Peer review of presentations through examination software.

BACKGROUND AND PURPOSE: Peer evaluations are often utilized to allow student pharmacists practice in giving and receiving feedback. In a small class setting, these can easily be completed and feedback distributed quickly. However, in the larger class setting, reviewing and disseminating peer feedback can be quite cumbersome, especially if using paper format. The purpose of this educational activity was to create a process for peer evaluations that allows for efficient collection and dissemination of peer feedback of presentations of student pharmacists and describe the student experience with this new format. EDUCATIONAL ACTIVITY AND SETTING: In Research Topics in Pharmacy II, an electronic peer-evaluation tool was created using electronic examination software to collect and distribute this peer review in a timely fashion during and after each class session. At the completion of this course, a survey was distributed to collect student pharmacists' perception of this electronic peer-review process. FINDINGS: A total of 63 of 91 students (69%) completed the survey. The majority of the students (98.4%) "strongly agreed" or "agreed" the peer-evaluation items made it easy to provide feedback to their peers and 79% preferred this electronic method of feedback vs. paper format. Overall, 93.6% of student pharmacists felt they were more engaged during the presentations as a result of providing electronic feedback. SUMMARY: Maximizing our resources by creating an electronic peer evaluation with our current examination software, allowed for an efficient means of obtaining and disseminating peer review that was timely and well-received by students.

Duration of therapy with acetylcholinesterase inhibitors in patients with mild-to-moderate Alzheimer's disease as reported in the literature.

OBJECTIVE: To review the literature regarding the treatment duration of acetylcholinesterase inhibitor (AChEI) therapy for mild-to-moderate Alzheimer's disease (AD) patients. DATA SOURCES: A literature search was performed using MEDLINE/PubMed, Embase, International Pharmaceutical Abstracts, and Clinical Key (all through May 31, 2013) with the search terms Alzheimer's disease, cholinesterase inhibitors, dementia, treatment and duration, with limits to human, clinical, and observational trials, and English studies; no limits were placed on publication dates. STUDY SELECTION AND DATA EXTRACTION: Based on the study selection, 40 studies were identified. The criteria for studies reviewed focused on the duration of AChEIs in patients with mild or moderate AD for a minimum of one year. DATA SYNTHESIS: Based on the selection criteria, five studies were reviewed. These studies evaluated the cognitive efficacy of AChEI after "long-term" (1.5 years) treatment in the clinical trial with follow-up noted in the observational studies of a maximum of "greater than 3 years" (up to 7 years). Cognitive decline was measured by changes in Mini-Mental State Exam scores or Alzheimer's Disease Assessment Scale scores. There were no studies identified that suggested an optimal duration of AChEI therapy for AD patients. CONCLUSION: Based on the trials reviewed, the duration for AChEI use is very patient-specific; therefore, risk versus benefit of therapy needs to be evaluated regularly in AD patients. The maximum mean duration of follow-up in the clinical study analyzed here was only 1.5 years and observational studies with follow-up "greater than 3 years." Further long-term research is needed.

Recent advances in the treatment of life-threatening, invasive fungal infections.

INTRODUCTION: Invasive fungal infections (IFIs) pose significant morbidity and are often life-threatening to many high-risk patients. Timely diagnosis and treatment of these infections with optimal therapy is imperative. AREAS COVERED: Advances have been made in diagnostic biomarkers such as peptide nucleic acid fluorescent in situ hybridization, ß-D-glucan and galactomannan, although more research is needed in this area to assist with both diagnosis and monitoring for improvement of IFI management. Novel antifungal agents (azole antifungals and echinocandins) are being investigated that have activity against Candida spp. and Aspergillus spp. Optimizing the pharmacodynamics (PD) of our current antifungal therapies through such strategies as continuous infusion of amphotericin B and dose escalation of echinocandins and liposomal formulations of amphotericin B have also been investigated with mixed results. Therapeutic drug monitoring (TDM) shows promise as evident from data with such agents as flucytosine, itraconazole, voriconazole and posaconazole. EXPERT OPINION: The goal for the future of biomarkers in IFIs will be to have excellent sensitivity and specificity to ideally identify a particular fungus causing the infection or eliminate its existence to prevent unnecessary costs, resistance and antifungal usage. In addition, further developments of new antifungals are needed and judicious use of the current regimens needs to be optimized through antifungal PD properties and TDM.

