Emphasizing Bloom's Affective Domain to Reduce Pharmacy Students' Stigmatizing Attitudes.

Objective. To create a learning environment using Bloom's affective domain as a framework that would reduce third-year pharmacy students' stigmatizing attitudes toward patients with mental illness. Design. Prior to the start of the module, students were asked to complete the 27-question Attribution Questionnaire Short Form (AQ-27). The teaching approach and in-class activities were designed to allow students' to experience the major categories within Bloom's affective domain. The module used patient cases, interactive-learning activities, and reflective discussions to augment pharmacological and therapeutic knowledge with a humanistic understanding of mental illness. Students were asked to retake the AQ-27 after completing the module. Assessment. Paired responses on the AQ-27 were reported for 74 of 104 students, which represents a response rate of 71.2%. Students' scores changed significantly on nine of the 27 questions. Students' attitudes pre- to post-module revealed a significant increase in the help construct, while there was a significant decrease in the dangerousness and fear constructs. Conclusion. Designing and implementing a course along the continuum of Bloom's affective domain resulted in appropriate changes in students' attitudes toward patients with mental illness.

Utility of a clinical risk factor scoring model in predicting infection with extended-spectrum ß-lactamase-producing enterobacteriaceae on hospital admission.

OBJECTIVE: To validate the utility of a previously published scoring model (Italian) to identify patients infected with community-onset extended-spectrum ß-lactamase-producing Enterobacteriaceae (ESBL-EKP) and develop a new model (Duke) based on local epidemiology. METHODS: This case-control study included patients 18 years of age or more admitted to Duke University Hospital between January 1, 2008, and December 31, 2010, with culture-confirmed infection due to an ESBL-EKP (cases). Uninfected controls were matched to cases (3:1). The Italian model was applied to our patient population for validation. The Duke model was developed through logistic-regression-based prediction scores calculated on variables independently associated with ESBL-EKP isolation. Sensitivities and specificities at various point cutoffs were determined, and determination of the area under the receiver operating characteristic curve (ROC AUC) was performed. RESULTS: A total of 123 cases and 375 controls were identified. Adjusted odds ratios and 95% confidence intervals for variables previously identified in the Italian model were as follows: hospitalization (3.20 [1.62-6.55]), transfer (4.31 [2.15-8.78]), urinary catheterization (5.92 [3.09-11.60]), ß-lactam and/or fluoroquinolone therapy (3.76 [2.06-6.95]), age 70 years or more (1.55 [0.79-3.01]), and Charlson Comorbidity Score of 4 or above (1.06 [0.55-2.01]). Sensitivity and specificity were, respectively, more than or equal to 95% and less than or equal to 47% for scores 3 or below and were less than or equal to 50% and more than or equal to 96% for scores 8 or above. The ROC AUC was 0.88. Variables identified in the Duke model were as follows: hospitalization (2.63 [1.32-5.41]), transfer (5.30 [2.67-10.71]), urinary catheterization (6.89 [3.62-13.38]), ß-lactam and/or fluoroquinolone therapy (3.47 [1.91-6.41]), and immunosuppression (2.34 [1.14-4.80]). Sensitivity and specificity were, respectively, more than or equal to 94% and less than or equal to 65% for scores 3 or below and were less than or equal to 58% and more than or equal to 95% for scores 8 or above. The ROC AUC was 0.89. CONCLUSION: While the previously reported model was an excellent predictor of community-onset ESBL-EKP infection, models utilizing factors based on local epidemiology may be associated with improved performance.

Potential role of fosfomycin in the treatment of community-acquired lower urinary tract infections caused by extended-spectrum ß-lactamase-producing Escherichia coli.

