Death and dying in pharmacy learners: A critical review.

PURPOSE: This review article is the first comprehensive evaluation of the available literature surrounding the education of death and dying in pharmacy schools. The purpose of this review was to describe the available literature and methods utilized regarding the emotional preparation for patient death in pharmacy education. PROCEDURES: Searches were performed in three pharmacy databases to identify articles that contained descriptions of activities related to death and dying education in pharmacy curriculums. FINDINGS: Eleven journal articles were reviewed, detailing activities in pharmacy education including simulations, didactic sessions, and an innovative "death over dessert" model. Evaluation methods varied, with surveys being most common, followed by reflection. Didactic courses demonstrated increased empathy and knowledge, while simulations compared to case-based activities improved skills, knowledge, and comfort levels with providing end-of-life care. Simulations often involved interprofessional groups, with third-year pharmacy students most evaluated. CONCLUSION: Pharmacy students were mainly exposed to death and dying scenarios through didactic courses or simulations, with limited longitudinal exposure. Research suggests that students may lack preparation for handling death-related situations, leading to trauma and dysfunction. While existing studies focus on outward effects like empathy, internal factors such as coping methods receive less attention. Unlike nursing and medicine literature, pharmacy education lacks comprehensive coverage of coping and emotional support strategies for death and dying scenarios. Additional focus should be placed on intentional incorporation of these topics into pharmacy curriculums.

Improving Student Pharmacists' Learning Through the Use of Pediatric Simulation.

OBJECTIVE: The purpose of this study was to assess the effect of low-fidelity simulation on students' confidence, knowledge, and skills in pediatric physical assessments, and to compare students' interest ratings of topics and effectiveness of learning activities between students' who experienced simulation and those who did not. METHODS: Within a pediatric elective, a vital signs and physical assessment activity was re-designed to incorporate a low-fidelity heart and breath sounds simulator. Students rated their confidence in completing 9 different physical assessment skills before and after the activity and assessment. Students' perspectives of the activity were also assessed. Course evaluation surveys were compared with prior course offerings (without simulation) to determine a change in students' interest ratings of the topic and effectiveness of learning activities. The Wilcoxon signed rank test, thematic analysis, and descriptive statistics were used to analyze outcomes. RESULTS: All 106 second professional year students in the elective completed the pre- and post-simulation surveys and course evaluations for 3 offerings. Students' post-simulation average confidence scores increased statistically on all 9 skills compared with pre-simulation scores. All students agreed or strongly agreed "the lecture and simulation activity done in class helped me overcome challenges I had with learning the skill." Students (98%) successfully demonstrated competency on the formal assessment. Compared with previous course offerings, students reported higher interest ratings in the topics and instruction effectiveness when simulation was incorporated into the activity. CONCLUSIONS: Low-fidelity simulation is an effective teaching and learning approach to increase students' confidence, knowledge, and interest in pediatric vital signs and physical assessment.

Impact of Acid Suppression Therapy on Iron Supplementation in the Pediatric Intensive Care Unit.

OBJECTIVE: We assessed the impact of acid suppression therapy (i.e., ranitidine or proton pump inhibitors) on iron supplementation and its ability to maintain or alter laboratory values that are commonly associated with anemia. METHODS: This was a prospective, observational trial. The primary outcome was changes in serum iron levels from baseline. Secondary outcomes were changes in hemoglobin (Hgb) and hematocrit (Hct), transfusions, and maintenance of an alkalotic gastric pH. RESULTS: Thirty-four patients (mean 24 ± 43 months) met inclusion criteria. The serum iron levels increased to 50.9 ± 24.6 mcg/dL by day 3. The mean difference from baseline was 1.5 mcg/dL (95% CI, 1.14-1.98, p = 0.0056). Gastric pH increased to 4.68 ± 1.49 on day 5. The mean Hgb and Hct increased on day 5 to 10 ± 1.06 g/dL and 29.6% ± 3.27%, respectively. The mean difference of Hgb was 1.15 g/dL (95% CI, 0.51-1.78, p = 0.0009). The mean difference of Hct was 3.04% (95% CI, 1.11-4.97, p = 0.0032). CONCLUSIONS: The use of antacids along with oral ferrous sulfate supplementation did not affect the absorption of iron. Serum iron, Hgb, and Hct all showed statistically significant increases despite combined antacid and iron therapy. Thus, despite use of antacids, combination use showed increases in iron absorption.

