A Case Series of Adult Patients Diagnosed with IgA Vasculitis Requiring Systemic Immunosuppression.

BACKGROUND IgA vasculitis (IgAV) is a rare and potentially life-threatening small-vessel vasculitis in adults. The disease course is often more severe than its childhood counterpart. The disease is noted for its heterogeneous presentation with varying severity. There are no current treatment guidelines for severe multi-organ involvement of IgAV. The treatment approaches based on the clinical discretion of treating doctors remain controversial, especially regarding the role, duration, and type of immunosuppression. CASE REPORT We present 3 cases of severe multi-organ IgAV encountered at our tertiary referral center between 2016 and 2021, which were treated with different immunosuppression regimens, including combination of systemic corticosteroids, oral immunosuppressants (azathioprine, mycophenolate, and sirolimus), rituximab, and cyclophosphamide. In these patients, IgAV presented differently but were all organ-threatening or life-threatening in nature. IgAV in all patients responded to therapies; however, infection complicating underlying comorbidities was the cause of death in 1 patient and the cause of comorbidities in the other 2. Other treatment-related complications included weight gain, adrenal insufficiency, and secondary hypogammaglobulinemia. CONCLUSIONS IgAV can be a polyphasic and a potentially challenging severe organ-threatening disease to treat in adults. The outcomes presented here highlight the morbidity and substantial risks involved in treating complex IgAV patients. Early use of biologics may have a role in preventing treatment-related toxicity. Further studies on IgAV in adults are urgently needed.

Prevalence and Social Acceptability of Cannabis, Tobacco, and Alcohol Use in Adult Women.

Background: As more US states legalize cannabis use, prevalence of use continues to rise and attitudes toward use are changing. This study examined (1) the relationship between cannabis use and social acceptability of use and (2) how social acceptability and use of cannabis relate to anxiety, depression, and several pain conditions. Materials and Methods: Participants were n = 210 nonpregnant women recruited from two women's health clinics for an anonymous survey of complementary and integrative health practices. Survey domains included demographics, recent and lifetime cannabis, cigarette, and alcohol use, depression, anxiety, pain, and social acceptability of substances studied. Results: The sample had a mean age of 38.7 years and was 50.0% Black. Approximately 12.9% of the sample endorsed recent cannabis use, 17.2% endorsed recent cigarette use, and 57.5% endorsed recent alcohol use. Acceptability of use varied by substance. One-third (33.3%) of women found cannabis use to be socially acceptable. Higher social acceptability scores for cannabis were correlated with higher acceptability scores for each of the other substances studied, with the strongest correlation for e-cigarettes (R 2 of 0.395, p < 0.001) and the weakest for alcohol (R 2 of 0.296, p < 0.001). Women reporting anxiety (38.9%) and recent acute pain (28.6%) rated cannabis use as more socially acceptable than those without such symptoms. Conclusions: Women with recent cannabis use were more likely to find use of alcohol, tobacco, and cannabis to be socially acceptable than those not reporting cannabis use. More research is needed to better understand these relationships, as they might help to identify opportunities for education and intervention in this population.

Developing a Measure of Students' Potential Involvement in Scholarly Activities.

BACKGROUND: Pharmacy schools must encourage a culture of inquiry so future pharmacists approach practice in a scholarly fashion. OBJECTIVES: To develop an instrument measuring intentions to engage in various scholarly activities. METHODS: Items representing scholarly activities relevant to pharmacists were developed. Exploratory factor analysis (EFA) was used to refine the list and identify underlying factors. Internal consistency was examined using Cronbach's alpha. Results were compared across student characteristics using unpaired t tests and 1-way analysis of variance. Key Findings: The initial list of 54 items was reduced to 31 after review and then administered to 381 pharmacy students (337 complete responses; 88% response rate). EFA suggested 3 factors with 4 items being removed due to low factor loadings. The final Potential Involvement in Scholarly Activities (PISA) instrument contained 27 items in 3 domains: research activities (13 items), professional writing (9 items), and practice evaluation/quality improvement (5 items). Cronbach's alphas were ≥0.85 for the total scale and domains. PISA scores were statistically higher for first-year students and those with previous research experience or post-graduate training interests. CONCLUSIONS: Initial development of the PISA instrument suggested a 3-factor structure with acceptable internal consistency in this sample. Continued work is needed to examine the instrument in more diverse samples.

