Evaluation of the Addition of Pharmacist Management to a Medication Assistance Program in Patients with Hypertension and Diabetes Resistant to Usual Care.

OBJECTIVE: To evaluate the effect of a medication assistance program and the addition of pharmacist management on clinical outcomes in patients with hypertension and diabetes through an Advanced Pharmaceutical Care program. METHODS: This was a prospective quality improvement study on patients with hypertension and/or diabetes resistant to usual care. The primary outcomes were change in A1C, blood glucose, and blood pressure between 3 phases: usual care, free medications, and free medications plus pharmacist management. Secondary outcomes included achievement of A1C, blood glucose, and blood pressure goals as well as pharmacist interventions. RESULTS: Seven patients were included in the study. The mean A1C decreased from 11.3% to 8.3% with free medications (p = 0.28) and from 8.3% to 6.4% with pharmacist management (p = 0.119). Mean blood pressure during usual care, free medications, and pharmacist intervention was 150/87 mm Hg, 148/85 mm Hg, and 125/78 mm Hg, respectively. After pharmacist management, 75% of patients with type 2 diabetes were able to achieve A1C and blood glucose goals, and 71% of patients with hypertension achieved blood pressure <130/80 mm Hg. CONCLUSIONS: The Advanced Pharmaceutical Care program allowed pharmacists to identify and overcome patient-specific barriers to care, provide individualized disease state education, and optimize medication management. Medication assistance led to improvements in A1C and blood pressure, but did not affect achievement of disease state goals. Pharmacist involvement in hypertension and diabetes care led to clinically significant reductions in blood pressure and A1C and enabled patients to reach guideline-recommended blood pressure and glycemic goals.

Avoiding patient morbidity: Updated statin drug interactions and risks for patient harm.

Almost 50% of serious adverse events with statin therapy are attributed to unfavorable drug-drug combinations. This article reviews updated FDA warnings on capping the dose of simvastatin, recent package insert labeling changes of particular statins that address combinations with potent cytochrome P450 inhibitors, and current renal dosing recommendations for statins.

Sustainability of Improved Glycemic Control After Diabetes Self-Management Education.

Objective. The purpose of this study was to evaluate glycemic control as measured by A1C during a 2-year period after patients received diabetes self-management education (DSME). Methods. Patients who completed DSME in 2009 and received medical follow-up with A1C measurements for at least 2 years after DSME were included in the evaluation. Primary endpoints were changes in A1C from before to immediately after, 1 year after, and 2 years after DSME. Secondary outcomes included the effects of the following factors on change in A1C: sex, duration of diabetes, uncontrolled diabetes (A1C ≥ 9%), health insurance coverage, and self-reported education level. Results. Forty-three patients were included in the evaluation. Mean A1C before DSME was 10.2 ± 3.7%. Mean A1C after DSME was 7.8 ± 2.2% (P < 0.0001), a 23.5% reduction. Mean A1C at 1 and 2 years after DSME was 7.8 ± 2.1% for each year and remained unchanged from just after DSME to 1 and 2 years after DSME (P > 0.05). Patients with a duration of diabetes of < 1 year had a significantly greater reduction in mean A1C than those with a duration of diabetes ≥ 1 year (28.7 and 20.2%, respectively, P = 0.001). Conclusion. DSME improved glycemic control to a substantial degree, and the effect was sustained for up to 2 years. Although the reduction in A1C was significant for all patients receiving DSME, there was a significantly greater reduction for patients who had a duration of diabetes of < 1 year than for those with a duration of diabetes > 1 year.

Detection of favorable oral cephalosporin-clavulanate interactions by in vitro disk approximation susceptibility testing of extended-spectrum-Beta-lactamase-producing members of the enterobacteriaceae.

Extended-spectrum-beta-lactamase (ESBL)-producing members of the Enterobacteriaceae are often resistant to multiple drug classes, making therapy of urinary infections with oral antibiotics difficult. Previously it was shown that amoxicillin-clavulanate can provide clavulanate inhibition of ESBLs and protect an oral cephalosporin present in combination when tested by broth microdilution. This study has shown that disk approximation testing could detect favorable cephalosporin-clavulanate interactions among a group of 101 previously characterized members of the Enterobacteriaceae with CTX-M, SHV, or TEM ESBLs.

Warfarin-cranberry juice interaction.

OBJECTIVE: To report a case of warfarin-cranberry juice interaction, which resulted in an international normalized ratio (INR) elevation on 2 separate occasions. CASE SUMMARY: A 46-year-old female was receiving a total weekly dose of 56 mg of warfarin. During the 4 months prior to the incident INR, her average INR was 2.0, with a range of 1.6-2.2, while taking the same weekly dose of warfarin. Her INR increased to 4.6 after drinking approximately 1.5 quarts (1420 mL) of cranberry juice cocktail daily for 2 days. Her INR 14 days later without cranberry juice cocktail consumption was 2.3. For the next 3 months, while taking warfarin 56 mg per week, her average INR was 2.1, with a range of 1.4-2.5. At a subsequent visit, after drinking approximately 2 quarts (1893 mL) of cranberry juice cocktail daily for 3-4 days, her INR had increased to 6.5. Her INR after holding warfarin for 3 days was 1.86. Her INR 7 days after resuming the weekly dose of warfarin 56 mg was 3.2. During both of the elevated INR episodes, no other factors were identified that would have resulted in an elevated INR, such as drug, herbal, disease, or other food interactions. An objective causality assessment revealed the interaction was highly probable. DISCUSSION: Warfarin is the most commonly used anticoagulant for chronic therapy. There have been several case reports of cranberry juice or cranberry sauce potentiating the effects of warfarin by elevating the INR; however, clinical trials evaluating this interaction have failed to demonstrate a significant effect on an INR. CONCLUSIONS: Our case report describes INR elevations in a patient previously stable on warfarin after ingestion of cranberry juice cocktail daily for several days. This elevation occurred on 2 separate occasions, which distinguishes our case from other published literature.

