Acquired Thrombophilia.

Acquired thrombophilia is associated with an increased risk of venous thromboembolism (VTE). Antiphospholipid syndrome (APS) is the most prevalent acquired thrombophilia and is associated with both venous and arterial thromboses. Human immunodeficiency virus (HIV) is another form of acquired thrombophilia. Risk factors associated with VTE in this population include those related to the disease itself, host factors, and the pharmacotherapy for HIV. A significant proportion of VTE events occur in patients with malignancies. There is an increase in mortality associated with patients having cancer who experience VTE when compared to patients having cancer without VTE. Combination oral contraceptive (COC) use infers risk of thromboembolic events. The risk is dependent upon the presence of an underlying inherited thrombophilia, the estrogen dose, and generation of progestin. Patients at highest risk of VTE include those receiving high-dose estrogen and fourth-generation, progesterone-containing contraceptives. With the exception of APS, thrombophilia status does not alter the acute treatment of an initial VTE in nonpregnant patients.

Pregnancy-Related Venous Thromboembolism.

Pregnancy is associated with an increased risk of venous thromboembolism (VTE), with a reported incidence ranging from 0.49 to 2 events per 1000 deliveries. Risk factors include advanced maternal age, obesity, smoking, and cesarian section. Women with a history of previous VTE are at a 4-fold higher risk of recurrent thromboembolic events during subsequent pregnancies. Additionally, the presence of concomitant thrombophilia, particularly factor V Leiden (homozygosity), prothrombin gene mutation (homozygosity), or antiphospholipid syndrome (APS), increases the risk of pregnancy-related VTE. Low-molecular-weight heparin (LMWH) and unfractionated heparin (UFH) are the drugs of choice for anticoagulation during pregnancy. LMWH is preferred due to ease of use and lower rates of adverse events. Women with high thromboembolic risk particularly those with a family history of VTE should receive antepartum thromboprophylaxis. Women with low thromboembolic risk or previous VTE caused by a transient risk factor (ie, provoked), who have no family history of VTE, may undergo antepartum surveillance. Postpartum anticoagulation can be considered in women with both high and low thromboembolic risk.

Inherited Thrombophilia.

Thrombophilia alters normal hemostasis, shifting the balance in favor of thrombus formation. Inherited conditions include factor V Leiden (FVL), prothrombin G20210A mutation, deficiencies in natural anticoagulants (antithrombin [AT], protein C, and protein S), hyperhomocysteinemia, and elevations in clotting factors (factors VIII and XI). Although FVL and prothrombin mutation are common disorders, deficiencies in the natural anticoagulants are rare. The risk of initial thrombosis conferred by inherited thrombophilia varies with the highest risk in those homozygous for either FVL or prothrombin mutation, or with AT deficiency. In the nonpregnant patient, the presence of a thrombophilia does not affect treatment of an acute event. Although vitamin B supplementation has been shown to decrease the levels of homocysteine, the treatment has failed to show a benefit in thrombus prevention and is therefore not recommended.

Thrombophilia Screening.

Although controversial, screening for thrombophilia has become common. Testing for antiphospholipid antibodies is indicated in order to guide treatment decisions if there is clinical suspicion for antiphospholipid syndrome. The utility of identifying other thrombophilias in symptomatic venous thromboembolism (VTE) is questionable, as the risk of recurrence does not appear to be increased by an appreciable degree with the most common disorders (heterozygosity for factor V Leiden or prothrombin mutation). Although recurrence appears to be increased in those with homozygous or multiple abnormalities and potentially deficiencies in natural anticoagulants, screening to detect these conditions is difficult to justify based on their rarity. The American College of Chest Physicians' current guidelines note the increased risk of recurrence with idiopathic, proximal events regardless of thrombophilia status. They suggest duration of anticoagulation therapy be based on location and provoking factors rather than whether or not the individual has a thrombophilia. Because routine prophylaxis in asymptomatic individuals with thrombophilia is not recommended, screening of asymptomatic family members is difficult to justify. Screening prior to prescribing combination oral contraceptives is not cost effective, may result in unwanted pregnancies, and may have little effect on the overall rate of VTE.

A quality improvement course review of advanced pharmacy practice experiences.

OBJECTIVES: To determine strengths of and quality improvements needed in advanced pharmacy practice experiences (APPE) through a systematic course review process. DESIGN: Following the "developing a curriculum" (DACUM) format, course materials and assessments were reviewed by the curricular subcommittee responsible for experiential education and by key stakeholders. Course sequence overview and data were presented and discussed. A course review worksheet was completed, outlining strengths and areas for improvement. ASSESSMENT: Student feedback was positive. Strengths and areas for improvement were identified. The committee found reviewing the sequence of 8 APPE courses to be challenging. CONCLUSIONS: Course reviews are a necessary process in curricular quality improvement but can be difficult to accomplish. We found overall feedback about APPEs was positive and student performance was high. Areas identified as needing improvement will be the focus of continuous quality improvement of the APPE sequence.

Survey of patient knowledge related to acetaminophen recognition, dosing, and toxicity.

