Pharmacist initiation of postexposure doxycycline for Lyme disease prophylaxis.

OBJECTIVES To enhance public access to prophylaxis for Lyme disease following an identified Ixodes scapularis tick bite through pharmacist-initiated antibiotic therapy and to assess patient satisfaction with the pharmacy-based service provided. SETTING Independent community pharmacy in Charlestown, RI, from May to October 2012. PRACTICE DESCRIPTION Under a collaborative practice agreement, trained pharmacists at an independent pharmacy identified patients eligible for postexposure antibiotic prophylaxis following attachment and removal of an I. scapularis tick (commonly known as a deer tick) and dispensed two 100 mg tablets of doxycycline. Patients were included if they were 18 years or older, provided informed consent, had an estimated time of tick attachment of 36 hours or more, had the tick removed within 72 hours of visit, denied contraindications to doxycycline therapy, and reported telephone access for follow-up. Patients enrolled in the study protocol were given counseling related to doxycycline, signs and symptoms of Lyme disease, and future tick prevention strategies. PRACTICE INNOVATION Pharmacist initiation of doxycycline prophylaxis has not been described in the literature previously. Successful pharmacist initiation of antibiotic prophylaxis may have broader implications for states with endemic Lyme disease or other infectious disease public health concerns. MAIN OUTCOME MEASURES Patient self-reported adverse outcomes and satisfaction with the pharmacy-based service. RESULTS Eight patients enrolled in the study and completed the follow-up survey. The results indicated a high level of satisfaction with the pharmacy services provided, with no reports of the subsequent development of Lyme disease symptoms or major adverse events. CONCLUSION The project has expanded to three community pharmacy sites in southern Rhode Island based on this experience. Similar pharmacy-based collaborative practice models should be considered in highly endemic Lyme disease areas.

Use of electronic personal health records to identify patients at risk for aspirin-induced gastrointestinal bleeding.

OBJECTIVE(S): The aim of this paper is to describe the utility of electronic personal health records (ePHRs) to identify patients with potential risk factors for aspirin-induced upper gastrointestinal bleeding (UGIB). SETTING: ER-Card, LLC. a for-profit ePHR company located in Rhode Island from October 2008 to May 2010. PRACTICE DESCRIPTION: Clinical pharmacists reviewed the records of 615 patients enrolled in an ePHR service. Records included patient self-report of all known medical conditions, current prescription medications, and self-care therapies utilized. PRACTICE INNOVATION: Pharmacists reviewed ePHR profiles for actual or potential medication-related problems. Patients taking low-dose aspirin (81 mg-325 mg daily) were screened for known additional risk factors for aspirin-induced UGIB. Patients identified were notified to contact their provider for information and/or providers were contacted directly by pharmacists with therapy recommendations. MAIN OUTCOME MEASURE(S): Number of patients at increased risk for aspirin-induced UGIB as a result of concomitant medications. RESULTS: Ninety-seven patients (16% of total records screened) with an average age of 72.1 years had risk factors for aspirin induced UGIB. In addition to daily aspirin therapy patients reported regular use of nonsteroidal anti-inflammatory drugs or cyclooxygenase-2 inhibitors (38%), other antiplatelet agents (22%), anticoagulants (24%), corticosteroids (4%), or a combination of these medications (12%). None of the patients included in this analysis reported use of prescribed or overthe-counter gastroprotective therapy (such as proton-pump inhibitors or histamine-2 receptor antagonists). CONCLUSION: Pharmacist screening of patient self-reported health information as part of an ePHR service can result in the detection of a significant number of patients at increased risk for aspirin-induced UGIB.

Exploring the Career Engagement, Interests, and Goals of Pharmacy Students Identifying as Underrepresented Racial Minorities.

Objective. To examine pharmacy career engagement, interest, and confidence in Doctor of Pharmacy (PharmD) students identifying as underrepresented racial minorities (URMs).Methods. A 15-item survey about career engagement, confidence, and goals was administered at a business session of a national conference. The survey included demographic items and items about career exposure prior to and during school, career aspirations after graduation, frequency of engagement in various settings, career factors, and career confidence. Cronbach alpha was used to examine survey reliability. Descriptive statistics and nonparametric statistical tests were used to analyze survey responses.Results. Sixty-nine URM students completed the survey. Most indicated frequent engagement with community pharmacy prior to and during school; no engagement with hospital pharmacy prior to school, yet occasional or frequent engagement during school; and no engagement with the pharmaceutical industry prior to and during school. Most selected hospital pharmacy as their career aspiration, followed by community pharmacy and industry. Approximately half indicated an interest in completing a postgraduate fellowship. Items selected as important to career choice included patient care, job security, and level of stress. Group differences were found by gender and year in school.Conclusion. Despite calls for diversity in pharmacy, there is a paucity of research in this area. This study provides a first glimpse into the career engagement, confidence, and goals of students identifying as URMs, raising a number of critical issues for pharmacy education. Moving forward, schools, employers, and researchers must work to better understand the career development of URM students, including barriers and facilitators to access and success.

Effects and generalizability of communally oriented HIV-AIDS prevention versus general health promotion groups for single, inner-city women in urban clinics.

