Clinical pharmacy specializations at a school of pharmacy: Development and implementation.

BACKGROUND AND PURPOSE: Specializations within doctor of pharmacy (PharmD) programs allow student pharmacists to advance their knowledge and expertise in a specific area of pharmacy. The purpose of this manuscript is to expand the knowledge of pharmacy specializations within a PharmD program by describing two patient care specializations at a school of pharmacy and their assessment strategies. EDUCATIONAL ACTIVITY AND SETTING: A pediatric pharmacotherapy and acute care pharmacotherapy specialization are described. The development of the specializations and assessment strategies are discussed. Student feedback in addition to postgraduate training and employment in specialization area are used to continually assess the specializations. FINDINGS: Sixty students completed the patient care specializations by completing the specialization coursework, which included extra assignments and a research project. A total of 34 students (57%) who completed the specializations also completed postgraduate year one training. SUMMARY: Patient care specializations allow students to develop skills used in specialty areas, and these added skills may help them be successful in finding postgraduate training related to the specialization. Creating detailed specialization requirements and assessment strategies may ensure that the specialization is of appropriate rigor to enhance specialty-specific skills and knowledge. This report can help other schools of pharmacy with their plans for developing a specialization at their institution.

The Daily Dose: Utilizing WhatsApp to engage pharmacy students in clinical discussion.

BACKGROUND AND PURPOSE: There are many challenges associated with longitudinally applying therapeutic knowledge in the pharmacy curriculum. This study investigated student participation using the messaging platform, WhatsApp (Meta Platforms, Inc.), as a discussion-based platform for pharmacy students. EDUCATIONAL ACTIVITY AND SETTING: The created WhatsApp group chat discussion, "The Daily Dose," was a longitudinal learning experience occurring during pharmacy students' last year of clinical rotations or third year of didactic learning. Students were asked daily clinical questions in the application and participation was primarily assessed. This study included a pre-survey, discussion participation assessment, and a post-survey. The surveys assessed student self-evaluations of their learning, clinical confidence levels, board preparedness, and program learning experience feedback. FINDINGS: A total of 115 questions were asked and 37 students voluntarily joined. Students participated by responding to 97% of questions. Of the 37 students who joined, 81% were experiential education students and 19% were didactic education students. A moderator needed to prompt for participation for 34% of the questions. The majority of students (95%) learned something new. Experiential education students were more likely to participate than didactic education students. A moderator may be beneficial to keep the discussion active. Students' self-evaluations of clinical confidence and board preparedness increased after participating in The Daily Dose. SUMMARY: The Daily Dose is an innovative way to engage student discussion and reinforce pharmacy therapeutic knowledge. This tool could be expanded to use with multiple pharmacy learners.

Creation of a State Drug Shortage Dashboard in the COVID-19 Pandemic.

Purpose: Drug shortages are anticipated to worsen with time as the Coronavirus Disease 2019 (COVID-19) pandemic continues. The aim of this study is to track drug shortages within Illinois and identify causes and trends to this time-sensitive problem. Methods: In order to communicate between health systems within the state, the Illinois Council of Health-System Pharmacists (ICHP) developed a medication shortage dashboard, which collects information from health systems in the state on current drug shortages. Classes of medications inquired about included: anti-infectives, neuromuscular blocking agents (NMBAs), sedatives/analgesics, vasopressors, and "others." Data was gathered from 6 different medication shortage dashboards, ranging from May 20, 2020 to June 22, 2020 and was used to track drug shortages within Illinois. Additionally, this data was analyzed in conjunction with the number of hospital beds utilized by COVID-19 patients at the time. Results: Illinois's medication shortage dashboard tracked the supply level of 42 medications used in the treatment of patient's hospitalized with COVID-19. Data from an average of 75 health systems was analyzed each week (average response rate: 52%). For each medication, health systems identified if they had ample supply, mild shortage, moderate shortage, or critical shortage. Overall the trends of these medications positively correlated with the number of hospital beds utilized by COVID-19 patients in Illinois (r 2 = 0.7). Conclusion: The data from this study supports the conclusion that increased hospital bed utilization by COVID-19 patients is correlated with increased drug shortages of medications used in the treatment of COVID-19. It is imperative that health systems take appropriate action to prevent and manage drug shortages.

Acute Pain Management for Patients with Substance Use Disorder Receiving Buprenorphine or Methadone Compared to Patients without Opioid-Dependence Disorder.

