On pleasure and thrill: the interplay between arousal and valence during visual word recognition.

We investigated the interplay between arousal and valence in the early processing of affective words. Event-related potentials (ERPs) were recorded while participants read words organized in an orthogonal design with the factors valence (positive, negative, neutral) and arousal (low, medium, high) in a lexical decision task. We observed faster reaction times for words of positive valence and for those of high arousal. Data from ERPs showed increased early posterior negativity (EPN) suggesting improved visual processing of these conditions. Valence effects appeared for medium and low arousal and were absent for high arousal. Arousal effects were obtained for neutral and negative words but were absent for positive words. These results suggest independent contributions of arousal and valence at early attentional stages of processing. Arousal effects preceded valence effects in the ERP data suggesting that arousal serves as an early alert system preparing a subsequent evaluation in terms of valence.

Osteoporosis risk in premenopausal women.

Although clinically significant bone loss and fractures in healthy premenopausal women are rare, more women are seeking evaluation for osteoporosis from their health care providers. As pharmacists are in an ideal position to influence the management of premenopausal women with osteoporosis, it is important that pharmacists understand the available data on bone loss, fractures, and risk factors and secondary causes for osteoporosis, as well as when to recommend testing and treatment in premenopausal women. Limited data are available; therefore, we conducted a MEDLINE search of the literature from January 1993-August 2008. Studies evaluating bone loss, fractures, and fracture risk in healthy premenopausal women were targeted and summarized; most recommendations are based on expert opinion. A small but statistically significant loss in bone mineral density of 0.25-1%/year by dual-energy x-ray absorptiometry is seen healthy premenopausal women; the clinical significance of this is unknown. Whereas absolute fracture risk is low, premenopausal fractures appear to increase postmenopausal fracture risk by 1.5-3-fold. Risk factors for low bone density appear to be similar between pre- and postmenopausal women. Bone density screening in healthy premenopausal women is not recommended, but bone mineral density testing is advisable for those who have conditions or who receive drug therapy that may cause secondary bone loss. Lifestyle modification emphasizing bone-healthy habits such as adequate calcium and vitamin D nutrition, regular exercise, limitation of caffeine and alcohol consumption, and avoidance of tobacco are essential to the management of osteoporosis risk. The efficacy and safety of osteoporosis drugs have not been adequately demonstrated in premenopausal women. Therefore, pharmacologic interventions cannot be recommended in young women with low bone mass but may be considered in those having a more significant fracture risk, such as those with a previous low-trauma fracture or an identified secondary cause for bone loss.

Switching statin therapy using a pharmacist-managed therapeutic conversion program versus usual care conversion among indigent patients.

UNLABELLED: STUDY OBJECTIVE. To evaluate the effectiveness of switching statin therapy using a therapeutic conversion program versus usual care conversion among patients enrolled in the Colorado Indigent Care Program when atorvastatin was removed from the formulary. DESIGN: Prospective cohort study. SETTING: Family medicine center and other ambulatory care clinics of a university-based health care system. PATIENTS: One hundred seventeen ambulatory care patients with dyslipidemia who were treated with atorvastatin. INTERVENTION: Clinical pharmacists in the family medicine center implemented a therapeutic conversion program (30 patients), switching atorvastatin to a new formulary regimen of simvastatin, rosuvastatin, or ezetimibe-simvastatin, using an algorithm designed to achieve patient-specific goals for low-density lipoprotein cholesterol (LDL). Usual care occurred in the other ambulatory care clinics without clinical pharmacists (87 patients), where medical providers switched atorvastatin to a formulary regimen based on a suggested (but optional) equipotency conversion algorithm. MEASUREMENTS AND MAIN RESULTS: Primary end points were LDL concentration and LDL goal attainment before and after conversion. Before and after conversion, respectively, mean LDL concentrations were 86.7 and 82.3 mg/dl in the therapeutic conversion group (p=0.44) versus 78.3 and 85.2 mg/dl in the usual care group (p=0.01). Percentages of patients attaining LDL goal were 80% before and 97% after conversion in the therapeutic conversion group (p=0.04) compared with 90% before and 75% after conversion in the usual care group (p=0.01). CONCLUSION: Use of a prospective, therapeutic statin conversion program was associated with increased control of dyslipidemia, whereas usual care statin conversion was associated with decreased control. These data suggest that proactive involvement of clinical pharmacists in converting lipid-lowering drugs results in superior patient care outcomes compared with a less aggressive approach.

Inconsistent health perceptions for US women and men with diabetes.

