The prevalence of gender stereotypes in pharmacy student simulated counseling sessions utilizing standardized patients.

INTRODUCTION: Simulation in healthcare has been a widely adopted modality to gain practical experience prior to working directly with patients. While simulation in academic settings affords many opportunities to enhance learning, it may also present an opportunity to identify cultural stereotypes. The objective of this study was to assess the prevalence of gender stereotypes in pharmacy student simulated counseling sessions. METHODS: Simulated counseling sessions completed across several cohorts of pharmacy students were reviewed. A video database of these counseling sessions was manually reviewed retrospectively to determine if students or trained actors portraying the role of the pharmacist and patient, respectively, assigned providers a gender without prompting. Secondary analysis included time to provider gender assignment and acknowledgement. RESULTS: A total of 73 unique counseling sessions were reviewed. Gender was preferentially assigned in 65 sessions. Assigned provider gender was male for all 65 cases. In most (45 out of 65) cases, gender was assigned by the actors. CONCLUSIONS: Predetermined gender stereotypes exist in simulated counseling sessions. Simulation needs to be continually monitored for promoting cultural stereotypes. Integration of cultural competency into counseling simulation scenarios represents an opportunity to better train healthcare professionals to function within a diverse work environment.

The Use of Neuromuscular Blockers to Prevent Shivering in the Setting of Postcardiac Arrest Targeted Temperature Management: A Narrative Review of an Off-Label Indication.

Targeted temperature management (TTM) has become a standard of care over the past two decades for the improvement in neurologic function and mortality in postcardiac arrest patients. There are various mechanisms by which hypothermia helps to improve these outcomes, one of which is by reducing oxygen requirements. Less established is the use of nondepolarizing neuromuscular blockers (NMBs) to prevent shivering during TTM. Shivering can be disadvantageous in this setting as it increases oxygen requirements, which TTM is actively trying to decrease, in an already oxygen-deprived system as well as generates heat making it difficult to maintain hypothermia. Whether NMBs can improve these outcomes is conflicting in the currently available literature and there lacks a consensus on their role in shivering management. The pharmacokinetic and pharmacodynamic responses of these agents may be altered in hypothermic patients, therefore, their standard of monitoring may be unreliable. The accurate dosing and administration of these agents also remain unclear, further complicated by the lack of a standard use protocol. Various studies have been conducted regarding the use of NMBs to prevent shivering in postcardiac arrest patients undergoing TTM; however, it remains an off-label indication requiring further investigation.

A Review of the Food and Drug Administration Adverse Event Reporting System for Tramadol-Related Hypoglycemia.

Background: Hypoglycemia is a rare adverse effect of tramadol that is described in the medical literature and package insert. Objective: The purpose of this study was to review reports of tramadol and hypoglycemia in the Food and Drug Administration Adverse Event Reporting System (FAERS) database to determine a potential association. Methods: Disproportionality analysis with Bayesian correction was used to compare tramadol and hypoglycemia with other medications in FAERS. The results were considered significant if the fifth percentile of the Empirical Bayesian geometric mean distribution (EB05) >2. Logistic regression odds ratios was used to determine if age, diabetes medications, and renal insufficiency masked the disproportionality of hypoglycemia, with the fifth percentile of the logistic regression odds ratio (LR05) >2 indicating a potential signal. The Interaction Signal Score (INTSS) was computed to determine the influence of predisposing risk factors on the signal. Results: A total of 605 cases of tramadol-associated hypoglycemia were reported, but our results were not significant (EB05: 1.590). Tramadol-associated hypoglycemia was significant in patients who did not take diabetes medications (EB05: 2.256; LR05: 2.2104). Renal insufficiency was not found to increase the risk of tramadol-associated hypoglycemia (INTSS: 0.865). There was a significant signal for tramadol-associated hypoglycemia in patients aged 0 to 1 year (LR05: 3.0240) and 2 to 4 years (LR05: 2.6853). Conclusion and Relevance: Results of our analysis suggest a potential signal between hypoglycemia and tramadol use in patients not taking diabetes medications. Our results do not support a predisposition for tramadol-associated hypoglycemia in patients with renal insufficiency, increasing age, and/or diabetes as noted in the tramadol package insert.

Variation between Point-of-care and Laboratory HbA1c testing in Clinical Practice.