An evaluation of community pharmacy recommendations regarding alternating antipyretics in children.

OBJECTIVES: Alternating antipyretics is a common practice despite a lack of quality evidence to support it. Limited efficacy has been demonstrated, but the practice is fraught with potential safety concerns. Many pediatric organizations question the safety of this practice and do not advocate its use. Nonetheless, many physicians and pharmacists routinely recommend alternating acetaminophen (ACET) and ibuprofen (IBU) in children who are febrile. This study assesses the recommendation practices of community pharmacists regarding alternating ACET and IBU in febrile children. METHODS: This was a prospective, noncontrolled, descriptive assessment of the pediatric fever recommendations of pharmacists in the Gulf Coast region: 125 pharmacists were identified and sent surveys. Another 40 pharmacies were randomly chosen to participate in a mock scenario of a child with a fever. The main outcome measure was the number of community pharmacists who recommended alternating ACET and IBU and the instructions given for alternation. RESULTS: Fifty-six pharmacists responded to the survey (45% response rate), and 35 pharmacists participated in the mock scenario. In the survey, 82% of pharmacists indicated that they routinely recommend alternating between ACET and IBU. In the mock scenario 51% of pharmacists recommended alternating. Of the pharmacists recommending an alternating schedule, the recommended schedule varied widely from every 2 hours to every 6 hours. The most common alteration schedule recommended was every 4 hours (29%) in the survey and every 3 hours (37%) in the mock scenario. CONCLUSION: This study elucidated that most of the participating pharmacists in the Gulf Coast region recommend the practice of alternating ACET and IBU to reduce fever in children. Results show that there is a lack of a standardized schedule for alternating, which can lead to caregiver confusion and the possibility of overdosing.

Recommendations for meeting the pediatric patient's need for a clinical pharmacist: a joint opinion of the Pediatrics Practice and Research Network of the American College of Clinical Pharmacy and the Pediatric Pharmacy Advocacy Group.

Children warrant access to care from clinical pharmacists trained in pediatrics. The American College of Clinical Pharmacy Pediatrics Practice and Research Network (ACCP Pediatrics PRN) released an opinion paper in 2005 with recommendations for improving the quality and quantity of pediatric pharmacy education in colleges of pharmacy, residency programs, and fellowships. Although progress has been made in increasing the availability of pediatric residencies, there is still much to be done to meet the direct care needs of pediatric patients. The purpose of this joint opinion paper is to outline strategies and recommendations for expanding the quality and capacity of pediatric clinical pharmacy practitioners by elevating the minimum expectations for pharmacists entering pediatric practice, standardizing pediatric pharmacy education, expanding the current number of pediatric clinical pharmacists, and creating an infrastructure for development of pediatric clinical pharmacists and clinical scientists. These recommendations may be used to provide both a conceptual framework and action items for schools of pharmacy, health care systems, and policymakers to work together to increase the quality and quantity of pediatric training, practice, and research initiatives.

Recommendations for Meeting the Pediatric Patient's Need for a Clinical Pharmacist: A Joint Opinion of the Pediatrics Practice and Research Network of the American College of Clinical Pharmacy and the Pediatric Pharmacy Advocacy Group.

Children warrant access to care from clinical pharmacists trained in pediatrics. The American College of Clinical Pharmacy Pediatrics Practice and Research Network (ACCP Pediatrics PRN) released an opinion paper in 2005 with recommendations for improving the quality and quantity of pediatric pharmacy education in colleges of pharmacy, residency programs, and fellowships. While progress has been made in increasing the availability of pediatric residencies, there is still much to be done to meet the direct care needs of pediatric patients. The purpose of this Joint Opinion paper is to outline strategies and recommendations for expanding the quality and capacity of pediatric clinical pharmacy practitioners by 1) elevating the minimum expectations for pharmacists entering practice to provide pediatric care; 2) standardizing pediatric pharmacy education; 3) expanding the current number of pediatric clinical pharmacists; and 4) creating an infrastructure for development of pediatric clinical pharmacists and clinical scientists. These recommendations may be used to provide both a conceptual framework and action items for schools of pharmacy, health care systems, and policymakers to work together to increase the quality and quantity of pediatric training, practice, or research initiatives.

