Evaluating Practice Readiness of Advanced Pharmacy Practice Experience Students Using the Core Entrustable Professional Activities.

Objective. To evaluate levels of entrustability and practice readiness in advanced pharmacy practice experience (APPE) students using a pilot instrument designed to assess their competency in performing the entrustable professional activities (EPAs) expected of new pharmacy graduates. Methods. A pilot instrument was developed directly from EPAs to measure entrustability levels on a scale of one to five. Five APPE preceptors from several different practice areas participated. Fourth-year students used the instrument to self-evaluate their knowledge and skills at the beginning, midpoint, and end of the APPE. The preceptors evaluated students using the same instrument at APPE midpoint and end. The instrument had assigned weights for each EPA and entrustability level for a score of 100 if all items were marked five. If a rating of non-applicable was chosen, score adjustments were made. All students in the graduating class of 2018 were invited to perform a self-evaluation at the end of the fourth (APPE) year using the same instrument that study participants used. Results. Twenty-eight students and five preceptors completed evaluations during the APPE year. Overall scores from both preceptor evaluations of students and student self-evaluations increased significantly from pre-APPE to midpoint to final. Student self-evaluations were only slightly higher than preceptor evaluations. The mean (SD) preceptor scores for students and student self-assessment scores at the end of each APPE were 85.4% (7.1) and 87.2% (10.3), respectfully. One practice manager EPA and three population health EPAs were considered to not be applicable by preceptors on ≥50% of evaluations. Approximately 94% of all graduating students completed the year-end self-evaluations, with a mean (SD) score of 89% (8.6) and no EPAs marked as not applicable. Conclusion. Pharmacy students' proficiency in EPA improved during individual APPEs. According to preceptors, students' greatest improvement in entrustability was in educating patients and colleagues regarding appropriate use of medications and collecting information to identify medication-related problems.

Statin-Associated Bilateral Foot Myopathy.

OBJECTIVE: To report a case of statin-induced bilateral foot myopathy that resulted from 2 different statins. Case Summary: A 44-year-old Caucasian male with a history of ventricular fibrillation cardiac arrest, hyperlipidemia, and coronary artery disease experienced bilateral foot pain, weakness, and soreness while taking atorvastatin 20 mg daily. The pain subsided within weeks of discontinuing atorvastatin but returned years later after the initiation of rosuvastatin. The Naranjo probability scale indicates that this is a definite association between bilateral foot myopathy and statin use. DISCUSSION: There is an association with statin use and lowering cardiovascular risk in patients with dyslipidemia and cardiovascular disease. However, statin metabolites can accumulate in the myocytes of muscle groups to cause a common side effect of myopathy. Statin myopathy typically occurs in large, bilateral, or proximal muscle groups, such as the thighs, back, calves, or buttocks. This patient was unusual in that his muscle symptoms only occurred in his feet and was severe enough to affect his ambulation. CONCLUSION: Stain-associated muscle symptoms have been reported to lessen medication adherence. There is also a risk with muscle symptoms that the patient could develop rhabdomyolysis, a rare but serious condition. Recognizing statin-associated muscle symptoms even in uncommon locations is important, so that alternative lipid-lowering strategies can be implemented to lower cardiovascular risk.

The Use of Low-Dose Naltrexone for Chronic Pain.

The use of low-dose naltrexone for the treatment of chronic pain is novel because it is a nonopioid alternative. Oral naltrexone in a dosage range from 1 mg to 4.5 mg is referred to as low-dose naltrexone. Low-dose naltrexone use is "off label" and has been used successfully to manage chronic pain, autoimmune disorders, and dermatologic conditions. Low-dose naltrexone could be a viable treatment option for chronic pain because other agents for chronic pain, such as nonsteroidal agents, have adverse effects of gastrointestinal bleeding, renal injury, and increase a patient's risk of myocardial infarction or stroke. Additionally, low-dose naltrexone has minimal adverse effects, no drug-drug interactions, and is relatively inexpensive compared with other options for chronic pain.