BACKGROUND: Two health status measures for adults with diabetes are compared in order to identify gender-based differences between norm-based scores for health status and self-rated health scores. METHODS: Data were obtained from the 2001 and 2003 Medical Expenditure Panel Survey(MEPS). Diabetes was identified by self-report or ICD-9 code. Demographic and clinical (e.g., body mass index [BMI], comorbidities) parameters were included. Outcomes were norm-based measures of physical and mental health (SF-12 Physical and Mental Component Scores: SF-12 PCS and SF-12 MCS) and self-rated perception of health status. Sex-based differences in the three outcome measures, SF-12 PCS, SF-12 MCS, and self-rated health scores, were evaluated in univariate analyses and multivariate linear regression for survey data. RESULTS: A cohort of 3640 respondents with diabetes was identified (2037 women, 1603 men). In unadjusted analyses, women were older than men (60.7 vs. 59.3 years, p<0.001), reported higher mean BMI (31.1 vs. 30.4), more comorbidities, depression, and physical limitations (all p<0.001), had poorer SF-12 MCS scores (p=0.01), and self-rated their health status significantly higher than did men (p<0.01). In adjusted analyses, female gender was associated with lower SF-12 MCS scores and higher self-rated health scores. No factors were positively associated with higher scores across all three measures; only cognitive limitations consistently predicted lower health status scores in all three measures. CONCLUSIONS: Among adults with diabetes in a nationally representative sample of the U.S. adult population, discrepancies exist in health status measures. Despite being older, having more comorbidities and physical limitations, and lower norm-based scores for mental functional status, women self-rate their own health status higher than do men. Further research into the gender-based determinants and clinical implications of self-rated health status is warranted.

Evaluation of an evidence-based peer teaching assessment program.

OBJECTIVE: To determine faculty perceptions about an evidence-based peer teaching assessment system. METHODS: Faculty members who served as instructors and assessors completed questionnaires after year 1 (2002-2003) and year 4 (2005-2006) of the peer assessment program. Factors were evaluated using a Likert scale (1 = strongly disagree; 5 = strongly agree) and included logistics, time, fostering quality teaching, diversifying teaching portfolios, faculty mentoring, and value of structured discussion of teaching among faculty members. Mean responses from instructors and assessors were compared using student t tests. RESULTS: Twenty-seven assessors and 52 instructors completed survey instruments. Assessors and instructors had positive perceptions of the process as indicated by the following mean (SD) scores: logistics = 4.0 (1.0), time = 3.6 (1.1), quality teaching = 4.0 (0.9), diversifying teaching portfolios = 3.6 (1.2), faculty mentoring = 3.9 (0.9), and structured discussion of teaching = 4.2 (0.8). Assessors agreed more strongly than instructors that the feedback provided would improve the quality of lecturing (4.5 vs. 3.9, p < 0.01) and course materials (4.3 vs. 3.6, p < 0.01). CONCLUSION: This peer assessment process was well-accepted and provided a positive experience for the participants. Faculty members perceived that the quality of their teaching would improve and enjoyed the opportunity to have structured discussions about teaching.

Levonorgestrel-only dosing strategies for emergency contraception.

The United States Food and Drug Administration-approved progestin-only dosing strategy for emergency contraception is levonorgestrel 0.75 mg taken as soon as possible within 72 hours of unprotected intercourse, with a second 0.75-mg dose taken 12 hours later. However, different dosing strategies have been studied and promoted by various organizations. The American College of Obstetricians and Gynecologists recommends a single dose of levonorgestrel 1.5 mg for emergency contraception as one option. As another option, they recommend two doses of levonorgestrel 0.75 mg may be effective when taken 12-24 hours apart. We performed a search of MEDLINE and International Pharmaceutical Abstracts from 1967-2006 to evaluate and describe the existing pharmacokinetic and patient outcome data regarding administration of levonorgestrel as a 1.5-mg single dose or two 0.75-mg doses taken 12 or 24 hours apart. Additional studies were identified from the bibliographies of the selected literature. Several pertinent articles were identified. All of the studies demonstrated that emergency contraception effectively prevented pregnancy. In addition, evidence supports the safety and efficacy of a single dose of levonorgestrel 1.5 mg for emergency contraception. Furthermore, when two doses of levonorgestrel 0.75 mg are administered, the second dose can confidently be taken 12-24 hours after the first without compromising efficacy. Understanding the evidence that supports the different emergency contraception dosing strategies is critical for clinicians, and especially pharmacists, who have interactive roles in dispensing emergency contraception.

Pharmacy clarification of prescriptions ordered in primary care: a report from the Applied Strategies for Improving Patient Safety (ASIPS) collaborative.

