Understanding the association between fatigue and neurocognitive functioning in patients with glioma: A cross-sectional multinational study.

Background: Fatigue and neurocognitive impairment are highly prevalent in patients with glioma, significantly impacting health-related quality of life. Despite the presumed association between these two factors, evidence remains sparse. Therefore, we aimed to investigate this relationship using multinational data. Methods: We analyzed data on self-reported fatigue and neurocognitive outcomes from postoperative patients with glioma from the University of California San Francisco (n = 100, UCSF) and Amsterdam University Medical Center (n = 127, Amsterdam UMC). We used multiple linear regression models to assess associations between fatigue and seven (sub)domains of neurocognitive functioning and latent profile analysis to identify distinct patterns of fatigue and neurocognitive functioning. Results: UCSF patients were older (median age 49 vs. 43 years, P = .002), had a higher proportion of grade 4 tumors (32% vs. 18%, P = .03), and had more neurocognitive deficits (P = .01). While the number of clinically fatigued patients was similar between sites (64% vs. 58%, P = .12), fatigue and the number of impaired neurocognitive domains were not correlated (P = .16-.72). At UCSF, neurocognitive domains were not related to fatigue, and at Amsterdam UMC attention and semantic fluency explained only 4-7% of variance in fatigue. Across institutions, we identified four distinct patterns of neurocognitive functioning, which were not consistently associated with fatigue. Conclusions: Although individual patients might experience both fatigue and neurocognitive impairment, the relationship between the two is weak. Consequently, both fatigue and neurocognitive functioning should be independently assessed and treated with targeted therapies.

Evaluating the Use of Phenobarbital for the Management of Alcohol Withdrawal Syndrome in Psychiatric Inpatients.

OBJECTIVES: To describe the potential role of phenobarbital as appropriate therapy in the treatment and prevention of alcohol withdrawal syndrome (AWS) among medically cleared psychiatric inpatients. METHODS: This was a single-center, retrospective, observational study of adult patients admitted to the psychiatric unit and administered phenobarbital for the treatment or prevention of AWS. Changes in vital signs and signs and symptoms of AWS were observed to assess the safety and efficacy of phenobarbital. The primary outcome was safety of phenobarbital for AWS as measured by change in the respiratory rate (RR). RESULTS: A total of 122 patients were included in the study. There were no significant changes in RR among patients who received phenobarbital for AWS. Significant reductions in blood pressure and heart rate were observed. Of patients with documented signs and symptoms of AWS upon admission, 94% had improvement in the signs and symptoms during phenobarbital therapy. Approximately 12% of patients had documented sedation or altered mental status during phenobarbital therapy. No patients required transfer to a medical or critical care unit. CONCLUSIONS: Phenobarbital was safe, not leading to severe adverse effects or requiring a higher level of care, and efficacious for the prevention and treatment of AWS in this cohort of psychiatric inpatients.

Pharmacy Student Performance in a Capstone Course Utilizing the Pharmacists' Patient Care Process.

Objective. To develop, implement, and assess student performance and confidence in a pharmacy capstone course that used case-based instruction and the Pharmacist's Patient Care Process (PPCP) to develop patient work-up skills in third-year Doctor of Pharmacy (PharmD) students. Methods. A skills-based capstone course was developed by a team of faculty members and instructional designers that focused on patient evaluation skills and applying the steps of the PPCP to complex patient cases housed in a simulated electronic health record (SEHR). The acuity of the cases increased over the course of the semester. For each patient case, students were expected to identify drug-related problems and develop an assessment and plan based on the information provided in the SEHR. Results. Students (n=134) were assessed through weekly quizzes and two practical examinations. The average score for all quizzes was 81%. A significant correlation was found between average quiz scores and performance on the end-of-course practical examination. Student scores significantly improved from the first to the second practical examination (10.4 vs 12.9, respectively), and student confidence with regard to all course objectives significantly improved from the beginning to the end of the semester. Conclusion. A capstone course that applied the PPCP framework successfully taught third-year PharmD students the patient care skills they would need in advanced pharmacy practice experiences.

Using debates as the primary pedagogy to teach critical care in a PharmD curriculum elective course.

