four-year) programs. The Academy cannot sustain more than 140 schools much longer. Market forces are establishing a new equilibrium between the number of graduates and the availability of pharmacist jobs. As more jobs become available, more applicants will apply. Until then, the fittest Doctor of Pharmacy programs will thrive, while others might have to downsize to survive, and the weakest will be at risk of extinction.

Current Impact and Application of Abuse-Deterrent Opioid Formulations in Clinical Practice.

BACKGROUND: Abuse-deterrent formulations (ADFs) represent one novel strategy for curbing the potential of opioid abuse. OBJECTIVE: We aim to compare and contrast the characteristics and applications of current abuse-deterrent opioid products in clinical practice. METHODS: Literature searches were conducted in databases (Pubmed Medline, International Pharmaceutical Abstracts, Google Scholar) and official reports. Relevant data were screened and organized into: 1) epidemiology of opioid abuse, 2) mitigation strategies for reducing opioid abuse, 3) development of ADFs, and 4) clinical experience with these formulations. RESULTS: Increasing trends of opioid abuse and misuse have been reported globally. There are 5 types of abuse-deterrent opioid products: physical chemical barrier, combined agonist/antagonist, sequestered aversive agent, prodrug, and novel delivery system. The advantages and disadvantages of the 5 options are discussed in this review. A total of 9 products with abuse-deterrent labels have been approved by the Food and Drug Administration (FDA). The rates of abuse, diversion, and overdose deaths of these new products are also discussed. A framework for collecting in-time data on the efficacy, benefit and risk ratio, and cost-effectiveness of these new products is suggested to facilitate their optimal use. LIMITATIONS: The present review did not utilize systematic review standards or meta-analytic techniques, given the large heterogeneity of data and outcomes reviewed. CONCLUSIONS: ADFs provide an option for inhibiting the abuse or misuse of oral opioid products by hindering extraction of the active ingredient, preventing alternative routes of administration, or causing aversion. Their relatively high costs, uncertain insurance policies, and limited data on pharmacoeconomics warrant collaborative monitoring and assessment by government agencies, pharmaceutical manufacturers, and data analysis services to define their therapeutic role in the future. KEY WORDS: Opioid abuse, abuse-deterrent formulations, ADF, post-marketing, FDA guidance, cost impact, abuse liking, physician attitude, generic abuse-deterrent formulation, clinical application.

Once-daily aminoglycoside dosing: An update on current literature.

PURPOSE: The advantages and disadvantages of once-daily versus conventional dosing of aminoglycoside antibiotics are reviewed. SUMMARY: Although administration of multiple daily doses remains the standard method of aminoglycoside dosing, once-daily dosing may provide enhanced clinical efficacy and reduced toxicity in selected patient populations; demonstrated pharmacokinetic and pharmacodynamic advantages include enhanced postantibiotic effect and an increased likelihood of a high ratio of serum peak concentration to minimum inhibitory concentration. Published evidence identified in a MEDLINE search covering the period 1985-2014 indicates that once-daily high-dose aminoglycoside therapy generally provides clinical effectiveness equivalent or superior to that of multiple-daily dosing. The risk of nephrotoxicity appears to be comparable with once- and multiple-daily aminoglycoside dosing. Several nomograms have been developed to facilitate once-daily dosing; the Hartford nomogram (using a dose of 7 mg/kg) is the most extensively tested and generally considered the most reliable. However, although those nomograms are convenient to use and may reduce expenses, a daily dosing regimen determined by individualized pharmacokinetic monitoring is likely to be more effective for achieving specific serum concentrations and may be a preferable approach for some patients. Patients who are pregnant or have liver failure, severe renal insufficiency, serious illness, or nutritional deficiency are not appropriate candidates for once-daily dosing. CONCLUSION: Once-daily aminoglycoside dosing is an effective, well-established method to achieve therapeutic efficacy while limiting the risk of toxicity and simplifying the processes of dosing and monitoring.

Rethinking the Role of Clinical Practice Guidelines in Pharmacy Education.

Clinical practice guidelines (CPGs) play a major role in pharmacy education. Students learn to locate, retrieve, and apply CPGs in didactic coursework and practice experiences. However, they often memorize and quote recommendations without critical analysis, which tends to undermine their clinical growth. Students should become genuine drug experts, based on strong critical-thinking skills and the ability to assimilate extensive clinical and scientific knowledge. Clinical practice guidelines improve health care, and students should be familiar with them, but there are legitimate criticisms of CPGs, stemming largely from potential conflicts of interest and limitations in the quality and scope of available evidence. Despite such flaws, CPGs can be used to facilitate the clinical growth of students if the emphasis is placed on critically analyzing and evaluating CPG recommendations, as opposed to blindly accepting them. From that perspective, the role that CPGs have come to play in education may need to be reconsidered.