Comparing point-of-care A1C and random plasma glucose for screening diabetes in migrant farm workers.

OBJECTIVE: To compare point-of-care (POC) glycosylated hemoglobin (A1C) and random plasma glucose (RPG) as a POC screening tool for prediabetes and diabetes in migrant farm workers of eastern North Carolina. DESIGN: Prospective, observational, single-center study. SETTING: Federally qualified community health center in eastern North Carolina, from August to October 2011. PARTICIPANTS: Migrant farm workers 18 years or older who resided in a migrant camp in eastern North Carolina. INTERVENTION: Diabetes screening using POC A1C and RPG via fingerstick followed by venipuncture A1C and basic metabolic panel in individuals with a positive screening. MAIN OUTCOME MEASURES: Positive predictive value (PPV) of POC A1C and RPG, incidence of positive screening, incidence of confirmed diagnosis, concordance rate of the screening tools, and correlation between POC A1C and laboratory A1C. RESULTS: 206 workers participated in the screenings; screening identified 39 individuals with a POC A1C greater than 5.7% and 1 individual with both an RPG of 200 mg/dL or more and a POC A1C greater than 5.7%. Of the 39 individuals found to have a positive screening, 24 presented to Carolina Family Health Centers, Inc., for follow-up venipuncture; however, 1 participant did not have a venipuncture A1C, leaving 23 individuals with complete data. Two participants were diagnosed with diabetes and 17 with prediabetes. POC A1C had a PPV of 82.6%; however, the PPV of RPG could not be calculated due to the number of participants lost to follow-up. POC A1C correlated well with laboratory A1C regardless of time to follow-up. CONCLUSION: POC A1C should be considered for diabetes screening in high-risk populations. If the screening had been performed with RPG alone, 38 individuals would have gone undetected. Early identification of individuals with elevated blood glucose will likely decrease the risk of long-term complications.

Documenting the use of calcium supplements with oral bisphosphonates.

OBJECTIVE: Patients receiving an oral bisphosphonate for treatment of osteopenia or osteoporosis without adequate calcium intake are not optimally treated. Physicians prescribing bisphosphonates may not consistently document calcium supplementation recommendations. DESIGN: This is a retrospective chart review of osteoporotic or osteopenic outpatients with an active prescription for an oral bisphosphonate. This cross-sectional study was designed to determine the point prevalence of calcium supplementation recommendations by physicians. SETTING: Academic family medicine outpatient clinics. PATIENTS: Of the 1,229 patients with osteoporosis or osteopenia, 425 patients had an active prescription for an oral bisphosphonate and were included in the study. INTERVENTIONS: The active/inactive medication list and physician clinic notes in the electronic medical record were reviewed for documentation regarding calcium. MAIN OUTCOME MEASURES: The primary endpoint was the percentage of patients on bisphosphonates also receiving calcium. The secondary endpoint was the identification of demographic characteristics associated with lower use of calcium. RESULTS: The patient sample was 94% female, 69% white, with a mean body mass index of 27, and mean age of 72 years. Of the 425 patients, 387 (91.1%) were taking calcium or had a documented recommendation for calcium supplementation. Of the demographic characteristics evaluated, only age was statistically significantly different, with an average age of 76 years in the calcium group and 66 years of age in the noncalcium group. CONCLUSION: In this study, 91% of outpatients who were prescribed a bisphosphonate also were taking calcium or had it recommended to them. The only statistically significant difference between groups was greater age for those who received calcium.

Potential role of tigecycline in the treatment of community-acquired bacterial pneumonia.

