Educational content and strategies to support nurses from culturally and linguistically diverse backgrounds caring for patients considering voluntary assisted dying: The Australian experience.

OBJECTIVES: Drawing on findings from a qualitative study that aimed to explore the knowledge and attitudes of nurses from culturally and linguistically diverse (CALD) backgrounds about voluntary assisted dying (VAD). The study also aimed to identify the strategies that assist nurses in their readiness and preparation for exposure to VAD. This paper reports on the educational content and strategies that could assist nurses from CALD backgrounds to be better prepared when they encounter VAD requests. BACKGROUND: Around the world, healthcare professionals have roles to play in caring for patients requesting voluntary assisted dying. Nurses, particularly those from diverse geographic and clinical settings, have voiced inadequate knowledge and understanding about voluntary assisted dying. DESIGN: A qualitative descriptive approach was undertaken. METHODS: Data collection involved one focus group and 16 in-depth interviews. A total of 21 nurses from CALD backgrounds were recruited from one Australian state. Thematic analysis was conducted to interpret the data. FINDINGS: Nurses identified their knowledge gaps and specified the need for education and workplace training on VAD, its legal and ethical aspects, clarity on their role, communication techniques and how VAD intersects with their practice. They suggested various teaching strategies that could prepare nurses to work safely and confidently in a clinical environment where voluntary assisted dying is an option for patients. CONCLUSION: Given the high number of nurses from diverse backgrounds working in the Australian health sector, these nurses need to be fully prepared to care for patients requesting VAD.

NPH Insulin Versus Insulin Glargine Versus NPH Insulin Plus Insulin Glargine for the Treatment of Dexamethasone-Induced Hyperglycemia in Patients With COVID-19: A Retrospective Cohort Study.

Background: Dexamethasone use in patients hospitalized with COVID-19 significantly reduces mortality; however, it commonly results in hyperglycemia. Optimal treatment of dexamethasone-induced hyperglycemia is not well established. Objective: The study purpose was to assess the difference in blood glucose (BG) control between insulin glargine, neutral protamine hagedorn (NPH) insulin, and insulin glargine plus NPH insulin for dexamethasone-induced hyperglycemia in patients with type 2 diabetes (T2DM) and COVID-19 infection. Methods: This retrospective study was conducted in adult inpatients with T2DM and COVID-19 infection who received 6 mg of dexamethasone once daily and insulin during the 5-day study period. The primary outcome was the difference in mean point-of-care (POC) BG levels between study insulins. Secondary outcomes included the incidence of hyperglycemia and hypoglycemia, length of stay, and the percent difference between the mean daily inpatient and home basal insulin doses (for patients who were receiving basal insulin prior to admission in the insulin glargine and insulin glargine and NPH insulin groups only). Results: Ninety-six patients were included in the analysis (67 insulin glargine, 10 NPH insulin, and 19 insulin glargine plus NPH insulin). The difference in mean POC BG level was not different among groups (254 ± 60 mg/dL vs 234 ± 39 mg/dL vs 250 ± 51 mg/dL, respectively; P = 0.548). There were no significant differences in the secondary outcomes. Conclusions: No difference in the mean POC BG level was observed. Dexamethasone-induced hyperglycemia was poorly controlled in patients with T2DM and COVID-19 infection.

Elevated International Normalized Ratio Due to Apixaban in Patient With End-Stage Renal Disease on Hemodialysis.