Recognition and Management of Anaphylaxis in Older Adults.

OBJECTIVES: To discuss medications that cause anaphylaxis in older adults and its treatment, with a focus on epinephrine. DATA SOURCE: A search of PubMed using the terms "anaphylaxis," "drug-induced anaphylaxis," "epinephrine autoinjectable," "anaphylaxis diagnosis," "anaphylaxis treatment," and "epinephrine cost" was performed. English-language articles from January 2000 to August 2016 appearing in these searches were reviewed. STUDY SELECTION/DATA EXTRACTION: Relevant review articles, consensus statements, practice parameters, task force recommendations, and original articles were assessed for recognition and treatment of drug-induced anaphylaxis. DATA SYNTHESIS: Anaphylaxis is a serious allergic reaction that occurs with food, insect stings, latex, radio contrast agents, and medications. Medications that are commonly used by older adults can cause anaphylaxis. Epinephrine remains the first-line treatment option and does not have any contraindications. CONCLUSION: Early recognition of drug-induced anaphylaxis symptoms is critical and medication should be administered immediately to prevent cardiac arrest. Additionally, health care providers can provide others with education on administration of epinephrine auto-injectable agents, availability of alternative options, and patient-assistance programs to lower the cost of epinephrine agents.

Dangers of Nonprescription Medicines: Educating and Counseling Older Adults.

OBJECTIVE: To provide a review for health care providers regarding appropriate education and counseling for older adults involving commonly used nonprescription medicines with potential for adverse effects, drug-drug interactions, or toxicity when incorrectly selected or overused. DATA SOURCES: A literature search was performed using MEDLINE and PUBMED to locate relevant articles. DAILYMED was used for manufacturer dosage recommendations. Additionally, peer-reviewed textbooks were consulted for evidence-based standards of care. STUDY SELECTION/DATA EXTRACTION: Articles were reviewed and selected for inclusion based on relevance to the subject and accuracy of information provided. Articles chosen were published between March 2008 and December 2016. Additionally, several textbook chapters providing information for nonprescription medicines chosen for evaluation in this review were used. DATA SYNTHESIS: Nonprescription medicines are accessible and widely used by older adults. Polypharmacy and drug duplication are concerns because of negative outcomes. Given the accessibility and knowledge of pharmacists, they are often asked questions regarding nonprescription medicines. CONCLUSION: Pharmacists have a duty and responsibility to commit to lifelong learning and to provide appropriate education and counseling on the use of nonprescription medicines. This will help decrease overall health care costs and potential negative problems associated with polypharmacy among older adults that include adverse effects, toxicity, and drug-drug interactions.

Impact of abbreviated lecture with interactive mini-cases vs traditional lecture on student performance in the large classroom.

OBJECTIVE: To compare the impact of 2 different teaching and learning methods on student mastery of learning objectives in a pharmacotherapy module in the large classroom setting. DESIGN: Two teaching and learning methods were implemented and compared in a required pharmacotherapy module for 2 years. The first year, multiple interactive mini-cases with inclass individual assessment and an abbreviated lecture were used to teach osteoarthritis; a traditional lecture with 1 inclass case discussion was used to teach gout. In the second year, the same topics were used but the methods were flipped. Student performance on pre/post individual readiness assessment tests (iRATs), case questions, and subsequent examinations were compared each year by the teaching and learning method and then between years by topic for each method. Students also voluntarily completed a 20-item evaluation of the teaching and learning methods. ASSESSMENT: Postpresentation iRATs were significantly higher than prepresentation iRATs for each topic each year with the interactive mini-cases; there was no significant difference in iRATs before and after traditional lecture. For osteoarthritis, postpresentation iRATs after interactive mini-cases in year 1 were significantly higher than postpresentation iRATs after traditional lecture in year 2; the difference in iRATs for gout per learning method was not significant. The difference between examination performance for osteoarthritis and gout was not significant when the teaching and learning methods were compared. On the student evaluations, 2 items were significant both years when answers were compared by teaching and learning method. Each year, students ranked their class participation higher with interactive cases than with traditional lecture, but both years they reported enjoying the traditional lecture format more. CONCLUSION: Multiple interactive mini-cases with an abbreviated lecture improved immediate mastery of learning objectives compared to a traditional lecture format, regardless of therapeutic topic, but did not improve student performance on subsequent examinations.

