Long-acting Methylphenidate Induced Transient Orofacial Dyskinesia and Upper Extremity Choreoathetosis: A Case Report.

Attention-deficit/hyperactivity disorder (ADHD) is a commonly encountered diagnosis in the child and adolescent populations, and stimulant medications are often prescribed for their treatment. There are numerous available options in this category, including immediate and extended release formulations. There have been many case reports in the literature involving purposeful overdose on immediate release stimulants, but a relative paucity involving extended release forms. Additionally, they often involve Caucasian and Asian populations. We treated a Native American adolescent who took an overdose of extended-release methylphenidate with the intention of suicide. He developed transient orofacial dyskinesia and upper extremity choreoathetosis as a result which did not abate during his time in the emergency department. Once transferred to our care, he was given a one-time benzodiazepine dose with some benefit. This case report describes objective sequelae of a long-acting methylphenidate overdose as well as treatment for the benefit of treating clinicians with similar patient populations and situations.

Can Academic Detailing Move the Needle for Patients with Diabetes in a State-Based Prescription Drug Benefit Program?

BACKGROUND: Publicly funded prescription drug programs, such as state pharmacy assistance programs, provide critical benefits for the care of individuals, but they are frequently limited in their resources to optimize patient outcomes. The application of quality metrics to prescription drug claims may help to determine whether prescribers' adherence to national standards can be augmented through academic detailing. OBJECTIVE: To evaluate changes in diabetes drug prescribing patterns after an academic detailing educational intervention in 2013 and 2014 for prescribers in the Pennsylvania Pharmaceutical Assistance Contract for the Elderly (PACE) program. METHODS: We used a retrospective, quasiexperimental study design that applied interrupted time series and segmented regression analysis, and examined PACE pharmacy claims data for 1 year before and 1 year after the academic detailing intervention. Four diabetes prescribing metrics were evaluated at monthly intervals for a sample of 574 prescribers who received academic detailing and for a propensity score-matched comparison sample of 574 prescribers who did not receive the intervention. RESULTS: The prescribers who received academic detailing did not differ significantly after the intervention from the providers who did not receive the intervention in their prescribing trends for the 4 diabetes metrics. The observed time series patterns suggest that diabetes-related ceiling effects were likely, with relatively small room for improvement at the group level during the study period. CONCLUSION: The results of this study did not demonstrate group differences in prescribing trends that were attributable to the intervention. However, many prescribers in the detailed group had been exposed to similar educational outreach by PACE before 2013, which limits the interpretation of this finding. In addition, the diabetes quality metrics had been the standard of care during the preceding decade, with a broad dissemination of the treatment guidelines to the provider community. These results are consistent with a ceiling effect in the measured metrics, suggesting that most prescribers in both groups were largely following core diabetes guidelines before and after the intervention.

Impact of an innovative pain elective course on student beliefs and attitudes towards opioid medication use.

BACKGROUND AND PURPOSE: To determine if an innovative elective course in chronic pain management focused on a multimodal treatment approach changed student views on opioid use for chronic, non-cancer pain. EDUCATIONAL ACTIVITY AND SETTING: Offered to students in the second and third professional year, the course focused on various aspects of the treatment and impact of pain. Students completed two major, self-directed projects as well as four reflection journals throughout the semester. A nine question survey was provided to students on the first and last day of class that identified their beliefs and attitudes towards opioid use in chronic non-cancer pain using a five point Likert scale. FINDINGS: There was a statistical difference in one question asking if long acting opioids were effective in controlling pain long term. SUMMARY: There was evidence of change in student perceptions. Similar self-directed courses should be considered by other institutions as a means to change student beliefs and attitudes.

Escitalopram-associated acute urinary retention.

New-onset urinary retention can typically be explained by the use of the routine normally suspected medications (e.g., anticholinergics, antihistamines). However, selective serotonin-reuptake inhibitors are not typically presumed as the cause of acute urinary retention (AUR). The following case describes the introduction of escitalopram in a patient and the subsequent development of AUR. Medical causes of urinary retention had been ruled out, and ipratropium was initially suspected to be the cause of urinary difficulties and was discontinued. However, the retention persisted four days after suspending the ipratropium. Normal micturition resumed only after stopping the escitalopram without further need for catheterization. Escitalopram may cause rare cases of AUR and may often times be overlooked possibly because of the paucity of reporting.

Pharmacist instruction of physical assessment for pharmacy students.

OBJECTIVE: To assess the impact of a change from nurse to pharmacist instructors and a new curriculum intended to encourage students' use of physical assessment skills. DESIGN: Pharmacist faculty members redesigned the physical assessment curriculum to focus on those assessment skills most likely to be performed by practicing pharmacists. The 5 focus areas were general assessment skills, gastrointestinal system, pulmonary system, central and peripheral nervous system, and cardiovascular system. Instructional methods used included prelaboratory assignments, brief introductory lectures, demonstration of assessment techniques, application of techniques with a laboratory partner, and demonstration of competence using a mannequin. ASSESSMENT: A 16-item survey instrument was administered to determine students' perceptions of the revised curriculum. Students who received instruction from pharmacist faculty members used their physical assessment skills more, especially during advanced pharmacy practice experiences (APPEs), than students who received instruction from nurse faculty members. Students instructed by pharmacist faculty members also felt more comfortable with their skills and rated the instruction as more practical. CONCLUSION: A redesigned curriculum and pharmacist-led instruction resulted in improved pharmacy student comfort with and use of physical assessment skills.

Educational outreach (academic detailing) regarding osteoporosis in primary care.

BACKGROUND: Academic detailing utilizes educators trained in social marketing to conduct one-on-one visits with physicians using evidence-based data. Academic detailing programs have improved physician's prescribing behaviors; however, the feasibility of large-scale programs across a large, geographically disperse state is unclear. METHODS: The study team collaborated with a state-run pharmacy benefits program for low-income elderly in a trial to improve osteoporosis management. Community-practicing physicians who saw a minimum of 25 patients enrolled in the benefits program were randomized to receive academic detailing or not. Fourteen educators were trained in the principles of academic detailing as well as osteoporosis epidemiology, diagnosis, and treatment. From September 2003 to January 2004, they attempted to meet with physicians or an allied health professional to discuss osteoporosis and fracture prevention. RESULTS: The physician population was 356 and 148 (41.6%) visits were completed-100 with physicians, 38 with allied health professionals, and 10 with both the physician and an allied health professional. In mixed multivariable models, there were no physician characteristics associated with completed encounters, including gender, training, geographic location, years since medical school, and number of study patients (all p-values > 0.11). The detailer's gender, professional training, and professional experience were not statistically significant correlates of completed encounters (all p-values > 0.28). Number of years since a detailer's professional training was a predictor of a completed encounter, OR = 1.43 per 5 years (95%CI 1.05, 1.96). CONCLUSIONS: A moderate rate of completed encounters was achieved. There was only one predictor of completed encounters.