Apixaban is known to prolong international normalized ratio (INR) per some observational and in vitro studies. In patients with elevated INR secondary to apixaban use, median INR of 1.4-1.7 has been reported. Extreme elevation in INR is rare with apixaban. In patients with end-stage renal disease (ESRD) on hemodialysis (HD), there are no labeled indications for apixaban use; however, there are some pharmacokinetic data supporting its use in such patients. We present a case of a 68-year-old Hispanic man with ESRD who presented to the emergency room (ER) with INR of 27.42. INR testing was done as a part of routine workup in rehabilitation facility. Medication list was reviewed and included apixaban 2.5 mg twice daily which was recently started for postoperative thromboprophylaxis. INR testing was repeated for confirmation in ER and was reported as >18.5 and prothrombin time >200 seconds. His liver function tests were stable as compared to baseline testing five days ago with normal bilirubin, low normal transaminases, and mild hypoalbuminemia. The patient didn't have any active bleeding. An elevation of INR to >20 with apixaban is a rare event. No other factors including patient characteristics, laboratory results, co-existing conditions, or other medications except the direct oral anticoagulant (DOAC) were found to be responsible for elevated INR. Liver cirrhosis or vitamin K deficiency as cause for INR elevation was ruled out as the baseline INR was normal prior to starting apixaban, liver function tests were stable and INR normalized again shortly after discontinuing the medication. Plasma concentration of DOACs has been found to be correlating with the INR according to a pharmacokinetic study which potentially means that the high INR likely was secondary to high serum concentration of apixaban in this patient. However, INR monitoring is not recommended for monitoring anticoagulant activity of DOACs. As of note, renal clearance accounts for 27% of apixaban clearance. Pharmacokinetic studies have concluded that half dose apixaban, i.e., 2.5 mg twice daily in patients on hemodialysis (dose used in this case) results in drug exposure similar to that of the standard dose of 5 mg twice daily in patients with preserved renal function. Future studies are necessary to address questions about safety of DOACs in patients with ESRD, further elucidate the clinical significance of such high INR values associated with DOACs, and establish appropriate management guidelines. Andexanet alfa has since been approved for apixaban reversal in patients with life-threatening bleeding; however, would not be indicated in such cases when there is no evidence of bleeding.

Inmates Care: Computer-Based Training for Geriatric and End-of-Life Care in Prisons.

The growing aged and dying incarcerated population increases demands on corrections health care. People who are incarcerated can assist in care delivery; however, currently, their training is typically face-to-face, home grown, and variable in content and duration. Six focus groups conducted with peer caregivers (PCs) (n = 12) and staff (n = 15) identified priority training topics. Three prototype modules (Standard Precautions; Loss and Grief; and Role of the Inmate Caregiver in the Final Hours) were developed in consultation with an advisory board. Face-to-face usability testing with (n = 20) PCs and staff confirmed contextual relevance and feasibility of the Inmates Care training. The mean system usability score for all participant segments was 86.5. Inmates Care holds promise to complement nurse-led training with a standardized e-training package.

Estimation of the Prevalence of Antimicrobial Resistance in Badgers (Meles meles) and Foxes (Vulpes vulpes) in Northern Ireland.

Antimicrobial resistant (AMR) bacteria can be shared between humans and animals, through food, water, and the environment. Wild animals are not only potential reservoirs of AMR, but are also sentinels mirroring the presence of AMR zoonotic bacteria in the environment. In Northern Ireland, little is known about levels of AMR in bacteria in wildlife, thus the current study aimed to estimate the prevalence of AMR bacteria in wildlife using wildlife species from two ongoing surveys as a proxy. Nasopharyngeal swabs and faecal samples from European badgers (Meles meles) (146 faecal samples; 118 nasal samples) and red foxes (Vulpes vulpes) (321 faecal samples; 279 nasal samples) were collected throughout Northern Ireland and were used to survey for the presence of extended spectrum beta lactamase resistant and AmpC-type beta lactamases Escherichia coli (ESBL/AmpC), Salmonella spp. (only in badgers) and methicillin resistant Staphylococcus aureus (MRSA). ESBLs were detected in 13 out of 146 badger faecal samples (8.90%) and 37 out of 321 of fox faecal samples (11.53%), all of them presenting multi-drug resistance (MDR). Fourteen out of 146 (9.59%) badger faecal samples carried Salmonella spp. [S. Agama (n = 9), S. Newport (n = 4) and S. enterica subsp. arizonae (n = 1)]. Overall, AMR was found only in the S. enterica subsp. arizonae isolate (1/14, 7.14%). No MRSA were detected in nasopharyngeal swabs from badgers (n = 118) and foxes (n = 279). This is the first attempt to explore the prevalence of AMR in the two common wildlife species in Northern Ireland. These findings are important as they can be used as a base line for further research exploring the origin of the found resistance. These results should encourage similar surveys where environmental samples are included to bring better understanding of AMR dynamics, and the impact on wildlife, domestic livestock and humans.