Antacid-induced acute pancreatitis.

OBJECTIVE: To report a case of acute pancreatitis associated with the administration of high doses of over-the-counter (OTC) antacids containing calcium carbonate. SETTING: An acute care 276-bed community hospital. CASE SUMMARY: In this case report, a 68-year-old male was admitted to the hospital for nausea, vomiting, and stomach pain. Patient reported taking 15-20 OTC calcium carbonate (4.5-6.0 g elemental calcium) tablets for four to five days prior to admission. Patient's calcium level upon admission was 18.5 mg/dL. Laboratory values of amylase and lipase peaked at 2,768 U/L and 7,091 U/L, respectively. An abdominal computed tomography confirmed acute pancreatitis. For a period of 45 days, treatment in the intensive care unit for acute pancreatitis and latter for necrotizing pancreatitis was conducted. CONCLUSION: This case study supports an association between hypercalcemia and pancreatitis in patients who take greater than recommended dosages of calcium-containing antacids. OTC antacids are popular, but can cause serious adverse events when not used as directed.

Active-learning assignments to integrate basic science and clinical course material.

OBJECTIVE: To develop, implement, and evaluate active-learning exercises requiring the integration and application of pathophysiology, medicinal chemistry, pharmacology, and therapeutics knowledge of osteoarthritis and rheumatoid arthritis to formulate therapeutic recommendations for patients with musculoskeletal disorders. DESIGN: Two team-based case study exercises, one evaluating a patient with osteoarthritis and the second, a patient with rheumatoid arthritis, were developed, incorporating material and questions from pathophysiology, medicinal chemistry, pharmacology, and therapeutics. The learning assignments were implemented in a required pharmacotherapy module. ASSESSMENT: Student learning was evaluated using performance on the team-based case study exercises and on 2 examinations. A standard student course evaluation was used to assess students' impressions of the learning activity. The mean student grades for the osteoarthritis and rheumatoid arthritis activities were 9.1 and 8.9, respectively, on a 10-point scale. The majority of students indicated that the learning exercises were more than adequate to excellent in helping students learn. CONCLUSION: The addition of active-learning activities was successful in teaching pharmacy students the knowledge needed to formulate therapeutic recommendations for patients with musculoskeletal disorders.

Pharmacy students' participation in a research experience culminating in journal publication.

OBJECTIVES: To examine factors that influenced doctor of pharmacy (PharmD) students to collaborate with faculty members, preceptors, or others on scholarly activities that resulted in publication of an article in a pharmacy journal, and whether this experience influenced their consideration of a career in academic pharmacy. METHODS: A 17-question survey instrument was e-mailed to student authors of papers published between 2004 and 2008 in 6 pharmacy journals. Responses were analyzed to determine factors influencing student participation in research and whether the experience led them to consider a career in academic pharmacy. RESULTS: Factors about their participation in the scholarly activity that respondents found valuable included personal fulfillment and making a contribution to the literature. Respondents indicated they were more interested in a career in academic pharmacy after their participation in the scholarly experience (p < 0.001). CONCLUSIONS: Participation in scholarly activities and student authorship of a peer-reviewed journal manuscript during pharmacy school may lead to increased interest in a career in academic pharmacy.

Takotsubo cardiomyopathy, or broken-heart syndrome.