BACKGROUND AND PURPOSE: Debate is a pedagogy that incorporates deeper learning and has been used in many areas of healthcare and higher education. Debates have primarily been described within a course, but not as the predominant pedagogy for a course, particularly in pharmacy education or critical care instruction. EDUCATIONAL ACTIVITY AND SETTING: Debating the Evidence was a two-credit hour course taught by debate-style pedagogy on an extended campus to third year pharmacy students in a four-year curricular program. The class met weekly for two hours over 15 weeks, and students came prepared to debate preselected topics. Focus groups for students enrolled over two years were conducted to gauge students' perceptions of this course structure. FINDINGS: The debate-dominant course structure seemed to increase accountability of learning, pre-class preparation, and in-class engagement. Students had difficulty debating with lower quality evidence, but were able to use physiologic reason and adverse effect profiles when robust literature was lacking. All students enrolled over two course offerings consented and participated in the focus groups. Themes identified across both semesters included: 1) efficiency with accessing and evaluating drug literature, 2) increased understanding of an individualized patient-centered approach, and 3) an appreciation for patient care in the acute setting. SUMMARY: An entirely debate-style critical care elective course was perceived to be beneficial to students. Scalability and impact on student learning requires further assessment.

Evaluation of the use of script concordance test in a multicampus psychiatric pharmacy elective course.

INTRODUCTION: Evaluating a student's ability to accept complexity, uncertainty, and ambiguity as part of clinical practice is difficult in a classroom setting using written tests. This study was conducted to explore the feasibility and validation of using a script concordance test (SCT) to evaluate pharmacy student knowledge and clinical competence in a psychiatry elective course. METHODS: This study involved prospective validation of psychiatry-focused SCT questions using a panel of practicing psychiatric pharmacists and retrospective review of student performance on the same SCT questions. The reliability of the SCT was also evaluated using Cronbach alpha coefficient. RESULTS: A total of 13 practicing psychiatric pharmacists participated in the validation phase of the study of 75 questions. Pharmacy student scores (n = 17) averaged 39.79 (±5.02) points, and psychiatric pharmacist scores averaged 50.11 (±4.51) points, representing mean percentages of 61.2% and 77.1%, respectively, on the adjusted exam. The Cronbach alpha was 0.94. DISCUSSION: The development of a valid and reliable SCT to test student psychiatric pharmacy knowledge and clinical competence after taking a psychiatry elective course was feasible.

Neuropsychiatric Symptoms in Dementia: Considerations for Pharmacotherapy in the USA.

Dementia affects all domains of cognition. The relentless progression of the disease after diagnosis is associated with a 98% incidence of neuropsychiatric symptoms (NPS) at some point in the disease, including depression, psychosis, agitation, aggression, apathy, sleep disturbances, and disinhibition. These symptoms can be severe and lead to excess morbidity and mortality. The purpose of this article was to describe current literature on the medication management of NPS of dementia and highlight approaches to and concerns about the pharmacological treatment of NPS in the USA. Guidelines and expert opinion favor nonpharmacologic management of NPS as first-line management. Unfortunately, lack of adequate caregiver training and a high failure rate eventually result in the use of psychotropic agents in patients with dementia. Various psychotropic medications have been studied, although how they should be used in the management of NPS remains unclear. A systematic approach to evaluation, treatment, and monitoring, along with careful documentation and evidenced-based agent and dose selection, is likely to reduce risk and improve patient outcomes. Considerations should be given to the NPS presentation, including type, frequency, and severity, when weighing the risks and benefits of initiating, continuing, or discontinuing psychotropic management. Use of antidepressants, sedative/hypnotics, antipsychotics, and antiepileptic agents should include a clear and documented analysis of risk and benefit in a given patient with dementia.

Rates of new antipsychotic prescriptions and continuation at discharge from a medical unit in a community teaching hospital serving rural counties.