A primary prevention, behavioral intervention designed to reduce HIV risk behavior was tested in a randomized, controlled trial with single, inner-city women. A total of 935 women were randomly assigned to 1 of 3 conditions: a small group, 6-session communally oriented HIV prevention intervention; a yoked general health promotion intervention control; or a standard care control. Both interventions involved the interactive use of videotapes by live group leaders. The HIV prevention intervention, in particular, resulted in significant positive effects on self-reported and behaviorally assessed safer-sex behavior. Women in the HIV prevention group showed reduced point prevalences of medically tested sexually transmitted diseases at follow-up in some comparisons.

Resource loss, resource gain, and emotional outcomes among inner city women.

The authors examined a dynamic conceptualization of stress by investigating how economic stress, measured in terms of material loss, alters women's personal and social resources and how these changed resources impact anger and depressive mood. Resource change in women's mastery and social support over 9 months was significantly associated with changes in depressive mood and anger among 714 inner city women. Greater loss of mastery and social support was associated with increased depressive mood and anger. Loss of mastery and social support also mediated the impact of material loss on depressive mood and anger. Resource loss and worsening economic circumstances had more negative impact than resource gain and improving economic circumstances had positive impact, suggesting the greater saliency of loss than gain.

Improving medication management after a hospitalization with pharmacist home visits and electronic personal health records: an observational study.

BACKGROUND: Substantial opportunity exists to improve medication management in the period following a hospital discharge. The objective of this study was to assess and improve medication management during care transitions through pharmacist home visits and the use of an electronic personal health record (ePHR) system. METHODS: Recently discharged patients aged 50 years or older and having a chronic medical condition were offered the opportunity to meet with a pharmacist in the home setting to review medication instructions and receive a demonstration of an ePHR system. Patients agreeable to using the ePHR system were offered pharmacist support with setting up the ePHR system, having emphasis on documenting and reviewing medication regimens. Medication-related problems identified by the pharmacist during the visit were categorized according to ePHR use and by other characteristics. RESULTS: Thirty recently discharged patients with chronic disease were visited by a pharmacist over a 6-month period. The percentage of medication-related problems identified by the pharmacist was greater among those patients who agreed to use the ePHR system, as compared with patients whose visit did not include use of the ePHR (75% versus 40%, respectively; P=0.06). Differing types of medication-related problems were identified, including therapy duplications, lack of use of clinically important therapies, and patient nonadherence. CONCLUSION: For some patients, the home setting can be a suitable venue for medication review and education after discharge from hospital. Assisting patients with setting up the ePHR system may enhance pharmacists' ability to identify and resolve medication-related problems that may lead to rehospitalization.

Cultural competency in health care and its implications for pharmacy part 3A: emphasis on pharmacy education, curriculums, and future directions.

Culture influences patients' beliefs and behaviors toward health and illness. As the U.S. population becomes more diverse, a critical need exists for pharmacy education to incorporate patient-centered culturally sensitive health care knowledge and skills into the curriculum. Nursing was the first profession to incorporate this type of learning and training into its curriculums, followed by medicine. Pharmacy has also made great progress to revise curriculums, but inconsistency exists in depth, breadth, and methods across pharmacy colleges. This article addresses important aspects of pharmacy education such as curriculum development, incorporation of educational innovations and techniques into the teaching of patient-centered culturally sensitive health care across the curriculum from didactic to experiential learning, assessment tools, and global education. A preliminary model curriculum with objectives and examples of teaching methods is proposed. Future directions in pharmacy education, teaching and learning scholarship, postgraduate education, licensure, and continuing education are also presented.

Cultural competency in health care and its implications for pharmacy Part 3B: emphasis on pharmacy education policy, procedures, and climate.

The Institute of Medicine has stated that greater diversity within health care professionals leads to improved patient outcomes. Therefore, greater diversity within academia and student bodies is required to create future diverse health care professionals. Cultural sensitivity is required from recruitment to physical environment for administrators, faculty, staff, and students. University, college, and department recruitment, search committees, hiring practices, and admissions policies and procedures need to be assessed to determine whether they reflect the applicant pool and patient populations in their regions and whether they are culturally sensitive to a wide variety of cultures. The mission, vision, policies, procedures, curriculums, and environments should also be created or reviewed, modified, and/or expanded to ensure that no administrator, faculty member, staff member, or student is discriminated against or disadvantaged because of cultural beliefs or practices. In addition to discussing the interplay between cultural sensitivity and academic policies, procedures, and environments, this article briefly discusses specific cultural issues related to religion, spirituality, race, ethnicity, gender, age, marital status, veterans, physical, mental, and learning disabilities, and sexual orientation diversity.

Child sexual abuse and adulthood-interpersonal outcomes: Examining pathways for intervention.