INTRODUCTION: Prescription errors threaten patient safety and pharmacists often contact providers for prescription clarification. This study describes the principal reasons pharmacies call primary care practices to clarify prescriptions and subsequent implications for quality and patient safety improvement. METHODS: A cross-sectional study of 22 primary care practices participating in a patient safety study was performed. Callbacks from pharmacies were logged for 2 weeks to determine reasons for callbacks, most frequently involved drug classes, whether issues were resolved on the same day of the call, and variability of callbacks among practice types. Analyses were performed using frequencies, t tests, and chi(2) tests. RESULTS: Practices recorded 567 clarification calls, most frequently for prior authorization issues (n = 209; 37%), formulary issues (n = 148; 26%), and unclear/missing prescription dosages (n = 117; 21%). Drug classes most frequently requiring clarifications were gastrointestinal (n = 122; 21.7%), cardiovascular (n = 278; 13.9%), and analgesic/anesthetic (n = 74; 13.2%) agents. Issues were resolved on the same day 62% of the time. Residency practices averaged more issues per call (P < .001). CONCLUSIONS: Clarification calls made to primary care practices involve administrative and clinical issues, potentially impacting patient safety. Pharmacy callback data can identify potential prescription concerns, thereby helping practices develop interventions aimed at reducing errors and improving patient safety.

Evaluating sample medications in primary care: a practice-based research network study.

BACKGROUND: No reports have objectively evaluated safety of samples in primary care practices. A study was conducted to determine adherence to the Institute for Safe Medication Practices (ISMP) recommendations for safe distribution of medication samples to minimize medication errors. METHODS: In 2004, 17 urban and rural primary care practices participated in a two-phase observational study: (1) a site visit to collect inventory data and perform assessment of medication sample dispensing procedures and (2) a survey questionnaire for providers and patients upon sample medication provision. RESULTS: No practices were compliant with all seven ISMP recommendations. Twelve of 17 practices had policies for sample medication dispensing, and 7 had policies for labeling. Sample medication use was evaluated for 585 office visits and 27 patient surveys. Fifty-eight sample medications were dispensed during 55 of 585 patient visits. Common reasons for using sample medications included availability and need for a short-term trial for a chronic medication. Verbal communication only was provided most of the time for patient education regarding appropriate sample medication use and side effects. DISCUSSION: Primary care practices in this research network did not follow safe and appropriate sample medication dispensing procedures as outlined by ISMP. Both labeling and patient instructions were inadequate and may increase the risk for medication errors.

Osteoporosis update: effective prevention and treatment.

Osteoporosis is a public health threat to approximately 44 million individuals in the USA, or 55% of men and women over the age of 50 years. The primary goal of osteoporosis management is to prevent fracture, the most devastating consequence. Risk factors and bone mineral density can be assessed to determine appropriate action for prevention and treatment of osteoporosis. Prevention strategies include lifestyle modification, fall prevention, and adequate intake of calcium and vitamin D. Current treatment options include antiresorptive agents and anabolic agents. Adherence and cost issues play major roles in establishing optimal therapy for individual patients. New agents in development are designed to improve osteoporosis treatment and patient adherence. This review focuses on current and future prevention and treatment options for postmenopausal osteoporosis.

Current approaches to the management of osteoporosis in men.

PURPOSE: The epidemiology, pathophysiology, diagnosis, and management of osteoporosis in men are reviewed. SUMMARY: Men with osteoporosis account for approximately one fifth of all patients with osteoporosis, and their morbidity and mortality rates from this disease are higher than in other patients. Guidelines specifically addressing the management of osteoporosis in men are not available. Lifestyle modifications, including smoking cessation, limited alcohol consumption, routine exercise, and fall prevention strategies, are beneficial to maintain bone health. Appropriate calcium and vitamin D intakes are critical components of any osteoporosis management strategy. Drug therapy should be initiated in all men at high risk for fracture. Alendronate is indicated for the treatment of osteoporosis. It is considered first-line therapy because of its efficacy and safety profiles. Teriparatide is indicated for the management of osteoporosis in high-risk men, but the drug's cost, complex administration schedule, and potential risks have caused it to be restricted to a second-line therapy. Other options reserved for select patients include calcitonin and testosterone. Further studies are needed to better understand the distinctive features and management strategies for men with osteoporosis. CONCLUSION: While the rate of osteoporosis in men is lower than in women, the consequences are possibly more devastating. Evaluation of secondary causes, especially hypogonadism, is important, as they can play a significant role in the development of osteoporosis in men. All men should be educated to improve modifiable risk factors and maintain recommended daily intakes of calcium and vitamin D. Bone mineral density should be evaluated in high-risk men using central dual energy x-ray absorptiometry, and drug treatment should be considered in those with a history of low-trauma fracture or significant bone loss.

Impact of the women's health initiative trial results on hormone replacement therapy.