This single-center retrospective study assessed pain management between patients being treated for SUD and compared them to those without SUD who underwent orthopedic surgery. Patients with SUD could be admitted for any reason, while the control arm consisted of patients undergoing total knee arthroplasty or hip arthroplasty surgery. Primary endpoints were average pains scores and morphine milligram equivalents (MME) over the first 48h. Secondary endpoints include adjuvant pain medications and the average MME prescribed upon discharge. A total of the 60 patients were enrolled, 30 patients had history of SUD and 30 patients in the control arm. Average MME between the SUD and control was not significantly different (139.9 mg vs. 96.6 mg, p = 0.889). Average pain scores between the groups were significantly different (7.46 vs. 5.94, p = 0.002). Patients with SUD were not given a statistically different amount of MME for acute pain and experienced higher pain scores than patients without SUD. However, this study had a small population size, and further case-control studies are needed to confirm this result.

Predictors of 30-day hospital readmission: The direct comparison of number of discharge medications to the HOSPITAL score and LACE index.

Effective hospital readmission risk prediction tools exist, but do not identify actionable items that could be modified to reduce the risk of readmission. Polypharmacy has attracted attention as a potentially modifiable risk factor for readmission, showing promise in a retrospective study. Polypharmacy is a very complex issue, reflecting comorbidities and healthcare resource utilisation patterns. This investigation compares the predictive ability of polypharmacy alone to the validated HOSPITAL score and LACE index readmission risk assessment tools for all adult admissions to an academic hospitalist service at a moderate sized university-affiliated hospital in the American Midwest over a 2-year period. These results indicate that the number of discharge medications alone is not a useful tool in identifying patients at high risk of hospital readmission within 30 days of discharge. Further research is needed to explore the impact of polypharmacy as a risk predictor for hospital readmission.

Nivolumab-Associated Acute Demyelinating Encephalitis: A Case Report and Literature Review.

Nivolumab is a checkpoint inhibiting immunotherapeutic agent prescribed for the treatment of resistant cancers. Many immune-related adverse effects including neurological effects have been described, but central nervous system (CNS) toxicities are rarely reported. We present a 59-year-old Caucasian woman with a history of treatment-resistant, progressive, laryngeal squamous cell carcinoma. She received nivolumab and presented with gradual weakness, confusion, and progressive dyspnea. Magnetic resonance imaging of the head showed multifocal cerebral demyelination, primarily involving the parietal lobe. The diagnosis of acute demyelinating encephalitis was made. She improved dramatically after stopping nivolumab and receiving treatment with high-dose intravenous steroid and immunoglobin therapy. We conclude, from this case and literature review, that immune checkpoint inhibitor treatment requires more investigation to determine if autoimmune encephalitis with demyelination can occur as a severe form of immune-related adverse events. CNS toxicity appears to be reversible with prompt cessation of immunotherapy followed by treatment with high doses of steroid with or without intravenous immunoglobulin therapy.

Impact of oral anticoagulants on 30-day readmission: a study from a single academic centre.

Researchers are extensively searching for modifiable risk factors including high-risk medications such as anticoagulation to avoid rehospitalisation. The influence of oral anticoagulant therapy on hospital readmission is not known. We investigated the impact of warfarin and direct oral anticoagulants (DOACs) on all cause 30-day hospital readmission retrospectively in an academic centre. We study the eligible cohort of 1781 discharges over 2-year period. Data on age, gender, diagnoses, 30-day hospital readmission, discharge medications and variables in the HOSPITAL score (Haemoglobin level at discharge, Oncology at discharge, Sodium level at discharge, Procedure during hospitalisation, Index admission, number of hospital Admissions, Length of stay) and LACE index (Length of stay, Acute/emergent admission, Charlson comorbidity index score, Emergency department visits in previous 6 months), which have higher predictability for readmission were extracted and matched for analysis. Warfarin was the most common anticoagulant prescribed at discharge (273 patients) with a readmission rate of 20% (p<0.01). DOACs were used by 94 patients at discharge with a readmission rate of 4% (p=0.219). Multivariate logistic regression showed an increased risk of readmission with warfarin therapy (OR 1.36, p=0.045). Logistic regression did not show DOACs to be a risk factor for hospital readmission. Our data suggests that warfarin therapy is a risk factor for all-cause 30-day hospital readmission. DOAC therapy is not found to be associated with a higher risk of hospital readmission. Warfarin anticoagulation may be an important target for interventions to reduce hospital readmissions.

A Case of Trigger-Point Injection-Induced Hypokalemic Paralysis.

