Creation of a Didactic Clinical Pharmacology Lecture Series for Internal Medicine Residents.

INTRODUCTION: One of the noted areas of weakness for internal medicine residents is pharmacology. However, there is little data documenting the creation and effect of a comprehensive pharmacology didactic program. Our goal was to create a two-year clinical pharmacology didactic program focused on areas of stated weakness and to evaluate this program for an increase in knowledge and prescribing confidence of the participants. METHODS: From August 2020 to June 2022, a two-year pharmacology program was developed, which included 20 didactic lectures on a variety of topics. Pre- and post-tests were given for 15 of the lectures, and four surveys were given, two during each year of the program. Four questions on each survey were the same and asked about confidence in choosing an appropriate medication based on current guidelines, patient-specific factors, primary literature, and pharmacokinetics. RESULTS:  Over the two years, participation in the pharmacology sessions ranged from 17 to 29 residents (65-74% of the residency class). The average pre- and post-test scores increased by an average of 25.1%, which was a statistically significant increase (p<0.001, 95% CI [17.5, 32.8]). A Kruskal-Wallis H test showed a statistically significant difference in resident-reported confidence adjusting medications based on primary literature between the different survey groups, χ2 = 9.871, p = 0.02. CONCLUSION: A two-year, didactic pharmacology program improved the knowledge of resident participants and confidence in their ability to choose an appropriate medication based on primary literature.

Can we do it all? Reflections on the development of a collaborative, three day a week internal medicine rounding experience.

PURPOSE: Interdisciplinary training is a critical part of pharmacy education, and often much of the interdisciplinary participation occurs during the advanced practice experiences of the final professional year of pharmacy education. Creation and maintenance of these experiences can be difficult for faculty members, especially faculty at community hospitals or those with multiple roles and responsibilities at their practice site. The purpose of this article is to reflect on the development process and student acceptance of a collaborative, three-day a week internal medicine rounding student experience. DESCRIPTION: Instead of a traditional five-day a week rounding schedule with a single, primary faculty preceptor, students participated in a three-day a week internal medicine rounding experience where their primary faculty preceptor had a faculty partner who functioned as a substitute. The student activities on the other days were adapted by each faculty preceptor based on their internal medicine subspecialty duties and needs of the practice site. ANALYSIS/INTERPRETATION: Results from a seven-question, anonymous survey to students who participated in the three-day a week internal medicine rounds found high impact on their reported confidence and knowledge. Those responding "positive impact" or "extreme positive impact" ranged from 67% to 100%. In addition, 78% indicated comfort with the substitute faculty preceptor. CONCLUSIONS: This collaborative, three-day a week rounding experience was well received by pharmacy students. IMPLICATIONS: Non-traditional rounding may be an option that could help decrease pharmacy student and faculty burnout, while still providing a positive learning experience for students.

Application Site Reactions from the Buprenorphine Transdermal Patch: A Case Series.

Buprenorphine is a partial mu-opioid agonist available as a transdermal patch for use in patients with chronic pain. Transdermal products can be associated with application site reactions (ASRs). The incidence of ASRs to the buprenorphine transdermal patch (BTP) have been described as low and seldom requiring patch discontinuation. In this case series, we describe four patients who developed an erythematous, rash-like ASR to the BTP leading to treatment discontinuation or rotation to buprenorphine buccal films (BBF). All subjects had demonstrated tolerability to lower patch strengths before developing an ASR with titration to a BTP of a higher strength. The strength at which an ASR emerged varied among subjects; however, all ASRs developed with BTP strengths 10 mcg/hr or higher. The dose-response relationship and prolonged onset to ASR emergence may be suggestive of an allergic delayed hypersensitivity reaction. However, in this case series three subjects demonstrated tolerability to BBF either before or after developing a skin reaction to BTP.

Time to Deprescribe: A Time-Centric Model for Deprescribing at End of Life.

In end-of-life care, deprescribing practices may vary considerably from one practitioner to the next, although most published frameworks for evaluating medication appropriateness in advanced illness consider three key principles (1) patient and caregiver goals, (2) remaining life expectancy (LE), and (3) medication time to benefit (TTB). The objective of this article is to provide clinicians with a structured, consistent approach for deprescribing that does not replace clinical judgment or the preferences of patients and their families but enhances it through clinical data. The emphasis will be on the time component of published models, including how to estimate remaining LE and medication TTB. Through case examples of two new hospice admissions, LE and TTB will be estimated and applied to deprescribing decisions. This time-centric approach may satisfy the palliative and hospice clinicians' desire for clear clinical justification for medication discontinuation while at the same time providing a strategy for communicating deprescribing rationale to patients and families.

Role of Atypical Bacteria in Hospitalized Patients With Nursing Home-Acquired Pneumonia.

Background: Nursing home-acquired pneumonia (NHAP) has been identified as one of the leading causes of mortality and hospitalization for long-term care residents. However, current and previous pneumonia guidelines differ on the appropriate management of NHAP in hospitalized patients, specifically in regard to the role of atypical bacteria such as Chlamydiae pneumonia, Mycoplasma pneumoniae, and Legionella. Objectives: The purpose of this review is to evaluate clinical trials conducted in hospitalized patients with NHAP to determine the prevalence of atypical bacteria and thus the role for empiric antibiotic coverage of these pathogens in NHAP. Methods: Comprehensive MEDLINE (1966-April 2016) and Embase (1980-April 2016) searches were performed using the terms "atypical bacteria", "atypical pneumonia", "nursing-home acquired pneumonia", "pneumonia", "elderly", "nursing homes", and "long term care". Additional articles were retrieved from the review of references cited in the collected studies. Thirteen published clinical trials were identified. Results: In the majority of studies, atypical bacteria were infrequently identified in patients hospitalized with NHAP. However, when an active community-acquired pneumonia (CAP) cohort was available, the rate of atypical bacteria between NHAP and CAP study arms was similar. Only 3 studies in this review adhered to recommended strategies for investigating atypical bacteria; in 2 of these studies, C. pneumoniae was the most common pathogen identified in NHAP cohorts. Conclusion: Although atypical bacteria were uncommon in most NHAP studies in this review, suboptimal microbial investigations were commonly performed. To accurately describe the role of atypical bacteria in NHAP, more studies using validated diagnostic tests are needed.