OBJECTIVE: To report a case of takotsubo cardiomyopathy, also known as apical ballooning syndrome or stress cardiomyopathy. CASE SUMMARY: A 68-year-old female with a history of hypertension, hyperlipidemia, and anxiety presented with symptoms that mimicked acute coronary syndrome (ACS); the chief symptom was chest tightness. An electrocardiogram showed normal sinus rhythm, with minimal ST elevation in the anterior leads. The patient was initially treated for ST-segment elevation myocardial infarction and symptoms resolved. Coronary angiography ruled out ACS and confirmed a diagnosis of takotsubo cardiomyopathy. DISCUSSION: Takotsubo cardiomyopathy is commonly triggered by severe emotional or psychological stress and occurs primarily in postmenopausal women. A reversible contractility abnormality of the left ventricle causes the ventricle to take on a balloon-like appearance; hence the name of takotsubo, a Japanese octopus fishing pot that has a narrow neck and a wide midsection. Signs and symptoms of takotsubo cardiomyopathy mimic those of ACS. Takotsubo cardiomyopathy is best diagnosed with coronary angiography, which can rule out blockage. Treatment usually consists of carvedilol and an angiotensin-converting enzyme inhibitor or angiotensin II receptor blocking agent if left ventricular ejection fraction is less than 40%. The syndrome is usually spontaneously reversible and cardiovascular function returns to normal after a few weeks. CONCLUSIONS: Takotsubo cardiomyopathy causes a reversible left ventricle dysfunction which occurs most commonly in postmenopausal women with or without cardiovascular disease. Recognition is detected with coronary angiography. It is thought to primarily be due to an abnormally high sympathetic stimulation after emotional or psychological stress. Treatment consists of an angiotensin-converting enzyme inhibitor and/or beta blocker if needed for left ventricular dysfunction and possibly an anxiolytic agent.

Cognitive decline after invasive intervention in cardiovascular disease: is it drug related?

OBJECTIVE: To identify drugs used to treat cardiovascular disease (CVD) after an invasive intervention that may adversely affect cognitive function. SETTING: Ambulatory care setting. PRACTICE DESCRIPTION: A pharmacy faculty member serves as an ambulatory care preceptor for students at a cardiac rehabilitation and wellness center on the campus of St. Joseph's Hospital, Atlanta, Georgia. Pharmacy services include patient case reviews, consultations, patient education, and therapeutic recommendations. PRACTICE INNOVATION: As part of the advanced practice experience, students are responsible for monitoring drug therapy regimens and conducting medication reconciliations. A literature review of primary sources and education databases was conducted to report cognitive adverse drug reactions associated with cardiac drugs in selective electronic tertiary sources. MAIN OUTCOMES: Documentation of cognitive dysfunction associated with drugs used to treat CVD. RESULTS: Drugs used to treat CVD may be associated with adverse drug effects including short-term memory loss, amnesia, confusion, decreased mental acuity, and impaired concentration. CONCLUSION: Pharmacists providing consultation in the cardiac rehabilitation setting can provide insight into medications that can contribute to cognitive dysfunction.

An active-learning assignment using nonprescription medicines.

OBJECTIVE: To create and implement a web-based written assignment to evaluate student's abilities to select appropriate nonprescription medications and recommend therapy. DESIGN: Each student developed a patient case study from an assigned condition, made treatment recommendations, and provided patient counseling information using at least 2 nonprescription medicines. The active-learning exercise required students to apply information previously presented in a large classroom setting. ASSESSMENT: Cases most commonly submitted included therapy for burns, acne, conjunctivitis, lacerations, and poison ivy. One-hundred five students completed a 5-item questionnaire regarding the assignment. The majority of the respondents (51.9%) felt the assignment helped to reinforce course content and 58.1% felt it made them more comfortable with making product recommendations. CONCLUSION: The Personal Pharmacy assignment was an effective learning activity for enhancing student's understanding and appropriate selection of nonprescription medicines.

Perceived stress and quality of life among doctor of pharmacy students.