Adjunctive Phenobarbital for Alcohol Withdrawal Syndrome: A Focused Literature Review.

OBJECTIVE: To review the literature describing the use of adjunctive phenobarbital in the treatment of severe alcohol withdrawal syndrome (AWS). DATA SOURCES: PubMed and EMBASE were searched using the following terms: phenobarbital, adjunct, refractory or treatment resistant, severe or complicated, and alcohol withdrawal delirium or alcohol withdrawal seizures. STUDY SELECTION AND DATA EXTRACTION: The search was limited to randomized controlled trials (RCTs) and cohort studies published in English. DATA SYNTHESIS: Seven studies were identified in the emergency department (ED; RCT, n = 1; cohort, n = 2), general medicine ward (cohort, n = 1), and intensive care unit (ICU; cohort, n = 3) settings. For all studies set in the ED and general medicine ward and for 1 ICU study, phenobarbital plus symptom-guided benzodiazepine therapy was compared to symptom-guided benzodiazepine monotherapy. The other 2 ICU studies examined adjunctive phenobarbital before and after implementation of a protocol, meaning patients in both arms could have received phenobarbital. Overall risk of bias across all studies was low to moderate. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE: The specific role of adjunctive phenobarbital in AWS is not clear because a majority of studies are retrospective cohorts with varying primary outcomes in different patient care settings. CONCLUSIONS: In the ED and general medicine ward, phenobarbital demonstrated benzodiazepine-sparing effects. In the ICU, when a protocol guides phenobarbital use, the need for mechanical ventilation may be reduced. Adjunctive phenobarbital was well tolerated. Because of study limitations, it is challenging to provide specific recommendations for adjunctive phenobarbital use in severe AWS.

Mitochondrial donation - hope for families with mitochondrial DNA disease.

In 2015, the UK became the first country to approve the use of mitochondrial donation. This novel in vitro fertilisation treatment was developed to prevent transmission of mitochondrial DNA (mtDNA) disease and ultimately give more reproductive choice to women at risk of having severely affected offspring. The policy change was a major advance that surmounted many scientific, legislative and clinical challenges. Further challenges have since been addressed and there is now an NHS clinical service available to families with pathogenic mtDNA mutations that provides reproductive advice and options, and a research study to look at the outcome at 18 months of children born after mitochondrial donation.

Interviewer perceptions during the implementation of the multiple mini-interview model at a school of pharmacy.

INTRODUCTION: Studies reveal positive interviewer perceptions of multiple mini-interview (MMI) upon MMI completion. No studies evaluate change in interviewer perceptions during MMI implementation. The objective was to evaluate the change in interviewer perceptions during the implementation of the MMI model at the University of Toledo College of Pharmacy and Pharmaceutical Sciences. METHODS: Interviewers (faculty volunteers, preceptors, student pharmacists) were eligible for inclusion in the prospective cohort. Consenting individuals (1) completed a pre-MMI training survey regarding perceptions of MMI, (2) participated in a 90-minute MMI training program (PowerPoint presentation and review of videos demonstrating MMI practices), (3) completed a post-MMI training survey, and (4) after interviews, completed a post-interview survey. The six Likert-scale MMI perception questions were independently analyzed for changes in the rank response across the three survey time points using Friedman's nonparametric repeated-measures analysis. Each question was evaluated for all respondents together, and for nine different respondent subgroups. The overall criteria for significance was α = 0.05 for each question, with Bonferroni correction for the ten overall comparisons made for each question. RESULTS: Thirty-two interviewers participated (20 faculty members, five preceptors, and seven student pharmacists). From the pre-MMI training survey through the post-interview survey, interviewers gained confidence in their ability to explain the rationale behind the MMI model, were more likely to agree that six minutes was adequate time to assess an applicant and believed MMI provides a fair assessment of an applicant's noncognitive attributes. CONCLUSIONS: After interviewers received training and gained experience with MMI, perceptions of MMI improved.

