Pharmacy students as educators: An interprofessional approach to insulin management education.

INTRODUCTION: Student pharmacists may increase the knowledge and comfort level of student nurses and student physicians through peer-assisted teaching (PAT) on insulin management for patients with type 2 diabetes mellitus. METHODS: Fourth-year student pharmacists completing their primary care rotation provided instruction to third-year student nurses and third-year student physicians on the selection, dosing, administration, and counseling of insulin products in type 2 diabetes. Learners were asked to complete a pre- and post-survey to determine comfort level and knowledge before and after the educational experience. RESULTS: A total of 200 student nurses and student physicians were included in the analysis. All but two questions from the pre- to post-survey resulted in a statistically significant increase in the number of respondents who agreed or strongly agreed with the statements. In both the pre- and post-survey, >90% of participants agreed or strongly agreed that pharmacists add value to the medical team. An overwhelming majority of students indicated that this learning experience would assist them with making clinical decisions regarding insulin therapy for patients with type 2 diabetes during clinical rotations. CONCLUSION: The education provided by student pharmacists improved knowledge and confidence in selecting, dosing, administering, and counseling on insulin products, but not with adjusting therapy. Although the student nurses and student physicians valued pharmacy prior to the study, their willingness to reach out to pharmacists increased. This study demonstrates the usefulness of PAT for collaboration between healthcare professional students for improved knowledge and confidence to ultimately enhance patient-centered care.

Comparing faculty evaluations of student journal club presentations with student self- and peer evaluations during advanced pharmacy practice experiences.

BACKGROUND AND PURPOSE: Self-evaluation is a critical step in professional development. Peer evaluation may enhance student learning and help peer evaluators recognize their own limitations. However, these evaluations may not accurately assess performance. This study's purpose is to evaluate differences between faculty, self-, and peer evaluations of student journal club (JC) presentations during advanced pharmacy practice experiences (APPEs). EDUCATIONAL ACTIVITY AND SETTING: Student JC presentations for three APPE sites were identified between May 2015 and April 2018 and included if at least one faculty, self-, and peer evaluation were complete. Overall grades and individual rubric ratings were compared. FINDINGS: Seventy-four students had complete data sets. The mean overall scores for JC presentations were 82.72%, 86.05%, and 91.01% for faculty, self-, and peer evaluations, respectively. Self-evaluation ratings were significantly higher than faculty on each domain, except for "presentation and communication skills" (mean difference: -0.2, p = .034) and "ability to answer questions" (mean difference: -0.1, p = .247). Linear regression showed a statistically significant relationship between self-evaluation and faculty evaluation ratings for ability to answer questions (beta = 0.5, p < .001). Peer evaluation ratings were significantly higher than faculty and self-evaluations (p < .05). SUMMARY: Faculty scores on JC presentations completed during APPEs were lower compared to student evaluations of themselves and their peers. Further incorporation of self- and peer evaluation throughout pharmacy school curricula may improve student competence in performing these evaluations. Formal training is needed to improve students' ability to complete self and peer evaluations.

Morphine Use in Renal Failure: A Case Report of Single-Dose Morphine Toxicity in a Patient Requiring Peritoneal Dialysis.

OBJECTIVE: We describe a case of morphine toxicity presumably caused by accumulation of its active metabolite morphine-6-glucuronide (M6G) secondary to reduced clearance by peritoneal dialysis. METHODS: We present the relevant history and laboratory data and review pertinent literature regarding the use of opioids in renal failure. RESULTS: A 76-year-old African-American female received one dose of morphine sulfate and developed signs and symptoms of morphine toxicity for 2 days, even after multiple peritoneal dialysis sessions. CONCLUSION: Because of reduced renal clearance of morphine and its metabolites in patients requiring peritoneal dialysis, morphine should be avoided as an analgesic option in this population due to increased risk of morphine toxicity.

Development and Validation of a Rubric to Evaluate Diabetes SOAP Note Writing in APPE.

Objective. To develop and establish validity for a grading rubric to evaluate diabetes subjective, objective, assessment, plan (SOAP) note writing on primary care (PC) advanced pharmacy practice experiences (APPEs), and to assess reliability and student perceptions of the rubric. Methods. Ten PC APPE faculty members collaborated to develop a rubric to provide formative and summative feedback on three written SOAP notes per APPE student over a 10-month period. Correlation analyses were conducted between rubric scores and three criterion variables to assess criterion-related validity: APPE grades, Pharmaceutical Care Ability Profile Scores, and Global Impression Scores. Inter-rater and intra-rater reliability testing were completed using Cohen's kappa and Intraclass Correlation Coefficients (ICC). Student perceptions were assessed through an anonymous student survey. Results. Fifty-one students and 167 SOAP notes were evaluated using the final rubric. The mean score significantly increased from the first to second SOAP note and from the first to third SOAP note. Statistically significant positive correlations were found between final rubric scores and criterion variables. The ICC for inter-rater reliability was fair (.59) for final rubric scores and excellent for intra-rater reliability (.98 to1.00). Students responded that the rubric improved their ability (84.9%) and confidence (92.4%) to write SOAP notes. Conclusion. The rubric may be used to make valid decisions about students' SOAP note writing ability and may increase their confidence in this area. The use of the rubric allows for greater reliability among multiple graders, supporting grading consistency.