OBJECTIVES: To examine stress and health-related quality of life (HRQOL) among third-year doctor of pharmacy (PharmD) students. METHODS: Stress and HRQOL were determined using Perceived Stress and SF-12 HRQOL survey instruments. A questionnaire was administered to determine factors students believed produced and eliminated stress. RESULTS: Eighty percent of third-year students participated (n=109) in this pilot study. Mental HRQOL scores were significantly below US mean score for individuals aged 20-34 years (p<0.0001). As stress increased, mental HRQOL decreased and a significant negative correlation was found between the 2 measures (p<0.001). Family and relationships, examinations and scheduling, outside-of-class assignments, and finances were the most common stress triggers reported by students, while exercising, spending time with friends/family, sleeping, watching TV, and drinking alcohol were the most commonly reported stress-alleviating activities. CONCLUSION: Third-year PharmD students reported relatively high levels of stress and low mental HRQOL. Students employed mostly positive, but some negative, lifestyle choices to alleviate stress. Further investigation into the effectiveness of students' coping strategies is needed.

Vitamins: the wise choice for women with cardiovascular disease.

OBJECTIVE: Enhance the pharmacist's ability to recognize and make treatment recommendations for the safe use of vitamins and supplements for an ambulatory, postmenopausal woman with cardiovascular disease. DATA SOURCES: Literature listed in MEDLINE, IDIS, and PubMED, with emphasis on material published since 2002, were reviewed. An online search of government and proprietary nutrition Web sites as well were reviewed. STUDY SELECTION: Literature reports were selected for their clinical relevance with emphasis on randomized, controlled trials, meta-analyses, cohort studies, and information from the American Heart Association and the Food and Nutritional Board of the Institute of Medicine. DATA EXTRACTION: An outline was developed and literature reports were separated into the categories of vitamins, minerals, and supplements. DATA SYNTHESIS: The primary literature provided information for the use of vitamins, minerals, and supplements, which are popular with older women with chronic disease states. The results included current guidelines that have been established to assist in maintaining good health and to prevent disease in a specific population, those 51 years of age or older. CONCLUSION: When dietary intake is inadequate, a combination of a vitamin preparation, calcium, and an omega-3 preparation can help maintain good health in older women with cardiovascular disease.

Olmesartan medoxomil-induced angioedema.

OBJECTIVE: To report a case of olmesartan medoxomil-induced angioedema in an angiotensin-converting enzyme (ACE) inhibitor-naïve patient. CASE SUMMARY: A 61-year-old white woman with hypertension experienced significant swelling of her face, neck, and lips 10 days after initiation of olmesartan medoxomil 20 mg/day. After discontinuation of the drug, symptoms resolved within 10 days. Use of the Naranjo probability scale indicated a probable association between angioedema and olmesartan medoxomil. DISCUSSION: An angiotensin receptor blocker (ARB) is, in many cases, considered a safe alternative to an ACE inhibitor since serum bradykinin is thought not to be affected. However, angioedema has been reported with the use of ARBs, suggesting alternative pathways or mechanisms that result in this adverse reaction. Although not proven in humans, one explanation is that a secondary stimulation of angiotensin II AT2 receptors produces an increase in tissue bradykinin, resulting in angioedema. CONCLUSIONS: As of February 26, 2007, this is the first published reported case of olmesartan medoxomil-induced angioedema. Practitioners should be aware of this rare but potentially serious adverse event.

N-acetylcysteine and sodium bicarbonate versus N-acetylcysteine and standard hydration for the prevention of radiocontrast-induced nephropathy following coronary angiography.

BACKGROUND: Radiocontrast-induced nephropathy (RCIN) is thought to be caused by renal ischemia and direct toxic effects on renal tubular cells brought on by contrast media. The combination of N-acetylcysteine (NAC) and hydration fluids (NaCl 0.9% or 0.45%) has been shown to reduce these deleterious effects and is commonly given prior to coronary angiography. The use of bicarbonate as the hydration anion has been shown to confer additional RCIN protection compared with that of saline. However, limited data are available regarding whether sodium bicarbonate hydration, proven to be beneficial alone, can further improve outcomes when given with NAC. OBJECTIVE: To compare the incidence of RCIN in patients undergoing coronary angiography after pretreatment with NAC plus sodium bicarbonate hydration or NAC plus standard hydration (NaCl 0.9% or 0.45%). METHODS: A retrospective, single-center study evaluated 96 patients who underwent coronary angiography from January 2002 to December 2005. Data were collected through electronic chart reviews. RESULTS: Forty-seven patients received NAC and sodium bicarbonate for hydration and 49 received NAC and standard hydration. Baseline characteristics between the 2 groups were similar. All patients received at least one 600 mg oral dose of NAC before angiography was performed. RCIN was defined as impairment of renal function occurring within 72 hours of administering contrast media, indicated by an absolute increase in the serum creatinine level of 0.5 mg/dL or more. A total of 12.2% of the patients receiving NAC and standard hydration developed RCIN, versus 14.9% of the patients in the NAC and sodium bicarbonate group (p = 0.713). CONCLUSIONS: The addition of sodium bicarbonate to NAC does not appear to confer additional protection against the development of RCIN. Prospective, randomized, placebo-controlled trials are warranted to definitively determine how this combination compares with NAC and standard hydration in preventing RCIN.