INTRODUCTION: Antipsychotics are commonly used during hospitalization to manage a variety of acute indications and may be inadvertently continued at discharge. The purpose of this study was to identify the rate at which patients admitted to nonpsychiatric units were continued on newly prescribed antipsychotics at discharge from a rural community teaching hospital. METHODS: This study was a retrospective chart review of adult patients admitted to a large community teaching hospital and initiated on an antipsychotic from August 1, 2016, to August 31, 2017. Exclusion criteria were patients admitted to psychiatric or obstetrics/gynecology services, with a diagnosis of a psychotic disorder, or on an antipsychotic prior to hospitalization. The primary outcome measure was the number of new antipsychotic prescriptions during hospitalization that were continued at discharge. Secondary outcomes included antipsychotic characteristics and initiation indications. Descriptive statistics were used to describe antipsychotic use and demographic data. RESULTS: Of 100 patients included, 3 patients were discharged on an antipsychotic. Two patients had questionable indications, and 1 patient had a new psychotic disorder diagnosis. Of all antipsychotics newly initiated during hospitalization, haloperidol was the most commonly prescribed antipsychotic. The majority of doses were scheduled as 1-time or as-needed doses. Approximately 20% of antipsychotics were administered orally. No relevant indication was found for 35% of patients newly initiated on antipsychotics, and documented indications included agitation, psychosis, delirium, and anxiety. DISCUSSION: In an institution that largely serves a rural population, antipsychotic prescribing at discontinuation was not worse than what has been previously reported in other regions of the United States. Limitations for this study include the retrospective nature, single-center study, and small sample size. Although there was a lack of continuation after discharge, there was also a deficit of documentation with 35% of the antipsychotic initiations having no documented indication.

Pain Assessment Documentation After Opioid Administration at a Community Teaching Hospital.

PURPOSE: To compare pain assessment documentation postopioid administration in hospitalized patients before and after implementing nurse education. METHODS: Patients 18 years and older were randomly selected for inclusion if they received 1 opioid dose while admitted to the hospital. Through retrospective chart review, opioid data, including date and time, were collected for each opioid administered. Pain score data, including time and date of documentation, were recorded for analysis. The primary objective of this study was to determine whether a nursing education intervention would improve documentation of pain scores within an appropriate time frame postadministration of an opioid medication. The intervention was a training presentation uploaded to the institution's intranet with an assessment. The primary outcome was measured by comparing the frequency by which nurses documented pain scores following opioid administration before and after education. RESULTS: Three hundred twenty patients (160 patients per time period) were evaluated. The percentage of pain scores recorded within the appropriate assessment time following opioid administration increased from 32.9% to 37.8% ( P = .003). The proportion of appropriate pain score documentation increased 4.9% (95% confidence interval [CI]: 1.6%-8.2%). CONCLUSION: An increase in the documentation of efficacy assessments after opioid administration was demonstrated after nursing education. Further studies should be done to identify additional strategies to increase monitoring as well as to identify a benchmark for institutions with regard to pain management monitoring.

Cases in Psychiatry: A description of a multi-campus elective course for pharmacy students.

Cases in Psychiatry was a multi-campus elective course aimed to expand psychiatry knowledge beyond the required course curriculum. The format of the class included didactic course work, small group discussion of patient cases and article evaluation, submission of written notes, debates, and script concordance test questions delivered via a live online platform. Based on student assessment and feedback at the end of the course, the elective course was determined to meet the prespecified course objectives.

Effect of various antipsychotic regimens on incidence of delirium in critically ill adults.

PURPOSE: Delirium is common during critical illness but it is unknown whether the choice of antipsychotic or dosing strategy impacts delirium outcomes. We evaluated the incidence of delirium in critically ill adults receiving different antipsychotic regimens. MATERIALS AND METHODS: Single center retrospective cohort study of adult patients admitted to the intensive care unit (ICU). Patients who received haloperidol or quetiapine and scored negative on the Confusion Assessment Method for the ICU (CAM-ICU) prior to initiation were included. Patients were divided into four groups based on dosing schedule of the antipsychotic. The primary outcomes were the incidence and duration of delirium. RESULTS: Eighty patients were included in the study. Patients received scheduled quetiapine (35%), PRN haloperidol (55%), and PRN quetiapine (10%). The overall incidence of delirium in patients receiving antipsychotics was 39%. The incidence of delirium was similar between the scheduled quetiapine group, PRN haloperidol and PRN quetiapine groups, at 39%, 50% and 36%, respectively (p=0.79). The scheduled quetiapine group had a longer time to first episode of delirium, but this was not statistically significant (11days vs 4.8days vs 5.6days; p=0.20). CONCLUSIONS: There was no difference in incidence or duration of delirium between quetiapine and haloperidol regimens.