A Review of ACE Inhibitors and ARBs in Black Patients With Hypertension.

OBJECTIVE: To review current guidelines and recent data evaluating the efficacy and safety of angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) in black hypertensive patients. DATA SOURCES: Articles evaluating race-specific outcomes in hypertension were gathered using a MEDLINE search with keywords black, African American, ACE inhibitor, angiotensin receptor blocker, angiotensin system, and hypertension. Studies published from 2000 through April 2018 were reviewed. STUDY SELECTION AND DATA EXTRACTION: Six guidelines, 8 monotherapy publications, and 5 combination therapy publications included race-specific results and were included in the review. The authors individually compared and contrasted the results from each publication. DATA SYNTHESIS: Numerous monotherapy trials indicate that black patients may have a reduced blood pressure (BP) response with ACE inhibitors or ARBs compared with white patients. Conversely, additional studies propose that race may not be the primary predictor of BP response. Reduced efficacy is not observed in trials involving combination therapy. Some studies suggest increased cardiovascular and cerebrovascular morbidity and mortality with ACE inhibitor or ARB monotherapy in black patients; however, data are conflicting. Relevance to Patient Care and Clinical Practice: This article clarifies vague guideline statements and informs clinicians on the appropriate use of ACE inhibitors or ARBs for hypertension treatment in black patients through an in-depth look into the evidence. CONCLUSIONS: Potentially reduced efficacy and limited outcomes data indicate that ACE inhibitors or ARBs should not routinely be initiated as monotherapy in black hypertensive patients. Use in combination with a calcium channel blocker or thiazide diuretic is efficacious in black patients, and there are no data showing that this increases or decreases cardiovascular or cerebrovascular outcomes.

Epilepsy: Treatment Options.

The occurrence of a single seizure does not always require initiation of antiepileptic drugs. Risk of recurrent seizures should guide their use. In adults, key risk factors for recurrence are two unprovoked seizures occurring more than 24 hours apart, epileptiform abnormalities on electroencephalography, abnormal brain imaging, nocturnal seizures, or an epileptic syndrome associated with seizures. In children, key risk factors are abnormal electroencephalography results, an epileptic syndrome associated with seizures, severe head trauma, and cerebral palsy. The risk of adverse effects from antiepileptic drugs is considerable and includes potential cognitive and behavioral effects. In the absence of risk factors, and because many patients do not experience recurrence of a seizure, physicians should consider delaying use of antiepileptic drugs until a second seizure occurs. Delaying therapy until a second seizure does not affect one- to two-year remission rates. Treatment should begin with monotherapy. The appropriate choice of medication varies depending on seizure type. Routine monitoring of drug levels is not correlated with reduction in adverse effects or improvement in effectiveness and is not recommended. When patients have been seizure free for two to five years, discontinuation of antiepileptic drugs may be considered. For patients with seizures that are not controlled with these agents, alternative treatments include surgical resection of the seizure focus, ketogenic diets, vagus nerve stimulators, and implantable brain neurostimulators. Patients who have had a recent seizure within the past three months or whose seizures are poorly controlled should refrain from driving and certain high-risk physical activities. Patients planning for pregnancy should know that antiepileptic drugs are possibly teratogenic.

Genetic Variation in CYP2R1 and GC Genes Associated With Vitamin D Deficiency Status.

This cross-sectional study enrolled 180 patients at a private family practice in Virginia. Total serum vitamin D concentrations were obtained weekly from January 30, 2013, through March 30, 2013, in consecutive patients regularly scheduled for laboratory work at the practice. Patients were categorized into 2 groups and analyzed for variant alleles in vitamin D receptor ( VDR; rs2228570), cytochrome P450 2R1 ( CYP2R1; rs10741657), 7-dehydrocholesterol reductase ( DHCR7; rs12785878), and group-specific component ( GC; rs2282679) to determine whether variants of those alleles influenced total serum 25(OH)D concentrations. One-hundred and eighty patients were enrolled, with 40 (22%) being sufficient, 25-hydroxy vitamin D level 25(OH)D ≥ 30 ng/mL, and 140 (78%) being insufficient, 25(OH)D < 30 ng/mL. Of the 4 genes, 2 genes, CYP2R1 (rs10741657) and GC (rs2282679), demonstrated a significant association related to vitamin D status. Subjects with 1 or more variant alleles at rs10741657 were almost 3.7 (odds ratio [OR] 3.67; 95% confidence interval [CI]: 1.35-9.99) times more likely be insufficient in vitamin D and subjects with 1 or more variant alleles at rs2282679 were about half (OR 0.42; 95% CI: 0.18-0.93) as likely to be insufficient in vitamin D. Allelic variations in CYP2R1 (rs10741657) and GC (rs2282679) affect vitamin D levels, but variant alleles on VDR (rs2228570) and DHCR7 (rs12785878) were not correlated with vitamin D deficiency, 25(OH)D < 30 ng/mL.

Is an SGLT2 inhibitor right for your patient with type 2 diabetes?

Metformin isn't quite doing the job or is contraindicated? Here's a look at the patients who may benefit from these agents and the monitoring required.