Barriers to and Strategies for Gaining Entry to Correctional Settings for Health Research.

Conducting research in corrections can contribute to improved individual and public health. Challenges to gaining entry to correctional settings to conduct research can impede research productivity, delay the launch of studies and inhibit researchers from proposing health research in corrections. The purpose of this paper is to share lessons learned from a large-scale corrections research project designed to develop computer-based learning modules to train front-line corrections personnel about geriatric and end-of-life care. Key lessons learned include the importance of building a team of experts, planning and punting, coordinating with institutional review boards and examining denied applications to inform future planning. To be effective in a correctional setting, leaders in nursing research and corrections nursing must work together within the contextual nature of prisons and jails to advance evidence-based practices for this vulnerable population. These lessons serve to establish best practices on how to access correctional settings and to enable more research in corrections.

Impact of the implementation of a pharmacist-driven chronic obstructive pulmonary disease exacerbation orderset in an inpatient setting.

PURPOSE: The Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines provide recommendations for the management of chronic obstructive pulmonary disease (COPD) exacerbation. Studies have demonstrated shortened hospital length of stay (LOS) with use of guideline-adherent systemic corticosteroid therapy. There are no published studies evaluating the impact of an inpatient orderset on patient-oriented outcomes. METHODS: This institutional review board-approved, retrospective, quasi-experimental, single-center cohort study included adult patients admitted to an internal medicine service for a documented COPD exacerbation from January 2014 through December 2015 (the pre-orderset group) or January 2017 through December 2018 (the post-orderset group). A pharmacy and therapeutics committee-approved orderset recommending guideline-adherent treatment with systemic corticosteroids, scheduled short-acting bronchodilators, and antibiotics was used in the post-orderset group. The primary outcome was hospital LOS. Secondary outcomes included 30-day all-cause and COPD-related readmission rates, systemic corticosteroid-related adverse events, and antibiotic use. RESULTS: A total of 358 unique patient encounters were identified for the pre-orderset group (n = 220) and post-orderset group (n = 138). The mean (SD) hospital LOS was significantly shorter in the post-orderset group (3.4 [2.4] days vs 4.3 [3.0] days; P = 0.004). There were no significant between-group differences in rates of 30-day all-cause and COPD-related readmissions. The overall rate of antibiotic use was lower in the post-orderset group vs the pre-orderset group (71% vs 90.2%; P < 0.001). The rate of occurrence of new blood glucose elevation was significantly lower in the post-orderset group (49.3% vs 79.1%; P < 0.001), with no significant between-group difference in occurrence of new blood pressure elevation. CONCLUSION: A significant reduction in hospital LOS was found with the implementation of a pharmacist-driven COPD exacerbation orderset.

Impact of a Pharmacy-Initiated Inpatient Diabetes Patient Education Program on 30-Day Readmission Rates.

BACKGROUND: In October 2012, a pharmacy-driven Inpatient Diabetes Patient Education (IDPE) program was implemented at the University of Toledo Medical Center (UTMC). OBJECTIVE: To determine the difference in 30-day hospital readmission rates for patients who receive IDPE compared to those who do not. METHODS: This retrospective cohort was completed at UTMC. Patients admitted between October 1, 2012, and September 30, 2013, were included if they were ≥18 years and had one of the following: (1) diagnosis of diabetes mellitus, (2) blood glucose >200 mg/dL (>11.11 mmol/L) on admission, or (3) hemoglobin A1C of >6.5% (>48 mmol/mol). Patients who received IDPE from a pharmacist or student pharmacist (intervention group) were compared to patients who did not receive IDPE (control group). RESULTS: The 30-day readmission rate was 13.2% for the intervention group (n = 364) and 21.5% for the control group (n = 149) (P = .023). Average time to 30-day readmission was 13.1 (±8.3) days for the IDPE group and 11.9 (±7.9) days for the control group. There was no significant difference in diabetes-related readmission between the intervention and control groups (25.5% vs 21.9%). CONCLUSIONS: An IDPE program delivered primarily by pharmacists and student pharmacists significantly reduced 30-day readmission rates among patients with diabetes.