Don't Get Stuck: A Quality Improvement Project to Reduce Perioperative Blood-Borne Pathogen Exposure.

BACKGROUND: Blood-borne pathogen exposure (BBPE) represents a significant safety and resource burden, with more than 380,000 events reported annually across hospitals in the United States. The perioperative environment is a high-risk area for BBPE, and efforts to reduce exposures are not well defined. A multidisciplinary group of nurses, surgical technologists, surgeons, and employee health specialists created a BBPE prevention bundle to reduce Occupational Safety and Health Administration (OSHA) recordable cases. METHODS: Mandatory double gloving, a safety zone, engineered-sharps injury prevention devices, and clear communication when passing sharps were implemented in an evidence-based fashion at one institution. Days between exposures and total number of exposures were monitored. Analysis by specialty, role, location, type of injury, and timing was performed. RESULTS: During fiscal year (FY) 2015, 45 cases were reported. During the first year of implementation, cases decreased to 38 (a 15.6% decrease; p < 0.65). In the postimplementation period (FY 2017), only 21 cases were reported (an additional 44.7% decrease; p < 0.12), for a total decrease of 53.3% (p < 0.01). The mean number of days between injuries significantly increased (2.5 to 16.3) over the study period. For FY 2017, the main cause of BBPE was needlestick while suturing (47.6%); fellows and attendings combined had the most injuries (52.4%); among divisions, pediatric surgery (19.0%), operating room staff (19.0%), and orthopedics (19.0%) had the most events. CONCLUSION: A comprehensive and multidisciplinary approach to employee safety, focused on reduction of BBPE resulted in a significant progressive annual decrease of injuries among perioperative staff.

Improving haemodialysis fistula maturation following early ultrasound vascular mapping: 'The Venous Preservation Scan'.

AIM: Formation of autogenous arteriovenous fistula (AVF) in patients with chronic kidney disease (CKD) is complicated by a high primary failure rate. We hypothesized that early (months to years before AVF creation) Venous Preservation Scan (VPS) followed by vasculature preservation is effective in protecting the patient's best 'for fistula' vasculature. This study was performed to evaluate the impact of VPS on AVF outcomes. METHODS: The case records of 123 patients who underwent ultrasound mapping for AVF creation in a district hospital were reviewed. Ninety-seven were VPS and 26 were Routine Pre-Operative Planning Scan (RPOPS) performed immediately prior to surgery. Outcomes of 21 patients who went onto AVF creation in the VPS group were compared to 23 patients in the RPOPS group. RESULTS: Success and complication rates for AVF placement in patients who underwent VPS versus RPOPS were 100% versus 91.3% (P = 0.27) and 0 versus 8.7% (P = 0.23). A greater proportion of AVF created following RPOPS required intervention before maturation (47.6% vs 19%, P = 0.05). The median primary patency of AVF created following VPS versus RPOPS was 492 (IQR 222, 1219) versus 169 (IQR 116, 414) days (P = 0.02). The cumulative patency did not differ between the two groups (median = 807 (IQR 499, 1308) versus 1059 (IQR 331, 1263) days, P = 0.26). CONCLUSIONS: This small study suggests that VPS may favourably influence the survival of primary AVF and reduce the need for assisted interventions. However, confirmation with larger randomized controlled trial is warranted.

Implementation of an online ethics course into a pharmacy curriculum.