Extended-spectrum ß-lactamase-producing Escherichia coli (ESBLEC) are emerging pathogens causing urinary tract infections (UTIs) in community patients worldwide. Treatment for community-acquired ESBLEC UTIs, especially in the outpatient setting, may be problematic because many of the strains are resistant to the traditional oral therapies. Fosfomycin is an oral agent that is approved for the treatment of uncomplicated UTIs caused by Enterococcus faecalis and E. coli. Data evaluating the clinical efficacy of fosfomycin for the treatment of community-acquired ESBLEC lower UTIs are limited. Three studies evaluating fosfomycin in the treatment of ESBLEC lower UTIs have been conducted. Clinical success was documented in >78% of patients. From the available data, it seems that fosfomycin may be an effective and reasonable treatment option for outpatient management of community-acquired ESBLEC UTIs, excluding pyelonephritis. Fosfomycin is a very attractive agent because it is available orally, has limited drug interactions, has a favorable adverse event profile, and would be very cost effective considering the potential complications of inadequate treatment and the high cost associated with parenteral therapies. Limitations to the clinical use of fosfomycin may include optimal dose and duration not being established, fosfomycin not often being included on culture and sensitivity reports and emerging resistance.

Stress ulcer prophylaxis in hospitalized patients not in intensive care units.

PURPOSE: A review is presented of the evidence behind the current use of therapies for the prevention of stress-related mucosal disease and bleeding in the nonintensive care unit (ICU), general medicine population. SUMMARY: The use of proton pump inhibitors and histamine H2-receptor antagonists for the prevention of stress ulcers has been well-defined in critical care patients. In 1999, the American Society of Health-System Pharmacists (ASHP) published guidelines on the use of stress ulcer prophylaxis in medical, surgical, respiratory, and pediatric ICU patients. In recent years, the practice of stress ulcer prophylaxis has become increasingly more common in general medicine patients, with little to no evidence to support it. Multiple risk factors have been identified for the development of stress ulcers, such as major trauma, severe head injury, multiple organ failure, burns covering more than 25-30% of the body, and major surgical procedures. Multiple studies have demonstrated the overuse of acid-suppressive therapy (AST), with as many as 71% of patients admitted to the hospital receiving some form of treatment. While many practitioners view AST to be harmless, its use is not without risks. Subsequently, a significant number of patients are discharged home on these medications, increasing economic cost and potentially increasing the risk of pneumonia or Clostridium difficile-associated disease. CONCLUSION: AST is commonly misused in hospitals, with as many as 71% of patients in general medicine wards receiving some sort of AST without an appropriate indication. Anticoagulant therapy has been identified as a risk factor for GI bleeding in hospitalized patients, but prophylaxis with AST has not been found to lower that risk. Although PPIs, H2-antagonists, and antacids are often viewed as safe, patients--particularly those with complicated disease states and complex drug regimens--should not be unduly exposed to the adverse effects and drug interactions associated with those agents. Many such patients treated with the drugs while hospitalized continue to receive AST as outpatients. The cost of inappropriate stress ulcer prophylaxis in medicine patients was found in one trial to exceed $111,000 for one year. The use of AST for the prevention of stress ulcers in general medicine patients is currently not recommended or supported in the clinical literature.

Pharmacotherapy for human immunodeficiency virus-associated nephropathy.

Approximately 10% of adult patients with human immunodeficiency virus (HIV) infection have HIV-associated nephropathy (HIVAN). This condition, a leading cause of renal failure, is characterized by damage to specific areas of the renal filtration system. It manifests with increased serum creatinine levels, overt proteinuria, and in some patients, end-stage renal disease (ESRD). The mortality rate for HIVAN-related ESRD is high-30% within the first year of onset. Most instances of HIVAN occur in patients of African descent. Although advances in defining the pathology have been made, the optimal treatment strategy remains unclear. Potential benefits of potent combination antiretroviral therapy, angiotensin-converting enzyme (ACE) inhibitors, and corticosteroids have been reported in small clinical trials and case reports. Cyclosporine is another option, but clinical experience with this agent in managing HIVAN is limited. Few conclusions can be drawn from the limited body of available evidence. Antiretroviral therapy, ACE inhibitors, and corticosteroids are possibly associated with reversal of serum creatinine level increases and proteinuria, but studies are necessary to further define the role of these agents in therapy. Close monitoring is advised when treating any patient with HIVAN.