QTc prolongation associated with combination therapy of levofloxacin, imipramine, and fluoxetine.

OBJECTIVE: To report QTc interval prolongation associated with combination therapy including levofloxacin, imipramine, and fluoxetine. CASE SUMMARY: A 49-year-old white female presented to the emergency department with fever, aches, and pains for the past 3 days. She was diagnosed and treated for pyelonephritis in the hospital. Therapy included intravenous levofloxacin 500 mg every 24 hours and ceftriaxone 2 g every 24 hours, along with her medications upon admission, including imipramine 50 mg at bedtime and fluoxetine 10 mg/day. She was discharged after 5 days and returned the next day with chest tightness and shortness of breath. Upon the second admission, a 12-lead electrocardiogram showed a QTc interval of 509 msec. Levofloxacin was discontinued and the QTc interval fell to 403 msec. The patient was discharged 3 days later and instructed to consult with her primary care physician about discontinuing imipramine. DISCUSSION: This adverse drug reaction is thought to be a pharmacodynamic additive effect among fluoxetine, imipramine, and levofloxacin. Fluoxetine is a potent inhibitor of CYP2D6, and imipramine is metabolized by CYP2D6. Therefore, fluoxetine is able to increase the plasma concentrations of imipramine, leading to QT interval prolongation. Taken with imipramine, levofloxacin can lead to even greater prolongation of the QT interval. Based on the Naranjo probability scale, levofloxacin was possibly associated with cardiac arrhythmias in our patient. CONCLUSIONS: The use of levofloxacin alone, or more often in concomitant therapy with other medications that are known to prolong the QT interval, may cause QT interval prolongation; however, additional studies/case reports are needed to validate this conclusion.

Possible association of acute lateral-wall myocardial infarction and bitter orange supplement.

OBJECTIVE: To report a possible incidence of acute lateral-wall myocardial infarction (MI) coinciding with the use of a Citrus aurantium L. (bitter orange)-containing dietary supplement in a patient with undetected coronary vascular disease. CASE SUMMARY: A 55-year-old white woman presented to the emergency department with symptoms of dull aching shoulder and chest pain. A review of medications during cardiac rehabilitation revealed the patient had ingested a multicomponent dietary supplement for weight loss containing 300 mg of bitter orange (Edita's Skinny Pill) for the past year. Although the patient's past medical history did not include hypertension, coronary disease, or hyperlipidemia, an arteriogram revealed a lesion in the left main coronary artery. She did have a smoking history. She was diagnosed with acute lateral-wall MI and hospitalized for 4 days. DISCUSSION: Consumers generally consider dietary supplements safe. However, some supplements taken for weight loss contain ingredients that have been associated with cardiovascular events. Although consumers are becoming more aware of the serious adverse effects secondary to products containing ingredients such as Ma huang and ephedra, reports involving other ingredients are increasing. Bitter orange or synephrine, found in bitter orange, has been associated with adverse cardiovascular reactions. Based on the Naranjo probability scale, C. aurantium is possibly associated with this cardiovascular event. CONCLUSIONS: The use of C. aurantium-containing supplements may present as a risk for cardiovascular toxicity; however, additional studies/case reports are needed to validate this conclusion.