STUDY OBJECTIVE: To describe the impact of the results of the Women's Health Initiative (WHI) on hormone replacement therapy (HRT) discontinuation rates. DESIGN: Retrospective chart review. SETTING: University-based family medicine clinic. SUBJECTS: Ninety-eight postmenopausal women (aged 50-79 yrs) with an intact uterus who were receiving HRT. MEASUREMENTS AND MAIN RESULTS: Two study periods were defined: pre-WHI (July 9, 2001-January 9, 2002) and post-WHI (July 9, 2002-January 9, 2003). Patient demographics and HRT discontinuation or persistence data were collected. Seven women were eligible for only for pre-WHI, 13 only for post-WHI, and 78 were eligible for both groups based on HRT use during both time periods. Forty-two of the 78 women were randomized to the pre-WHI group and 36 to the post-WHI group to yield equal groups of 49 each. No significant demographic differences existed between the groups. Time-to-event analysis revealed an increased probability of HRT discontinuation after WHI versus before WHI (log-rank test, p<0.01). A subset of 85 women taking HRT 1 year before WHI were followed for 18 months. Discontinuation rates were 8% (7 of 85 patients) during the 12 months before WHI and 38% (30 of 78) during the 6 months after WHI, with 80% (24 of 30) of these patients discontinuing within 3 months. CONCLUSION: Increased HRT discontinuation was temporally associated with release of WHI data, which implies that highly publicized, negative outcomes data can quickly influence pharmacotherapy decisions.

Pharmacist compensation for cognitive services: focus on the physician office and community pharmacy.

We provide a stepwise approach for the clinical pharmacy practitioner in the physician clinic or community pharmacy setting to secure compensation for cognitive services. How to establish compensation for pharmacist services is explored, including evaluating the payer mix, developing a relationship with the first- or third-party payer, becoming credentialed with a third-party payer, and creating a fee structure. We detail the physical process of billing, which involves completing appropriate billing forms, appropriately using billing codes, documenting cognitive services in the patient record, and obtaining the proper waivers and/or approvals to provide specific services such as laboratory services and immunizations. This comprehensive review of compensation for cognitive services available in the community pharmacy and physician office environment is designed to be a template for pharmacists to further develop specific strategies, implement fee structures, and obtain compensation in their pharmacy environment and payer mix. Exploration into these innovative markets will enable pharmacists to increase revenue as they enhance and expand their cognitive services for patients.

Prevention and treatment of nonpostmenopausal osteoporosis.

PURPOSE: The causes, prevention, and treatment of osteoporosis in specific populations are discussed. SUMMARY: Osteoporosis and osteopenia affect 44 million women and men ages 50 years or older. Fractures are the most devastating consequence of this disease and significantly affect quality of life, activities of daily living, survival, and health care costs. Most osteoporosis research has focused on postmenopausal women, but several other populations are at risk for osteoporosis, such as patients taking certain medications that affect bone health and those with various health conditions that cause bone loss, including anorexia nervosa, hyperthyroidism, organ transplantation, chronic obstructive pulmonary disease, and inflammatory bowel disease. Glucocorticoids are the most common secondary cause of osteoporosis. Other medications that have been implicated as secondary causes include anticonvulsants, heparin, warfarin, and methotrexate. Preventing osteoporosis may be even more important in adolescence than after menopause. CONCLUSION: Osteoporosis needs to be recognized, monitored, and appropriately treated in patients taking medications that affect bone health and in patients with conditions that increase the risk of osteoporosis.

Current approaches to the prevention and treatment of postmenopausal osteoporosis.

Current approaches to the prevention, detection, treatment, and monitoring of postmenopausal osteoporosis are discussed. In the United States, 44 million men and women ages 50 years or older have low bone mass or osteoporosis. The most devastating consequence of this disease is fractures. The assessment of osteoporosis risk includes determining risk factors, conducting laboratory and physical examinations, and measuring bone density and bone-turnover markers. Once risk has been established, nonpharmacologic strategies, such as exercise, appropriate dietary habits, and discontinuing tobacco and alcohol use, are helpful. Fall prevention and adequate intake of calcium and vitamin D are critical. When pharmacologic therapy is warranted, bisphosphonates have shown the greatest benefit in preventing bone loss and lowering fracture rates. Selective estrogen-receptor modulators and calcitonin are also options for prevention or treatment of osteoporosis. Estrogen should not be used for the sole purpose of osteoporosis prevention; however, short-term use is acceptable for women with vasomotor symptoms or in whom the benefits outweigh the risks. Parathyroid hormone may offer another treatment alternative. A variety of pharmacologic options are available for patients with osteoporosis in whom lifestyle modifications have proven insufficient. Bisphosphonates are the mainstay of drug therapy.