OBJECTIVE: To assess patient knowledge regarding acetaminophen dosing, toxicity, and recognition of acetaminophen-containing products. DESIGN: Descriptive, nonexperimental, cross-sectional study. SETTING: Alabama, January 2007 to February 2008. PATIENTS: 284 patients at four outpatient medical facilities. INTERVENTION: 12-item investigator-administered questionnaire. MAIN OUTCOME MEASURES: Degree of patient knowledge regarding acetaminophen safety, dosing recommendations, toxicity, alternative names and abbreviations, and products. RESULTS: Two-thirds of the 284 patients completing the survey reported current or recent use of pain, cold, or allergy medication. Of these, 25% reported knowing the active ingredient. Of patients, 46% and 13% knew that "acetaminophen" and "APAP," respectively, were synonymous with "Tylenol." Several patients (12%) believed that ingesting a harmful amount of acetaminophen was difficult or impossible. One-third of patients correctly identified the maximum daily dose, 10% reported a dose greater than 4 g, 25% were unsure of the dose, and 7% were unsure whether a maximum dose existed. One-half recognized liver damage as the primary toxicity. Results were similar between acetaminophen users and nonusers. CONCLUSION: Deficiencies were found in patient knowledge regarding acetaminophen recognition, dosing, and potential for toxicity. The development of effective educational initiatives is warranted to ensure patient awareness and limit the potential for acetaminophen overdose.

Survey of physician knowledge and counseling practices regarding acetaminophen.

OBJECTIVE: To assess physician knowledge regarding acetaminophen dosing, toxicity, and recognition of acetaminophen-containing products and counseling practices when prescribing acetaminophen-containing medications. METHODS: Resident and faculty physicians at 1 internal medicine and 2 family medicine residency programs in Alabama were asked to participate in a voluntary survey. Participants completed a 7-item self-administered questionnaire. Questions were designed to assess physician knowledge of acetaminophen dosing and toxicity, recognition of prescription and over-the-counter products containing acetaminophen, and education provided to patients when prescribing acetaminophen-containing products. Questions were formatted as multiple choice, yes/no, true/false, and short answer. Certain items contained an answer choice of "unsure." RESULTS: Of the 76 physicians who completed the survey, only 76% were aware of the maximum daily dose of acetaminophen. Although 93% recognized Lortab and 90% Percocet as acetaminophen-containing products, only 83% identified Lorcet and 75% Darvocet. More than 90% of physicians correctly identified nonacetaminophen prescription medications with the exception of OxyContin (84%) and Ultram (79%). Knowledge of over-the-counter products was generally less accurate. Ninety-eight percent recognized hepatotoxicity as the primary toxicity. Although 72% of physicians stated they provide specific instructions to patients when prescribing acetaminophen-containing medications, the information provided was limited. CONCLUSIONS: Many physicians are unaware of acetaminophen dosing and toxicity issues and have some difficulty identifying acetaminophen-containing products. Information provided by physicians when prescribing acetaminophen products was limited. How this may contribute to unintentional acetaminophen overdose is unclear but should raise concern. These results reinforce the importance of public awareness, patient counseling, and physician education regarding acetaminophen toxicity issues.

An anticoagulation therapy elective for third-year pharmacy students.

OBJECTIVE: To develop an anticoagulation elective course for third-year pharmacy students to enhance their knowledge and skills for providing anticoagulation services. DESIGN: Content developed for the course focused on standards of care, evaluation of primary literature, clinical application, billing and regulatory issues, written and verbal communication, and patient education. Teaching methods included lectures, discussions, demonstrations, and self-directed learning. ASSESSMENT: Assessment methods included multiple-choice examinations, evaluation of patient cases, student presentations, and a practical examination. Students demonstrated competencies in multiple areas and rated the course favorably. Students who completed the elective reported being more prepared for anticoagulation activities than those who did not. Confidence levels regarding participation in anticoagulation services postgraduation were similar. CONCLUSION: The elective provided valuable experience in anticoagulation therapy and increased students' perception of their preparedness related to dealing with anticoagulation issues while on advanced pharmacy practice experiences (APPEs). More exposure to management topics and the logistics of initiating anticoagulation services should be incorporated.

Complementary and alternative medications for women's health issues.

Women often seek alternative treatment options such as herbs, dietary supplements, and vitamins and minerals to treat women's health issues across the lifespan. Women may use complementary and alternative supplements for dysmenorrhea, premenstrual syndrome, infertility, nausea and vomiting during pregnancy, and symptoms of menopause. In general, there is a deficit of well-designed, randomized, controlled trials to evaluate the efficacy and safety of complementary and alternative medicine for these indications, which makes it difficult to provide evidence-based recommendations. This review outlines the evidence for efficacy and safety that is currently available for dietary supplement use by women to manage health conditions specific to the female patient.

Potential interaction between warfarin and high dietary protein intake.

A 55-year-old Caucasian man was receiving warfarin therapy after undergoing aortic valve replacement. His international normalized ratio (INR) was stabilized with warfarin 95 mg/week for 5 weeks. Commencement of a low-carbohydrate, high-protein diet resulted in a series of subtherapeutic INRs that led to a 16% increase in the dosage requirement to maintain therapeutic INRs. After the patient discontinued the diet, his INR increased, and several dosage reductions were required until his INR stabilized with his original dosage of 95 mg/week. Two additional case reports have described a possible interaction between warfarin and a high-protein diet. The potential for increased dietary protein intake to raise serum albumin levels and/or cytochrome P450 activity has been postulated as mechanisms for the resulting decrease in INRs. Given the available animal and human data that demonstrate alterations in drug metabolism in the presence of altered dietary protein intake, an increase in warfarin metabolism due to cytochrome P450 activation appears to be the most likely cause. In addition to the previously reported cases, this case indicates a potential interaction between warfarin and a high-protein diet. Because of the popularity of high-protein diets and because of the risks associated with inadequate or excessive warfarin anticoagulation, patients and health care providers should be aware of this interaction to ensure appropriate monitoring when warranted.