Importance of direct patient care in advanced pharmacy practice experiences.

The Accreditation Council for Pharmacy Education issued revised standards (Standards 2007) for professional programs leading to the Doctor of Pharmacy degree in July 2007. The new standards require colleges and schools of pharmacy to provide pharmacy practice experiences that include direct interaction with diverse patient populations. These experiences are to take place in multiple practice environments (e.g., community, ambulatory care, acute care medicine, specialized practice areas) and must include face-to-face interactions between students and patients, and students and health care providers. In 2009, the American College of Clinical Pharmacy (ACCP) identified concerns among their members that training for some students during the fourth year of pharmacy curriculums are essentially observational experiences rather than encounters where students actively participate in direct patient care activities. These ACCP members also stated that there is a need to identify effective mechanisms for preceptors to balance patient care responsibilities with students' educational needs in order to fully prepare graduates for contemporary, patient-centered practice. The 2010 ACCP Educational Affairs Committee was charged to provide recommendations to more effectively foster the integration of pharmacy students into direct patient care activities during advanced pharmacy practice experiences (APPEs). In this commentary, the benefits to key stakeholders (pharmacy students, APPE preceptors, clerkship sites, health care institutions, academic pharmacy programs) of this approach are reviewed. Recommendations for implementation of direct patient care experiences are also provided, together with discussion of the practical issues associated with delivery of effective APPE. Examples of ambulatory care and acute care APPE models that successfully integrate pharmacy students into the delivery of direct patient care are described. Enabling students to engage in high-quality patient care experiences and to assume responsibility for drug therapy outcomes is achievable in a variety of practice settings. In our opinion, such an approach is mandatory if contemporary pharmacy education is to be successful in producing a skilled workforce capable of affecting drug therapy outcomes.

Treating Lennox-Gastaut syndrome in epileptic pediatric patients with third-generation rufinamide.

Lennox-Gastaut syndrome (LGS) is a rare but debilitating pediatric epileptic encephalopathy characterized by multiple intractable seizure types. Treatment of LGS is challenging because of the small number of antiepileptic drugs (AEDs) which are effective for this syndrome, as well as the need for polytherapy in the majority of patients. This review focuses on the treatment of LGS with rufinamide, a recently approved third-generation AED with reported efficacy as adjunctive therapy for LGS. All relevant papers identified through a PubMed search on the treatment of LGS with rufinamide were reviewed. To date, the literature suggests improvements in seizure frequency for pediatric patients with LGS on rufinamide. Rufinamide appears to be especially effective for atonic or drop attack seizures. Rufinamide also displays a favorable adverse event profile compared with the older anticonvulsants, as well as a minimal number of drug interactions, making it a promising option for the adjunctive treatment of seizures associated with LGS.

Use of second-generation antiepileptic drugs in the pediatric population.

Epilepsy is common in the pediatric population. Nine second-generation antiepileptic drugs have been approved in the US for use in epilepsy over the past 15 years: felbamate, gabapentin, lamotrigine, topiramate, tiagabine, levetiracetam, oxcarbazepine, zonisamide, and pregabalin. Their use in pediatric patients is fairly widespread, despite most of these agents not having US FDA indications for use. Felbamate and gabapentin were the first two second-generation antiepileptic drugs to be approved in the US. Felbamate use has been limited because of the occurrence of hepatotoxicity and aplastic anemia. Although gabapentin is a fairly well tolerated antiepileptic drug, its use has also been limited as a result of inconsistent efficacy and concern about seizure exacerbation. Lamotrigine and topiramate are broad-spectrum antiepileptic drugs with efficacy in a wide variety of seizure types. Both agents have some tolerability concerns: rash with lamotrigine and neuropsychiatric events with topiramate. There are very little data on tiagabine use in children, but this agent appears to be effective and to have a good tolerability profile. Levetiracetam is a second-generation antiepileptic agent that is available intravenously. Considering its good efficacy, fast onset of action, and low incidence of serious adverse effects, its use in the acute setting could potentially increase. Oxcarbazepine and zonisamide have been relatively well studied in pediatric seizure patients, including use as monotherapy. Both agents have demonstrated good efficacy and tolerability for patients as young as 1 month old. Vigabatrin and rufinamide are currently not available in the US, but have been shown to have some success in other countries. Pregabalin is the newest antiepileptic agent, but lacks pediatric data currently.