AUC versus peak-trough dosing of vancomycin: applying new pharmacokinetic paradigms to an old drug.

OBJECTIVES: To compare and contrast the pharmacokinetic/pharmacodynamic foundations of traditional "peak-trough" vancomycin dosing methods versus newer "area under the curve" (AUC) strategies. To propose a new AUC-based dosing chart for empirically determining an initial vancomycin dosing regimen designed to achieve a desired AUC24 using the minimum inhibitory concentration (MIC), creatinine clearance (CrCl), and vancomycin clearance (ClVanco). REVIEW OF VANCOMYCIN DOSING: Peak-trough vancomycin dosing is designed to achieve a Cpeak of 20-40 mg/L and a Ctrough of 10-15 or 15-20 mg/L, depending on the severity of the infection and the nature of the pathogen. New treatment guidelines for vancomycin suggest that therapy should achieve an AUC24/MIC of ≥400. AUC-based vancomycin dosing derives the daily dose from ClVanco, MIC, and the desired AUC24/MIC, without consideration of the patient's weight. NEW AUC DOSING CHART: A vancomycin dosing chart is proposed that estimates ClVanco using the following formula developed by Matzke et al: ClVanco in L/h = [(CrClmL/min × 0.689) + 3.66] × 0.06, which simplifies to (CrClmL/min × 0.41) + 0.22. Two levels of dosing are included-high dose (Ctrough: 15-20 mg/L) and moderate dose (Ctrough: 10-15 mg/L). Although the chart has not been validated clinically, it represents the product of standard dosing equations that are used to determine a starting dosing regimen based on well-established vancomycin pharmacokinetic parameters. CONCLUSIONS: An understanding of pharmacokinetic and pharmacodynamic principles, including the relevance of AUC in relation to MIC, enables clinicians to make the best use of vancomycin dosing options. The proposed dosing chart is pharmacokinetically valid but has yet to be applied clinically. It provides a foundation for further study of how clinicians can determine an optimal AUC-based starting vancomycin dosing regimen without having to derive ClVanco or AUC24.

Functional range of creatinine clearance for renal drug dosing: a practical solution to the controversy of which weight to use in the Cockcroft-Gault equation.

OBJECTIVE: To describe a practical solution for addressing body weight when using the Cockcroft-Gault equation to determine drug dosing. DATA SOURCES: A literature search was conducted using PubMed MEDLINE (1980-April 2013) using creatinine clearance, Cockcroft and Gault, Cockcroft-Gault, body weight, and obesity as search terms. Reference citations from publications reviewed were included. STUDY SELECTION AND DATA EXTRACTION: All English-language articles identified by the search were reviewed. Studies comparing the accuracy and bias of the Cockcroft-Gault equation using a variety of body weight designations in adult populations were included in the analysis. DATA SYNTHESIS: Study results indicated that, for obese patients, ideal body weight (IBW) underestimates creatinine clearance (CrCl) and total body weight (TBW) overestimates CrCl. Some studies suggest that adjusted body weight with a factor of 0.4 is most accurate, while others suggest the use of lean body weight. These studies have failed to produce a definitive resolution to the controversy. Despite many well-designed studies, the Cockcroft-Gault body weight controversy remains unresolved and uncertainty continues to exist as to which form of weight should be used in the equation. A different perspective is warranted. Since renal dosing guidelines are generally based on ranges of CrCl, applying a CrCl range to describe a patient's renal function might be more practical than relying on a specific CrCl value. Ultimately, CrCl-based drug dosing involves the use of an imperfect mathematical approximation, which is then applied as precisely as possible to the benefit versus risk analysis for a specific patient. CONCLUSIONS: We propose the use of a CrCl range for drug dosing purposes, with the lower boundary defined by using IBW in the Cockcroft-Gault equation and the upper boundary by using TBW.

Planning a pharmacy-led medical mission trip, part 2: servant leadership and team dynamics.

While pharmacy curricula can prepare students for the cognitive domains of pharmacy practice, mastery of the affective aspects can prove to be more challenging. At the Gregory School of Pharmacy, medical mission trips have been highly effective means of impacting student attitudes and beliefs. Specifically, these trips have led to transformational changes in student leadership capacity, turning an act of service into an act of influence. Additionally, building team unity is invaluable to the overall effectiveness of the trip. Pre-trip preparation for teams includes activities such as routine team meetings, team-building activities, and implementation of committees, as a means of promoting positive team dynamics. While in the field, team dynamics can be fostered through activities such as daily debriefing sessions, team disclosure times, and provision of medical services.