Evaluation of Bronchodilator Use During Chronic Obstructive Pulmonary Disease Exacerbation Inpatient Admissions.

Background: It is unknown whether the timing of initiation of a long-acting bronchodilator (LABD) during a chronic obstructive pulmonary disease (COPD) exacerbation or the method of short-acting bronchodilator (SABD) delivery may aid in improving patient outcomes. Objective: The goal of this study was to determine the impact of bronchodilator management in the hospital setting on clinical outcomes in patients with COPD exacerbation. Methods: This retrospective, single-center study evaluated patients admitted to the non-intensive care unit setting with a COPD exacerbation as defined by the International Classification of Diseases, Ninth Revision codes. The primary outcome was difference in 30-day readmission rates for early LABD therapy (<24 hours from hospital admission) versus late/no LABD therapy (>24 hours from hospital admission or not during hospitalization). Secondary objectives included length of stay (LOS) for this group, and 30-day readmission rates and LOS for the SABD via inhaler versus nebulizer groups. Results: Two hundred twenty patients were included. There was no difference in 30-day readmission rate (15.2% vs 18.2%, P = .6) and LOS (median 4 [interquartile range, IQR 3-6]) days for both groups, P = .34) between early versus late/no LABD therapy initiation, respectively. No difference was observed in 30-day readmission rate (16.7% vs 16.6%) and LOS (median 2.5 [IQR 1.1-3.9] days vs median 4 [IQR 2-6] days) between inhaler and nebulizer SABD therapy groups. Conclusions: No difference was observed in 30-day readmission rates or LOS when utilizing early LABD compared with late/no LABD therapy or comparing inhaler and nebulizer SABD delivery methods during COPD exacerbation.

Evidence-Based Review of Smartphone Versus Paper Asthma Action Plans on Asthma Control.

Objective: To summarize and evaluate existing literature regarding the impact of mobile asthma action plans (MAAPs) versus written asthma action plans (WAAPs) on degree of asthma control. Data Sources: PubMed, EMBASE, Web of Science, and ClinicalTrials.gov were searched (2000-January 2019) using the term asthma action plan with each of the following: smartphone, computers, handheld, mobile applications, portable electronic application, portable software application, tablet, or technology. Study Selection and Data Extraction: The search was limited to cohort and randomized controlled trials examining MAAP versus WAAP data. Data extracted included the following: study design, population, intervention, control, outcomes related to asthma control, and potential biases assessed using Cochrane Collaboration's Risk of Bias Assessment Tool. Data Synthesis: Four of the 41 studies identified were included, each of which were randomized control trials. One study showed significant improvement using a non-asthma-specific assessment tool, 1 study showed improvement only for patients with uncontrolled asthma at baseline, and 2 studies showed no difference in asthma control scores. Overall risk of bias across all studies was low to moderate. Relevance to Patient Care and Clinical Practice: Health care providers should select an asthma action plan (AAP) format based on what the patient is most likely to understand and consistently use. Conclusions: Because of conflicting published data regarding the use of MAAPs versus WAAPs and risk of bias, it is unclear at this time whether one format of AAP is superior to the other for either adolescents or adults.

Implementation of a Cardiac Transitions of Care Pilot Program: A Prospective Study of Inpatient and Outpatient Clinical Pharmacy Services for Patients With Heart Failure Exacerbation or Acute Myocardial Infarction.