BACKGROUND AND PURPOSE: To evaluate students' ethical reasoning skills after implementation of a series of online modules containing ethical content. EDUCATIONAL ACTIVITY AND SETTING: A four-module online ethics series was created and embedded in the learning management system of a second-year pharmacy skills lab course. The Defining Issues Test Version 2 (DIT-2) was administered before and after completion of the ethics module series. Results of the DIT-2 were used to evaluate the impact of the modules on students' ethical thinking ability. An optional written survey utilizing Likert-scale questions was administered at the end of the study to assess students' perceptions of the course. FINDINGS: A total of 134 students were enrolled in this study. After removal of voluntary exclusions and unreliable data, 107 DIT-2 tests were evaluated. The study failed to demonstrate a statistically significant increase in pre- and posttest DIT-2 scores. Student scores were higher than other pharmacy students' scores that were previously reported in the literature. Thirty-four (26.1%) students participated in the optional survey. The results demonstrated perceived value of the online ethics series, with students indicating improved understanding, confidence, and ability to consider other perspectives when dealing with medical ethical dilemmas. SUMMARY: Implementing an online ethics series into a pharmacy curriculum failed to produce statistically significant increases in ethical thinking ability as measured by the DIT-2. However, students indicated a benefit from participating in the course as evidenced by responses to a post-course survey.

Pharmacognosy, a Classical Theme Tuned to a Contemporary Melody.

Objective. To describe the development of a pharmacognosy course that uses a combination of didactic teaching, team-based projects, and practicum laboratory practice. Methods. A course titled "Pharmacognosy" was developed by applying a three-tier teaching methodology: in the classroom, the basic concepts and principles were introduced in a didactic manner; outside the classroom, students worked in teams and each team created an independent literature-based research project that was submitted as a poster presentation; in the pharmacy practicum laboratory, students worked individually and conducted a quality control experiment comprised of a quantitative analysis of an herbal product. Results. During the seven-year course implementation, 1091 first-year PharmD students participated in the course. Their performance was consistently satisfactory. On average, 30% of students in each class received a grade of "A" and teams received a "B" and above on their projects. Conclusion. The pharmacognosy course, equipped with concurrent teaching methods, implemented with a group research project, and reinforced by practicum laboratory experience, has reached the original goal of introducing a classical topic in an updated and contemporary fashion to meet the requirement of integrated pharmacy education and practice.

Patient-centeredness and empathy in a bilingual interprofessional primary care teaching clinic: a pilot study.

Utilizing the Consultation and Relational Empathy survey, this project examined the perceptions of care team empathy and patient-centeredness between English- and Spanish-speaking patients. From fall through spring semesters, patient surveys from a primary care, interprofessional student-led teaching clinic were collected and analyzed. Overall, mean scores for both English- and Spanish-speaking patients were above the reported normative average for general practitioners. While, overall, patients expressed satisfaction with the student-led teaching clinic in terms of empathy and patient-centeredness, English-speaking patients had higher median scores than Spanish-speaking patients. Analyzed individually, questions related to communication and provider attitudes were scored lower by Spanish-speaking patients. These results demonstrate that student-led clinics can deliver patient-centered care and highlight the continuing need to investigate and address disparities between English- and Spanish-speaking patients with regard to feelings of empathy and patient-centeredness.

Educational Needs in Supportive and End of Life Care.

With variable availability of RSC programmes available throughout Australia and New Zealand, there is a need for provision of training in this area to be available to all medical and paramedical staff On-line resources may be a potential source of training material for staff and information for patients and families. The possibility of exchange programmes between renal medicine and palliative care should be explored as a way of enhancing education in both fields. The ANZSN and the ANZ Society of Palliative Care both have special interest groups in RSC. The potential for bringing these two groups together to facilitate cross-specialty training should be explored.

Nosocomial Pneumocystis jirovecii pneumonia: lessons from a cluster in kidney transplant recipients.