BACKGROUND Trigger-point injection (TPI) therapy is an effective modality for symptomatic treatment of myofascial pain. Serious adverse effects are rarely observed. In this report, we present the case of a 39-year-old man who experienced severe, transient hypokalemic paralysis in the context of TPI therapy with methylprednisolone, bupivacaine, and epinephrine. He was successfully treated with electrolyte replacement in a closely monitored setting. CASE REPORT A 39-year-old man with no past medical history except for chronic left hip pain from a work-related injury received a TPI with methylprednisolone and bupivacaine. The TPI targeted the left iliopsoas tendon and was administered using ultrasound guidance. There were no immediately perceived complications, but within 12 h he presented with severe hypokalemic paralysis with a serum potassium 1.7 mmol/L. Judicious potassium repletion was initiated. Repeated tests after 6 h consistently showed normal potassium levels of 4.5 mmol/L. CONCLUSIONS Severe hypokalemic paralysis in the context of trigger-point injection is an incredibly rare occurrence and this is the first case report in English literature. A high index of clinical suspicion and a systematic approach are therefore required for prompt diagnosis and management of this obscure iatrogenic entity. Clinicians can enhance patient safety by allowing the primary pathology to guide them.

Assessing outcomes of educational videos in group visits for patients with chronic pain at an academic primary care clinic.

OBJECTIVES: This study evaluates the impact of pain education group visits on patients with chronic non-cancer pain (CNCP). The primary outcome of the study was to evaluate patients' functional status and secondary outcomes included knowledge, behavior, and satisfaction, before and after participation in the pain education group visits. METHODS: Locally produced patient educational videos on chronic non-cancer pain were delivered during patient group visits led by a healthcare provider. Study participants included patients with CNCP pain in an academic general medicine practice. The primary outcome was functional status, measured by the Pain Intensity, Enjoyment of life, and General Activity (PEG) score and the Oswestry Disability Index. Secondary outcomes were evaluated through a pre- and post-intervention knowledge assessment and chart review of opioid use and utilization of emergency and urgent care services. A satisfaction survey was administered after each group visit. RESULTS: Thirty-five patient-group visits were analyzed and 14 patient charts reviewed. A moderately positive correlation was observed between PEG and Oswestry Disability Index (r = 0.47, p < 0.05). Patient knowledge improved after watching the videos and participating in group discussion. The median amount of daily morphine equivalents for patients (n = 14) was 17.5mg (range 0-120mg) at the first study, and decreased to 12.5mg (range 0-110mg) at the last study visit (p = 0.39). None of the 14 patients utilized emergency or urgent care services for pain during the study. Overall, patient satisfaction scores with the intervention were high. CONCLUSION: Group visits providing patient education about CNCP may benefit patients' knowledge about this clinical condition, and was received with high patient satisfaction. Further investigation is needed to evaluate longer-term knowledge retention, sustainability of improvements resulting from the intervention, and longer-term effects of the intervention on functional status.

Interprofessional education involving medical and pharmacy students during transitions of care.

The transition of care from hospital to home is susceptible to clinical errors and adverse drug events. Despite this risk and the benefits of an interprofessional approach to patient care, medicine and pharmacy do not often collaborate during transitions of care. The purpose of this study was to evaluate the impact of an interprofessional education experience consisting of medical and pharmacy students performing transitions of care. A total of 88 students (13 pharmacy students and 75 medical students) participated and were surveyed before and after the experience, to evaluate their confidence in performing aspects of the transition of care process as well as their attitudes towards interprofessional care. Pharmacy students had higher baseline levels of confidence compared with the medical students, and both student groups revealed a significantly greater level of confidence in their abilities after the experience. The impact of the experience on students' attitudes towards interprofessional care varied, with medical students showing very little change from baseline and pharmacy students showing improved attitudes in several areas. The results of this study have positive implications for an interprofessional approach to transitions of care while highlighting potential future areas of study.

Protracted hypocalcemia following post-thyroidectomy lumbar rhabdomyolysis secondary to evolving hypoparathyroidism.

Rhabdomyolysis is characterized by skeletal muscle breakdown. It is a potential cause of serious electrolyte and metabolic disturbances, acute kidney insufficiency, and death. Recently, rhabdomyolysis has been increasingly recognized following certain surgical procedures. We discuss the case of a morbidly obese 51-year-old woman who developed postoperative rhabdomyolysis of the lumbar muscles following a prolonged thyroidectomy for a large goiter. We discuss how her morbid obesity, the supine surgical position, the duration of surgery (including prolonged exposure to anesthetic agents), and postoperative immobility contributed to the development of rhabdomyolysis. Immediately after surgery, the patient developed hypocalcemia, which was likely due to rhabdomyolysis since her serum parathyroid hormone level was normal. Later, however, persistent hypocalcemia despite resolution of the rhabdomyolysis raised a suspicion of iatrogenic hypoparathyroidism, which was confirmed by a suppressed parathyroid hormone level several days after surgery. In post-thyroidectomy patients with risk factors for rhabdomyolysis, maintaining a high degree of clinical suspicion and measuring serum creatine kinase and parathyroid hormone levels can allow for an accurate interpretation of hypocalcemia.