BACKGROUND:: Pharmacists may assist with reducing 30-day readmission rates for patients with heart failure (HF) exacerbation or acute myocardial infarction (AMI) by promoting medication adherence. OBJECTIVE:: To determine the change in 30-day readmission rates for patients with HF exacerbation or AMI after implementation of a "high-touch" standard of care. METHODS:: Patients admitted with HF exacerbation, non-ST-segment elevation AMI, or ST-segment elevation AMI from August 1, 2013, to June 30, 2015, were included in this prospective study. Patients were educated while in the inpatient setting and followed up in the outpatient setting through telephone contact and scheduling a medication therapy management (MTM) appointment with a pharmacist. Data were collected by pharmacy personnel involved in the implementation of the intervention. RESULTS:: Within the HF and AMI arms, 100 and 93 patients, respectively, were included in the study. The 30-day readmission rates were 24% and 17.2% for HF and AMI, respectively, which were not statistically significant when compared to historical institutional readmission rates prior to study initiation (18.2% for HF, P = .238; 11.4% for AMI, P = .252). CONCLUSION:: A "high-touch" pharmacist-driven transitions of care program may affect 30-day readmission rates for patients with HF exacerbation or AMI; potential processes for initiating transitions of care programs are provided.

Systemic Corticosteroid and Antibiotic Use in Hospitalized Patients With Chronic Obstructive Pulmonary Disease Exacerbation.

BACKGROUND: Effective inpatient chronic obstructive pulmonary disease (COPD) exacerbation management is critical to appropriately manage health care resources. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines provide recommendations on appropriate systemic corticosteroid and antibiotic use, in select patients, for COPD exacerbation. OBJECTIVE: To determine the impact of GOLD guideline-recommended systemic corticosteroid and antibiotic therapy in the hospital setting on clinical outcomes in patients with COPD exacerbation. METHODS: This was a noninterventional, retrospective, single-center study. Adults admitted to a non-intensive care unit internal medicine service with documented COPD exacerbation were included. Two analyses were conducted evaluating systemic corticosteroid and antibiotic therapy. RESULTS: A total of 220 patients were included in the systemic corticosteroid cohort. No difference in 30-day readmission rates was demonstrated for the standard (⩽200 mg prednisone equivalents [PEs] for exacerbation course) and high-dose groups (>200 mg PEs; 20.5% vs 13.1%, respectively; P = 0.15). Hospital length of stay (LOS) was significantly shorter for patients prescribed standard-dose therapy (3 days [2-4.5] vs 4 days [2-6]; P < 0.001). A total of 174 patients were included in the antibiotic cohort. For the appropriate and inappropriate antibiotic use groups, no significant differences were observed between 30-day readmission rates (15% vs 18.4%, respectively; P = 0.57) and hospital LOS (4 days [2-5] in both groups; P = 0.97). Conclusion and Relevance: Hospital LOS was shorter for patients prescribed standard-dose systemic corticosteroids; however, no differences in other clinical outcomes were found in either cohort. Use of guideline-recommended systemic corticosteroid and antibiotic therapy is recommended for hospitalized patients with COPD exacerbation.

Scientific and Ethical Issues in Mitochondrial Donation.

The development of any novel reproductive technology involving manipulation of human embryos is almost inevitably going to be controversial and evoke sincerely held, but diametrically opposing views. The plethora of scientific, ethical and legal issues that surround the clinical use of such techniques fuels this divergence of opinion. During the policy change that was required to allow the use of mitochondrial donation in the UK, many of these issues were intensely scrutinised by a variety of people and in multiple contexts. This extensive process resulted in the publication of several reports that informed the recommendations made to government. We have been intrinsically involved in the development of mitochondrial donation, from refining the basic technique for use in human embryos through to clinical service delivery, and have taken the opportunity in this article to offer our own perspective on the issues it raises.

ACE Inhibitor-Induced Angioedema of the Small Bowel: A Case Report and Review of the Literature.