Tigecycline is a member of the glycylcycline class of antimicrobials, which is structurally similar to the tetracycline class. It demonstrates potent in vitro activity against causative pathogens that are most frequently isolated in patients with community-acquired bacterial pneumonia (CABP), including (but not limited to) Streptococcus pneumoniae (both penicillin-sensitive and -resistant strains), Haemophilus influenzae and Moraxella catarrhalis (including ß-lactamase-producing strains), Klebsiella pneumoniae, and 'atypical organisms' (namely Chlamydophila pneumoniae, Mycoplasma pneumoniae, and Legionella pneumophila). Comparative randomized clinical trials to date performed in hospitalized patients receiving tigecycline 100 mg intravenous (IV) × 1 and then 50 mg IV twice daily thereafter have demonstrated efficacy and safety comparable to the comparator agent. Major adverse effects were primarily gastrointestinal in nature. Tigecycline represents a parenteral monotherapy option in hospitalized patients with CABP (especially in patients unable to receive respiratory fluoroquinolones). However, alternate and/or additional therapies should be considered in patients with more severe forms of CABP in light of recent data of increased mortality in patients receiving tigecycline for other types of severe infection.

Overview of treatment options for invasive fungal infections.

The introduction of several new antifungals has significantly expanded both prophylaxis and treatment options for invasive fungal infections (IFIs). Relative to amphotericin B deoxycholate, lipid-based formulations of amphotericin B have significantly reduced the incidence of nephrotoxicity, but at a significant increase in drug acquisition cost. Newer, broad-spectrum triazoles (notably voriconazole and posaconazole) have added significantly to both the prevention and treatment of IFIs, most notably Aspergillus spp. (with voriconazole) and the treatment of some emerging fungal pathogens. Finally, a new class of parenteral antifungals, the echinocandins, is employed most frequently against invasive candidal infections. While the role of these newer agents continues to evolve, this review summarizes the activity, safety and clinical applications of agents most commonly employed in the treatment of IFIs.

Echinocandin pharmacodynamics: review and clinical implications.

Echinocandins have made a significant impact in the treatment of select invasive fungal infections, most notably invasive candidiasis and aspergillosis. However, treatment outcomes for such infections are still less than optimal, prompting an examination of dosing and administration techniques in an attempt to exploit known pharmacodynamic properties and improve outcomes. Echinocandins generally exhibit concentration-dependent, fungicidal activity against Candida spp. and fungistatic activity against Aspergillus spp. However, increasing drug concentrations of echinocandins above the organism's MIC may result in a paradoxical increase in fungal growth as demonstrated in some in vitro and in vivo models (known most commonly as the 'Eagle effect'). Therefore, the potential impact of dose escalations on improving the clinical efficacy of echinocandins based on in vitro and animal models are uncertain and are still being evaluated. In addition, such strategies have to consider the potential for increased treatment-related toxicities and costs. To date, published clinical studies (both superiority and non-inferiority) demonstrating the potential for dose-related improvements in treatment outcomes have been limited to mucocutaneous and oesophageal candidiasis. Further research is needed to determine if a role exists for optimizing echinocandin pharmacodynamics in various clinical settings.

Hypoglycemia associated with the use of levofloxacin.

PURPOSE: A case of hypoglycemia associated with levofloxacin is reported. SUMMARY: A 58-year-old Caucasian man was admitted to the hospital for a heart failure (HF) exacerbation with suspected community-acquired pneumonia (CAP). His medical history included HF (left ventricular ejection fraction, 25-35%), hypertension, and type 2 diabetes mellitus. Renal insufficiency was noted during hospitalization, with a serum creatinine concentration of 1.5 mg/dL. The patient's only home medication was a self-reported "sugar pill," later identified as glimepiride. A chest radiograph revealed consolidation in both lung bases and bilateral pleural effusions. Levofloxacin 750 mg was administered orally on hospital day 1 for the treatment of CAP and was ordered to be administered every 48 hours. On hospital day 3, glipizide 10 mg was administered with a sliding-scale regimen of regular insulin in preparation for discharge. On hospital day 4, glipizide 10 mg was given again with the second dose of levofloxacin, 65 hours after the first levofloxacin dose was administered. The patient also received furosemide 40 mg orally twice daily, lisinopril 20 mg orally daily, and metoprolol 25 mg twice daily. The patient was discharged on hospital day 4 and returned to the emergency department early the next morning with a serum glucose concentration of 20 mg/dL. An i.v. infusion of 10% dextrose injection and three ampules of 50% dextrose injection were given to correct his hypoglycemia. Further glipizide doses were not administered. CONCLUSION: A malnourished 58-year-old man with diabetes developed hypoglycemia after receiving levofloxacin in conjunction with glipizide.