We examined a dual pathway, longitudinal mediational model in which child sexual abuse (CSA) influences adulthood-interpersonal functioning and sexual risk through its impact on resiliency resources and psychological distress. Women were recruited from two obstetrics and gynecological clinics serving primarily low-income, inner-city women (N = 693) and interviewed at pretest (Time 1) and 6-month follow-up (Time 2). The proposed mediators were resiliency resources (i.e., self-esteem and self-efficacy) and psychological distress (i.e., depressive and posttraumatic stress symptoms). The interpersonal outcomes were general interpersonal problems (measured via recent loss of interpersonal resources, lack of perceived current social support, and recent social conflict) and HIV/sexual risk (measured via lack of confidence asserting safe-sex practices, intimate-partner risk, and perceived barriers to safe sex). A respecified, partial structural equation model implying full mediation supported our hypotheses. Model fit was assessed using the chi-square goodness-of-fit statistic, comparative-fit index (CFI), root mean square error of approximation (RMSEA), and standardized root mean square residual (SRMR; CFI = .96, RMSEA = .05, SRMR = .04). The impact of CSA on interpersonal problems was mediated through its effect on psychological distress, whereas the impact of CSA on HIV/sexual risk was mediated through its effect on resiliency resources. Implications for intervention are discussed. (PsycINFO Database Record

Aspirin for CV prevention -- for which patients?

Put your patient on aspirin? Take him off? Here's what you need to know to get it right.

Emotional numbing weakens abused inner-city women's resiliency resources.

Conservation of resources theory (S. E. Hobfoll, 1988, 1999) hypothesizes that loss of resiliency resources can contribute to abused women's posttraumatic stress disorder (PTSD) symptoms, which, in turn, contribute to a further loss of resources, which can make abused women even more vulnerable to future stressors. This study investigates the impact of PTSD symptoms on abused women's future loss of resources-resources that women both value and need to aid their ongoing adjustment. Posttraumatic stress disorder symptoms contributed to future resource loss in abused women, even when controlling for the effects of prior resource loss and depression. Emotional numbing symptoms of PTSD accounted most for women's resource loss. Findings highlight the importance of research and intervention that more directly examines the link between emotions and resource loss.

The double-barreled burden of child abuse and current stressful circumstances on adult women: The kindling effect of early traumatic experience.

Child sexual abuse and child physical abuse were compared to assess how these experiences might both positively predict and sensitize women to the effects of current stress exposure, assessed in terms of psychosocial resource loss (e.g., personal and interpersonal resources). Resource loss was in turn, hypothesized to increase later depressive mood and posttraumatic stress disorder severity. Participants were 176 low-income women (58% African American, 38% European American), interviewed twice over 6 months. Child sexual abuse predicted increases in resource loss, which then predicted posttraumatic stress disorder and depressive mood. Women who reported higher levels of child physical abuse were more negatively impacted by resource loss than those who reported lower child physical abuse. Results suggest that child abuse results in both greater stress exposure later and greater vulnerability to that exposure.

The impact of SCHIP enrollment on adolescent-provider communication.

PURPOSE: Effective communication between physicians and adolescents is critical to convey health information, provide counseling and identify emerging health problems. This article addressed two questions: (a) After an adolescent enrolls in a State Children's Health Insurance Program (SCHIP), is there a change reported in communication between the adolescent and his/her health care provider; and (b) Is there a relationship between respondent's characteristics and change observed within specific content areas? METHODS: Adolescent preventive care guidelines developed by national organizations provided the study framework. Surveys were mailed to 3472 12-19-year-olds in a SCHIP; 1689 responded (response rate = 49%). Frequencies described the study population, chi-square analysis explored differences in adolescent-provider communication before and after enrollment, and multiple linear regressions were used to determine relationships between respondents' characteristics and provider communication topics. RESULTS: There were substantial increases after enrollment in SCHIP in the general area of communication between adolescents and their health care providers. Specifically, the presence of a special health care need had a significant influence on most communication areas. Further, females were more likely than males to talk about sexual health (p = .049) and diet and exercise (p < or = .001); older more likely than younger to discuss sexual health (p = .026) and mental health feelings (p = .023); and white more likely than nonwhite to have better overall communication with the provider after enrollment (p = .029) but Whites also were more likely to experience more negative mental health feelings after enrollment in SCHIP (p = .029). CONCLUSIONS: Practice guidelines define the content of preventive services; but, it appears that many adolescents do not receive adequate guidance from their physicians. For the group of adolescents in this study who had recently enrolled in SCHIP, there was a reported increase in their communication with their health care provider. The positive changes in communication suggest that encouraging providers and adolescents to discuss risky behaviors is a feasible, achievable goal.

The impact of communal-mastery versus self-mastery on emotional outcomes during stressful conditions: a prospective study of Native American women.

Past research has examined the stress resiliency of individuals high in sense of personal-mastery. However, it has been theorized that within more collectivist cultures, a sense of shared efficacy, which we call communal-mastery, may be more central to people's resiliency in the face of challenging life circumstances. We compared the impact of sense of self-mastery (ie., "I am the key to my success") to that of communal-mastery (ie., "I am successful by virtue of my social attachments") in a prospective study among a group of rural 103 Native American women residing on Indian Reservations in Montana. We found that women high in communal-mastery experienced less increase in depressive mood and anger, especially when faced with high stress circumstances, than women who were low in communal-mastery. In addition, the beneficial impact of communal-mastery was found to be more effective than self-mastery for these women.