Angiotensin-converting enzyme (ACE) inhibitors are known to cause angioedema. Most ACE inhibitor-induced angioedema cases describe swelling in the periorbital region, tongue, and pharynx. We describe a case of a 62-year-old female with presumed angioedema of the small bowel after more than a 2-year history of lisinopril use (with no recent changes in her dose of 40 mg orally twice daily). The patient presented with nausea and intermittent left middle and upper quadrant abdominal pain and denied history of angioedema or swelling with any medications or any history of abdominal pain. On physical examination, bowel sounds, liver, and spleen were normal. Laboratory tests revealed leukocytosis (15 400 per mm3) and normal complement 1 esterase inhibitor levels. Abdominal computed tomography (CT) showed segmental small bowel thickening and edema with ascites and surrounding inflammatory changes. There was no lymphadenopathy, obstruction, or ileus. Two days after discontinuation of the lisinopril, the patient reported improvement in symptoms. The Naranjo adverse drug reaction probability scale indicated a probable relationship (score of 7) between the development of angioedema of the small bowel and the lisinopril therapy. This case highlights the unique manner in which ACE inhibitor-induced angioedema may present. A review of published cases of ACE inhibitor-induced angioedema of the small bowel is provided.

Evidence Based Review of Pharmacotherapy for Opioid-Induced Constipation in Noncancer Pain.

OBJECTIVE: To summarize and evaluate the existing literature regarding medications to treat opioid-induced constipation (OIC) in patients with chronic noncancer pain (CNCP). DATA SOURCES: PubMed, EMBASE, and Web of Science were searched using the following terms: constipation, opioid, chronic, pain, noncancer, nonmalignant, methylnaltrexone, alvimopan, lubiprostone, naloxegol, and naldemedine. STUDY SELECTION AND DATA EXTRACTION: The search was limited to randomized controlled trials reporting human outcomes. Data extracted included the following: study design, population, intervention, control, outcomes related to OIC and safety, and potential biases assessed using Cochrane Collaboration's Risk of Bias Assessment Tool. DATA SYNTHESIS: After assessment, 16 of the 190 studies were included: methylnaltrexone (n = 4), naloxegol (n = 3), naldemedine (n = 2), lubiprostone (n = 3), and alvimopan (n = 4). Lubiprostone was the only nonperipherally acting µ-opioid receptor antagonist included. Only 1 study (naloxegol) used "usual care" (nonstudy laxative) rather than placebo as a comparator. Placebo-controlled trials demonstrated benefit for methylnaltrexone, naloxegol, naldemedine, and lubiprostone, with conflicting evidence for alvimopan. No data suggest that one agent is better than another. Overall risk of bias across all studies was low to moderate. CONCLUSIONS: With risk of bias determined to be low to moderate, published data to date suggest that methylnaltrexone, naloxegol, and naldemedine may be appropriate to treat OIC in patients with CNCP.

Impact of a Training Program on Pharmacists' Comfort With Pediatric Pharmacy Concepts and Basic Pediatric Knowledge.

Objective: To determine the impact of a training program on pharmacists' comfort with pediatric pharmacy concepts and basic pediatric knowledge. Methods: All pharmacists at our institution were invited to participate in the study. Consenting participants completed a baseline survey of 15 questions on basic knowledge in 5 pediatric topic areas (pharmacokinetics/pharmacodynamics, weight-based dosing, anticoagulation, renal dosing, and common antibiotics) as well as 8 statements rating self-reported comfort with pediatric pharmacy. Following the pretraining survey, a training program combining self-study of handouts on the 5 topics with optional attendance at live education sessions was completed. Participants then completed a posttraining survey of the 5 topics including repeat comfort assessment. The primary outcome was change in self-assigned scores on the comfort-based assessment before and after training. Results: Fifty-two pharmacists consented to participate. Participants reported significant improvement in 6 of 8 comfort questions after training (p < .001). Those without prior pediatric experience had lower comfort ratings at baseline and showed significant improvement after training for 5 of the 8 questions (p < .001). Significant improvement in the proportion of correct answers on the knowledge assessment occurred after training, regardless of prior experience (61% vs 89%, p < .001). Conclusions: Self-study training with optional live education resulted in significant improvement in most self-reported comfort scores for pharmacists, particularly those without recent pediatric pharmacy experience. Pharmacists, regardless of experience, improved basic pediatric knowledge scores after training.