Effect of pharmacists on medication errors in an emergency department.

PURPOSE: The frequency of medication errors in an emergency department (ED) before and after an ED pharmacist was assigned to check medication orders was studied. METHODS: A retrospective chart review was conducted for any patient admitted to the ED of a large rural hospital between November 6, 2005, and December 6, 2005 (control group), or between November 6, 2006, and December 6, 2006 (intervention group). For the control group, no pharmacist was present in the ED to check drug orders; for the intervention group, a pharmacist was present. Potential errors in medication orders were identified and validated. RESULTS: A total of 490 medication orders written for 198 patients were evaluated for errors. The control group (n = 94) and the intervention group (n = 104) did not differ significantly with respect to age, sex, race, or number of medication orders. A total of 37 and 14 medication errors were identified for the control and intervention groups, respectively. The rate of errors was 16.09 per 100 medication orders for the control group compared with 5.38 per 100 orders for the intervention group, a 66.6% difference (p = 0.0001). The ED pharmacists made 183 recommendations, of which 98.6% were accepted. CONCLUSION: The rate of medication errors in the ED decreased significantly when pharmacists prospectively reviewed ED medication orders.

Multidrug-resistant Ewingella americana: a case report and review of the literature.

OBJECTIVE: To describe and report a case of multidrug-resistant Ewingella americana associated with exacerbation of chronic obstructive pulmonary disease (COPD). CASE SUMMARY: A 77-year-old female presented to her physician with shortness of breath and an initial assessment of pneumonia. Her past medical history included COPD, Mycobacterium tuberculosis infection, recent Mycobacterium avium infection, and Crohn's disease. Blood and urine cultures revealed no growth; however, a sputum culture later revealed multidrug-resistant E. americana. The patient was ultimately treated with trimethoprim/sulfamethoxazole (TMP/SMX), with complete resolution of symptoms following a 10 day course. DISCUSSION: E. americana is a rare gram-negative bacillus that has infrequently been reported to cause infection. This organism has been reported in humans in the blood, sputum, conjunctiva, wounds, and peritoneal fluid. In several of these cases, as well as in our case, this organism appeared to occur more frequently in immunocompromised patients. Although generally susceptible to most antibiotics, our patient's organism was resistant to all antibiotics tested, with the exception of TMP/SMX, ticarcillin/clavulanate, and cefotetan. CONCLUSIONS: To our knowledge, this is only the second case of an E. americana respiratory infection, and the only one in which multidrug resistance has been reported.

Written versus oral recommendations made by pharmacy students during internal medicine rotations.

BACKGROUND: Pharmacy students use a variety of methods to communicate with physicians during clinical rotations regarding pharmacotherapy concerns. Documented acceptance rates for oral or written recommendations, when studied individually, range between 64% and 95%. OBJECTIVE: To compare the acceptance rates of written versus oral recommendations made by pharmacy students on internal medicine (IM) rotations. METHODS: Fourth-year pharmacy students completing an IM rotation made oral or written recommendations to physicians at a large, community-based medical center from November 2005 through April 2006 (excluding December). The types of recommendations and outcomes of the interventions were recorded using a data collection form. The primary endpoint was to determine differences in acceptance rates for written versus oral recommendations. Secondary endpoints included comparing the recommendation types and their corresponding acceptance rates. Additionally, the acceptance rates for evidence-based medicine (EBM) interventions were determined. RESULTS: A total of 625 recommendations were made by 10 pharmacy students during the 5 month study period; 47.5% of these were oral. A total of 82.8% of oral recommendations were accepted compared with 54.2% of written recommendations (p < 0.0001). Over 90% of the total recommendations were drug related. Overall, 68% of these recommendations were accepted. The major types of drug-related recommendations were indication for use (42.7%), inappropriate dose (17.2%), inappropriate route (11.3%), inappropriate drug (8.5%), and duplicate therapy (6.5%). The remaining types of interventions were laboratory related (6.4%) and requests for drug information (3.2%). A total of 227 (36.3%) recommendations were based on EBM guidelines, with an acceptance rate of 67.8%. CONCLUSIONS: Pharmacy student recommendations are well received by IM physicians. Oral recommendations are accepted at a statistically significantly higher percentage compared with written recommendations. High acceptance rates for recommendations may have the ability to positively impact patient care.