Early relapse and refractory disease remain risk factors in the anthracycline and autologous transplant era for patients with relapsed/refractory classical Hodgkin lymphoma: a single centre intention-to-treat analysis.

An intention-to-treat (ITT) analysis was performed in 103 unselected patients with relapsed/refractory classical Hodgkin lymphoma (CHL) comparing early relapse (<12 months) or failure of first-line therapy (ER/FTF) with late relapses (LR). Seventy one percentage proceeded to high-dose therapy/autologous stem cell rescue (HDT/ASCR) following salvage treatment. By ITT, 5-year overall survival (OS) was 50% for ER/FTF compared to 73% for LR patients (P = 0·012). However OS was equivalent for both groups if salvage treatment response was adequate to proceed to HDT/ASCR. ER/FTF patients remain a high-risk group largely due to a failure of salvage therapy: a point at which novel interventions could impact survival.

Evaluation of ion collection area in Faraday probes.

A Faraday probe with three concentric rings was designed and fabricated to assess the effect of gap width and collector diameter in a systematic study of the diagnostic ion collection area. The nested Faraday probe consisted of two concentric collector rings and an outer guard ring, which enabled simultaneous current density measurements on the inner and outer collectors. Two versions of the outer collector were fabricated to create gaps of 0.5 and 1.5 mm between the rings. Distribution of current density in the plume of a low-power Hall thruster ion source was measured in azimuthal sweeps at constant radius from 8 to 20 thruster diameters downstream of the exit plane with variation in facility background pressure. A new analytical technique is proposed to account for ions collected in the gap between the Faraday probe collector and guard ring. This method is shown to exhibit excellent agreement between all nested Faraday probe configurations, and to reduce the magnitude of integrated ion beam current to levels consistent with Hall thruster performance analyses. The technique is further studied by varying the guard ring bias potential with a fixed collector bias potential, thereby controlling ion collection in the gap. Results are in agreement with predictions based on the proposed analytical technique. The method is applied to a past study comparing the measured ion current density profiles of two Faraday probe designs. These findings provide new insight into the nature of ion collection in Faraday probe diagnostics, and lead to improved accuracy with a significant reduction in measurement uncertainty.

Pharmacy curriculum outcomes assessment for individual student assessment and curricular evaluation.

The Pharmacy Curriculum Outcomes Assessment (PCOA) is a standardized examination for assessing academic progress of pharmacy students. Although no other national benchmarking tool is available on a national level, the PCOA has not been adopted by all colleges and schools of pharmacy. Palm Beach Atlantic University (PBAU) compared 2008-2010 PCOA results of its P1, P2, and P3 students to their current grade point average (GPA) and to results of a national cohort. The reliability coefficient of PCOA was 0.91, 0.90, and 0.93 for the 3 years, respectively. PBAU results showed a positive correlation between GPA and PCOA scale score. A comparison of subtopic results helped to identify areas of strengths and weaknesses of the curriculum. PCOA provides useful comparative data that can facilitate individual student assessment as well as programmatic evaluation. There are no other standardized assessment tools available. Despite limitations, PCOA warrants consideration by colleges and schools of pharmacy. Expanded participation could enhance its utility as a meaningful benchmark.

White coat ceremonies in US schools of pharmacy.

BACKGROUND: Pharmacy and medical schools share similar concerns regarding the need to place greater emphasis on professional socialization. Many academic institutions of both professions have elected to establish a white coat ceremony to initiate the process of inculcating professional values. However, a recent literature search revealed little published information on pharmacy white coat ceremonies. OBJECTIVE: To determine the prevalence of white coat ceremonies in US schools of pharmacy and identify commonalities between ceremonies conducted at different schools. METHODS: In April 2002, a 25-question survey was sent via E-mail to the deans of the 83 accredited schools of pharmacy in the US. The survey solicited details about the nature of each school's white coat ceremony or reasons why the school does not conduct a ceremony. RESULTS: The first ceremony in pharmacy was held at the University of Kentucky in 1995. As of May 2002, 51 of the 83 schools had already conducted a white coat ceremony and another 10 indicated plans to initiate a ceremony by the end of the year. Telephone follow-up confirmed that, as of May 2003, the number had risen to 61 schools. Most schools conduct the ceremony during the first professional year. Common features include presentation of the coat, recitation of an oath, a speech by an honored guest, a class photograph, and a reception. CONCLUSIONS: The white coat ceremony is a growing phenomenon in pharmacy education that could play a pivotal role in the quest to better achieve professional socialization among students.