BACKGROUND: Pneumocystis jirovecii pneumonia (PJP) is an important infection-related complication, whose mode of transmission remains uncertain. METHODS: We investigated a nosocomial cluster of 14 PJP cases (11 confirmed and 3 probable) in kidney transplant recipients using epidemiological and genotyping methods. RESULTS: Poisson regression calculated an incidence density ratio of 42.8 (95% confidence interval [CI], 14.1-129.3) versus background 0.64 cases of 1000 patient-years (P<0.001). All patients presented with respiratory failure, 10 required ventilation, two died, and six transplants failed, costing $31,854 (±SD $26,048) per patient. Four-locus multilocus sequence typing analysis using DNA extracts from 11 confirmed cases identified two closely related genotypes, with 9 of 11 sharing an identical composite multilocus sequence typing genotype. Contact tracing found colocalization of cases within clinic waiting areas, suggesting person-to-person transmission. Minimal and maximal PJP incubation periods were 124±83 to 172±71 days, respectively. Oropharyngeal washes from outpatient staff and ambient air samples were negative for P. jirovecii DNA. Cohort analysis (14 cases vs. 324 unaffected clinic control patients) identified independent risk factors including previous cytomegalovirus infection (odds ratio [OR], 65.9; 95% CI, 7.9-550; P<0.001), underlying pulmonary disease (OR, 10.1; 95% CI, 2.3-45.0; P=0.002), and transplant dysfunction (OR=1.61 per 10 mL/min/1.73 m, 95% CI, 1.15-2.25, P=0.006). The outbreak was controlled by reintroduction of trimethoprim/sulfamethoxazole prophylaxis to all potentially exposed clinic patients and its extension to 12 months in recent recipients. CONCLUSIONS: Nosocomial PJP clusters are likely due to interhuman transmission by airborne droplets to susceptible hosts. Prompt recognition and a strategy of early preemptive blanket PJP prophylaxis to all exposed transplant clinic recipients from the third confirmed case are recommended to limit outbreak escalation.

Review: modelling the dialysate.

Dialysate prescription is evolving as new technology allows greater opportunity to alter dialysate constituents throughout dialysis, providing scope for tailored prescription for an individual patient. The intention of modelling or profiling is to improve the tolerability of dialysis and long-term patient outcomes. This approach can be applied to both electrolytes and water. Despite these advances in technology, benefits of modelling have not been demonstrated consistently. This review examines the use of individual prescription and modelling of dialysate sodium, ultrafiltrate, potassium, calcium, magnesium, bicarbonate and phosphate.

Evaluating student perceptions of a learner-centered drug literature evaluation course.

OBJECTIVE: To evaluate pharmacy students' perceptions of a drug literature evaluation course implementing learner-centered teaching principles. DESIGN: A drug literature evaluation course was redesigned to create a more learner-centered course through the inclusion of optional assignments, self-reflection opportunities, and a point-based grading system. A questionnaire was developed to assess student perceptions of the course and preferences for the learner-centered approach. ASSESSMENT: One hundred two questionnaires were returned (94.4% response rate). The most highly rated items were those related to student control in determining their overall grade (4.7 +/- 0.6; mean +/- SD), less pressure to perform well on every examination or assignment (4.5 +/- 0.9), and a less stressful learning environment (4.4 +/- 1.0). Eighty-eight percent of students found that completing the optional assignments helped reinforce material presented in class. CONCLUSIONS: Learner-centered methods were viewed favorably by students. The effects of learner-centered teaching on pharmacy education deserve further study.

An exploratory study of drug abuse and dependence information in package inserts.

Information about drug abuse and dependence from package inserts of centrally acting drugs was evaluated for content. Of the 77 labels reviewed, 40 were opiate agonists, 18 were stimulants, and the remainder fell into other selected categories. The amount of information ranged from 0-66 sentences, with greatest variability found in the opiate agonists (range 9-66). Information amount was significantly correlated with the year of drug approval (p < 0.001) but not with the latest label revision (p = 0.749). Information amount did not differ significantly with warning strength or schedule. While most package inserts explain physical dependence, tolerance, and withdrawal, there is a lack of information about psychological dependence. Variability in information about abuse and dependence potential is high and can affect prescribing by physicians and counseling by pharmacists, underscoring the need for further studies.