Successful treatment of Klebsiella rhinoscleromatis bacteremia with levofloxacin.

A 71-year-old Caucasian woman was admitted to the hospital with right-sided weakness and slurred speech. Glioblastoma multiforme was diagnosed, and resection of the tumor was performed. During the patient's hospitalization, blood and urine cultures were obtained after her temperature rose to 103.3 degrees F. Four blood cultures revealed Klebsiella rhinoscleromatis sensitive to trimethoprim-sulfamethoxazole, levofloxacin, cefazolin, gentamicin, and tetracycline, but resistant to ampicillin. The patient had no recent history of foreign travel. After a 3-week course with levofloxacin, the patient was afebrile, and repeat blood cultures were negative. To our knowledge, this was the first case of K. rhinoscleromatis bacteremia in the United States to be treated successfully with levofloxacin.

Tigecycline in the treatment of complicated intra-abdominal and complicated skin and skin structure infections.

Tigecycline, a glycylcycline related to the tetracycline class of antibiotics, represents a new option for the treatment of complicated intra-abdominal and complicated skin and skin structure infections. It displays favorable activity in vitro against the most common causative Gram-positive, Gram-negative and anaerobic pathogens. In addition, tigecycline demonstrates activity against drug-resistant pathogens such as methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci, and organisms (such as Escherichia coli and Klebsiella pneumoniae) producing extended-spectrum beta-lactamases. Tigecycline lacks activity in vitro against Pseudomonas and Proteus spp. In randomized clinical trials, tigecycline administered intravenously twice daily has demonstrated efficacy similar to comparators for a variety of complicated skin and skin structure and complicated intra-abdominal infections. The potential for significant drug interactions with tigecycline appears to be minimal. Dosing adjustment is needed for patients with severe hepatic impairment. The predominant side effect associated with its use to date has been gastrointestinal intolerance (nausea and vomiting).

Recent advances in the epidemiology, prevention, diagnosis, and treatment of fungal pneumonia.

Although pneumonia caused by fungi is not a common occurrence in the general population, disease in an enlarging immunocompromised population is encountered with increasing frequency. Fungal pneumonias are most frequently caused by Aspergillus spp., dimorphic fungi and Cryptococcus neoformans. Recent studies have identified risk factors of thrombocytopenia, environmental events (such as construction or renovation) and immunosuppressive drug therapies as being specific risk factors for invasive fungal disease in select patient populations. Diagnostic strategies to detect circulating antigens and polymerase chain reaction based detection systems have been explored to improve identification prior to the progressive advanced disease. Advances in prophylactic strategies include increased use of aerosolized formulations of amphotericin B, usually in conjunction with new and old systemic antifungal agents. Despite recent published guidelines for treatment of fungal pneumonia based on etiology, mortality remains high in some infections with advanced disease. Caspofungin, a new echinocandin antifungal, has recently been approved by the US Food and Drug Administration for the treatment of invasive Aspergillus infections in patients unresponsive to or unable to receive amphotericin B. A triazole antifungal, voriconazole, has shown promise in phase III clinical trials in patients with refractory fungal infections and is expected to be available in early 2002. Other echinocandin and triazole antifungals are under development in attempts to provide improved effective therapy for fungal pneumonia.