OBJECTIVE: The aim of this study was to identify potential disparities between point-of-care testing (POCT) and laboratory hemoglobin A1c (HbA1c) reporting at a Federally Qualified Health Center (FQHC). METHODS: The electronic medical record was reviewed to identify POCT HbA1c done at a FQHC and centralized laboratory venous HbA1c performed on the same day. Manual data extraction was used to identify potential variables that could account for disparities between POCT and laboratory testing. RESULTS: A total of 42 samples in 40 patients were identified. The median HbA1c difference was 1.5 mmol/mol (0.15%) and ranged from -26 to 52 mmol/mol (-2.4 to 4.8%). Of the patients in the study, two had underlying comorbidities that could affect the POCT HbA1c. CONCLUSION: Point-of-care HbA1c testing should not be used in solidarity to diagnosis pre-diabetes and diabetes. When using HbA1c results to guide therapy, self-monitoring of blood glucose and symptoms of both hypo- and hyperglycemia should be correlated to help determine appropriate therapy.

Pharmacologic Interventions for Intractable and Persistent Hiccups: A Systematic Review.

BACKGROUND: Chlorpromazine is the only drug approved by the US Food and Drug Administration for the treatment of hiccups; however, many other pharmacologic treatments have been proposed for intractable and persistent hiccups. Currently, there is little evidence to support the use of one agent over another. OBJECTIVE: This review aims to identify literature concerning the use of pharmacologic treatments for intractable and persistent hiccups with the goal of evaluating therapies in terms of their level of evidence, mechanism of action, efficacy, dosing, onset of action, and adverse effects. METHODS: A systematic literature search of PubMed, Embase, the Cochrane Library, and the New York Academy of Medicine was performed to find articles where a pharmacologic agent was used to treat intractable or persistent hiccups between the years 1966 and 2016. The GRADE method was used to assess the level of evidence for the studies included in this review. RESULTS: This review identified 26 articles involving 10 pharmacologic treatment options that met our inclusion criteria. Amitriptyline, baclofen, gabapentin, haloperidol, metoclopramide, midazolam, nifedipine, nimodipine, orphenadrine, and valproic acid were found in the literature to be successful in treating hiccups. CONCLUSION: Baclofen, gabapentin, and metoclopramide were the only agents that were studied in a prospective manner, while only baclofen and metoclopramide were studied in randomized controlled trials. No specific recommendations can be made for treating intractable and persistent hiccups with the evidence currently available in the literature. Therapy selection should be specific to individual patients, their underlying comorbidities, etiology of hiccups, and take into account the individual properties of the drugs.

Comparing methods of naloxone administration: A narrative review.

The effectiveness and safety of naloxone for the reversal of opioid toxicity are reviewed. A literature search was performed using PubMed, the Cochrane Library, CINAHL, and Medline. Clinical trials comparing either the clinical efficacy or pharmacokinetic/pharmacodynamic properties displayed by intravenous, intramuscular, intranasal, subcutaneous, and nebulized naloxone were included; however, trials with primary endpoints evaluating oral or endotracheal naloxone were excluded. Naloxone was shown to be clinically effective via all routes of administration, when compared to either baseline or control. The inconsistencies in data regarding the relative outcome comparisons between administration methods were likely due to differences in concentrations of naloxone preparations and method of administration for the same route of delivery between different studies. Choice of route depends on the environment in which the opioid toxicity occurs, individual patient characteristics, and provider preference.

Delayed cardiac dysrhythmias after fingolimod administration.

A 51-year-old woman with relapsing-remitting multiple sclerosis was initiated on fingolimod. She developed a Mobitz Type I (Wenckebach)second-degree atrioventricular (AV) heart block during the initial 6-hour monitoring. She was transferred to the emergency department for further monitoring, where she went into a junctional tachycardia then went back into a Mobitz Type I AV block. The patient was symptomatic with a heart rate nadir of 38 beats per minute and treated with atropine. Junctional tachycardia has not been previously reported with fingolimod use. Patients may require extended cardiac monitoring after fingolimod administration.

Hemorrhagic gastritis with dabigatran in a patient with renal insufficiency.

BACKGROUND: Dabigatran etexilate is the first oral direct thrombin inhibitor approved in the United States. Unlike warfarin, dabigatran has no known antidote. Providers should be aware of patients that may be at risk for dabigatran coagulopathies and recognize potential treatment options. OBJECTIVE: To report a case of hemorrhagic gastritis in a patient with chronic renal insufficiency recently initiated on dabigatran etexilate. CASE SUMMARY: An 85-year-old white man with a known history of hypertension and stage III chronic kidney disease presented to the Emergency Department complaining of dark stools, shortness of breath, and abdominal pain. The patient recently started dabigatran 150mg twice daily for new-onset atrial fibrillation. An upper gastrointestinal endoscopy identified non-specific gastritis with hemorrhage. It was determined to be probable using the Naranjo Probability Scale that gastrointestinal hemorrhaging was a result of dabigatran therapy. Fresh frozen plasma was used to reverse the dabigatran-induced coagulopathy. CONCLUSION: This case highlights the challenges that providers may face when dealing with life-threatening bleeding in patients receiving dabigatran.