The structure of the self-concept and its relation to psychological adjustment.

Research on the relation between the structure of the self-concept and psychological adjustment has produced seemingly inconsistent findings. Some research suggests that greater pluralism in self-concept structure enhances adjustment, whereas other research suggests that greater unity in the structure enhances adjustment. Four studies examined the relations among measures of self-concept structure and their relations with adjustment. The measures of self-concept structure included two that we viewed as reflecting self-concept pluralism (self-complexity and self-concept compartmentalization) and four that we viewed as reflecting self-concept unity (self-concept differentiation, self-concept clarity, self-discrepancies, and the average correlation among participants' self-aspects). The measures of self-concept pluralism were unrelated to one another, were unrelated to the measures of self-concept unity, and were unrelated to the measures of adjustment. The measures of self-concept unity were moderately related to one another and were moderately related to the measures of adjustment.

Does High Self-Esteem Cause Better Performance, Interpersonal Success, Happiness, or Healthier Lifestyles?

Self-esteem has become a household word. Teachers, parents, therapists, and others have focused efforts on boosting self-esteem, on the assumption that high self-esteem will cause many positive outcomes and benefits-an assumption that is critically evaluated in this review. Appraisal of the effects of self-esteem is complicated by several factors. Because many people with high self-esteem exaggerate their successes and good traits, we emphasize objective measures of outcomes. High self-esteem is also a heterogeneous category, encompassing people who frankly accept their good qualities along with narcissistic, defensive, and conceited individuals. The modest correlations between self-esteem and school performance do not indicate that high self-esteem leads to good performance. Instead, high self-esteem is partly the result of good school performance. Efforts to boost the self-esteem of pupils have not been shown to improve academic performance and may sometimes be counterproductive. Job performance in adults is sometimes related to self-esteem, although the correlations vary widely, and the direction of causality has not been established. Occupational success may boost self-esteem rather than the reverse. Alternatively, self-esteem may be helpful only in some job contexts. Laboratory studies have generally failed to find that self-esteem causes good task performance, with the important exception that high self-esteem facilitates persistence after failure. People high in self-esteem claim to be more likable and attractive, to have better relationships, and to make better impressions on others than people with low self-esteem, but objective measures disconfirm most of these beliefs. Narcissists are charming at first but tend to alienate others eventually. Self-esteem has not been shown to predict the quality or duration of relationships. High self-esteem makes people more willing to speak up in groups and to criticize the group's approach. Leadership does not stem directly from self-esteem, but self-esteem may have indirect effects. Relative to people with low self-esteem, those with high self-esteem show stronger in-group favoritism, which may increase prejudice and discrimination. Neither high nor low self-esteem is a direct cause of violence. Narcissism leads to increased aggression in retaliation for wounded pride. Low self-esteem may contribute to externalizing behavior and delinquency, although some studies have found that there are no effects or that the effect of self-esteem vanishes when other variables are controlled. The highest and lowest rates of cheating and bullying are found in different subcategories of high self-esteem. Self-esteem has a strong relation to happiness. Although the research has not clearly established causation, we are persuaded that high self-esteem does lead to greater happiness. Low self-esteem is more likely than high to lead to depression under some circumstances. Some studies support the buffer hypothesis, which is that high self-esteem mitigates the effects of stress, but other studies come to the opposite conclusion, indicating that the negative effects of low self-esteem are mainly felt in good times. Still others find that high self-esteem leads to happier outcomes regardless of stress or other circumstances. High self-esteem does not prevent children from smoking, drinking, taking drugs, or engaging in early sex. If anything, high self-esteem fosters experimentation, which may increase early sexual activity or drinking, but in general effects of self-esteem are negligible. One important exception is that high self-esteem reduces the chances of bulimia in females. Overall, the benefits of high self-esteem fall into two categories: enhanced initiative and pleasant feelings. We have not found evidence that boosting self-esteem (by therapeutic interventions or school programs) causes benefits. Our findings do not support continued widespread efforts to boost self-esteem in the hope that it will by itself foster improved outcomes. In view of the heterogeneity of high self-esteem, indiscriminate praise might just as easily promote narcissism, with its less desirable consequences. Instead, we recommend using praise to boost self-esteem as a reward for socially desirable behavior and self-improvement.

Self-esteem and persistence in the face of failure.

In 2 studies, the authors examined self-esteem, persistence, and rumination in the face of failure. Study 1 manipulated degree of failure and availability of goal alternatives. When an alternative was available, high self-esteem (HSE) participants persisted more than low self-esteem (LSE) participants after a single failure, but less after repeated failure. When no alternative was available, no self-esteem differences in persistence emerged. LSE participants ruminated more than HSE participants. Study 2 examined persistence and rumination for 10 personal goals across an academic year. HSE participants were better calibrated (higher within-subject correlations between perceived progress and persistence across goals), had higher overall levels of persistence, higher grade point averages, and lower levels of rumination than LSE participants. Although traditional views that emphasize the tenacious persistence of HSE individuals need revision, HSE people appear more effective in self-regulating goal-directed behavior.