Efficacy and economic evaluation of a volume-based cathflo activase protocol versus a fixed-dose alteplase protocol for catheter occlusions in pediatric patients.

OBJECTIVES: This prospective study evaluated the efficacy and economic benefit of Cathflo Activase and a volume-dependent protocol versus a previously utilized fixed-dose 2 mg/mL alteplase aliquot protocol for central venous catheter clearance in pediatric patients. METHODS: All pediatric patients with a medically diagnosed catheter occlusion were eligible for inclusion into this study. Retrospective data was analyzed from an approved data collection form, which had been implemented during the utilization of the alteplase protocol. Data collection indicators included catheter type, dose, dwell time, outcome of attempt (successful or unsuccessful), additional measures taken, and comments. A new protocol utilizing Cathflo Activase and manufacturer recommended volume-based dosing was prospectively implemented and data was collected and evaluated and compared to data from the alteplase protocol. RESULTS: Alteplase and Cathflo protocol data was evaluated for a total of 96 courses in 48 patients (0.09 - 22.8 years, 2.15 - 105.2 kg). Complete resolution was achieved in 69.6% of patients with the alteplase protocol, partial resolution was attained in 8.7%, and treatment failure occurred in 21.7% of patients. For the Cathflo Activase group, complete resolution was observed in 82% of occlusions, with 8% partial resolution and treatment failure of 10%. The average cost per dose utilized by our patients during this study was $49.68 and $30.56 for the alteplase and Cathflo Activase groups, respectively. CONCLUSIONS: Our data indicate that the Cathflo Activase protocol may be as efficacious as the previous alteplase protocol. Furthermore, there are added time and cost benefits.

Intentional topiramate ingestion in an adolescent female.

OBJECTIVE: To describe an intentional topiramate ingestion by an adolescent and warn of the potential for topiramate abuse. CASE SUMMARY: A 17-year-old female intentionally ingested approximately eight 100-mg topiramate tablets for the purpose of "getting high." Soon after ingestion, she was found at school obtunded and nonresponsive. Upon transfer to the emergency department, she became combative and aggressive with evolving neurologic abnormalities including incoherence, confusion, disorientation, and significant speech impairments including echolalia. Approximately 24 hours after ingestion, the patient had completely recovered without requiring specific treatment or experiencing sequelae. DISCUSSION: The clinical effects following acute topiramate intoxication appear consistent with the drug's known pharmacologic properties. There are few other reports of topiramate ingestions and most cases have had mild outcomes. CONCLUSIONS: Due to the multifactorial effects topiramate may have upon the central nervous system and its anorectic effect, abuse of this drug by adolescents should be considered upon presentation of an adolescent with mental status changes.

Antibiotics and breast-feeding: a critical review of the literature.

Continuous breast-feeding, an integral component of the postpartum period, is often threatened upon maternal initiation of antibiotics. The real risk of antibiotic use while breast-feeding must be carefully analysed with regard to all the variables that influence the extent of antibiotic distribution into breast milk, including breast milk composition, physicochemical properties of the antibiotic (molecular weight, lipid solubility, pH, protein binding), length of feeding, and maternal disposition. In addition, infant disposition, including ability to absorb, metabolize, eliminate, and tolerate any amounts of antibiotic, must also be considered prior to maternal administration of antibiotic. The milk to plasma (M/P) ratio is a frequently quoted parameter used to predict drug distribution into breast milk. However, its utility is questionable and often fraught with misinterpretation. An alternative approach when the amount of antibiotic concentration in breast milk is known (through clinical trials) is to calculate an estimated or expected infant drug exposure factoring in known/expected milk consumption, drug concentration and bioavailability. In this review, the following antibiotic classes and current literature regarding their distribution into breast milk are critically reviewed: beta-lactam antibiotics, fluoroquinolones, sulfonamides, macrolides, aminoglycosides, tetracyclines, nitrofurantoin, metronidazole, vancomycin, clindamycin and chloramphenicol. In the majority of instances, these antibiotics do not distribute into breast milk in sufficient concentrations to be of any clinical consequence in the breast-feeding infant.