bluuebunny/crossref_metadata_2025 huggingface dataset:
Communication Training and Assessment Using Webcams
Authors: Powers Mary F , Bright David R
Published: September 2013

Background:

Communication training is a necessary and valuable component of the education of pharmacists and pharmacy technicians. Video recording students during communication exercises provides a basis for providing feedback that allows the students to improve their skills.

Objective:

To describe how webcams and notebook computers were used as an alternative method for recording students during communication exercises in a professional practice development laboratory in a PharmD program.

Methods:

P-2 pharmacy students participated weekly in 3-hour laboratory sessions in a professional practice development course and engaged in interviewing and counseling activities. This article describes the transition from VHS camcorders to webcams. Surveys were distributed to 107 students, 8 teaching assistants, and the laboratory instructor. Student perspectives, teaching assistant perspectives, and faculty perspectives for the VHS method and webcam method were evaluated and compared.

Results:

The majority (75%) of teaching assistants reported a perceived time savings with the webcams, and all teaching assistants and faculty perceived a benefit in providing the students with a digital recording for immediate feedback as compared with a 2-week delay in distributing VHS recordings of patient counseling sessions. More students reported having access to a computer capable of playing the digital video recording as compared with access to a VHS player (96.1% vs 39.8%; p < 0.001). Furthermore, 61.2% of students reported watching the recorded counseling session outside of class.

Conclusions:

Using webcams for recording pharmacy communication exercises in a pharmacy practice laboratory was demonstrated to provide a useful means for self-assessment and constructive feedback. Additionally, the technique may be useful in other laboratory courses for PharmD students.
Ramelteon Treatment of Insomnia
Authors: Singh Angela C , Hill Angela M , Ghazvini Patty , Patel Jalpa , Mahdavian Soheyla
Published: September 2013

Objective:

To provide an overview of the use of ramelteon for the treatment of insomnia.

Data Sources:

A literature review was conducted through PubMed using the terms ramelteon, insomnia, treatment, adverse events, elderly, and melatonin. Additionally, reference citations from publications identified were reviewed. Data from 1982 to 2009 were gathered.

Study Selection and Data Extraction:

All articles in English that were identified from the data sources were evaluated.

Data Synthesis:

Long-term clinical trials of ramelteon have demonstrated that it is effective and safe, causing minimal adverse effects and no potential for abuse. Additionally, discontinuation of ramelteon does not result in rebound insomnia, which makes it an ideal agent for the management of insomnia in the elderly population.

Conclusions:

Ramelteon offers a safe and effective new therapeutic option for patients experiencing transient or chronic insomnia.
Improved Stability in INR with Coumadin for a Patient Requiring Very Low Warfarin Doses
Authors: Anderson Douglas C , Poulos Phillip , Scoggins Bernard P
Published: September 2013

Objective:

To describe a patient who required very low doses of warfarin but who could not achieve therapeutically stable anticoagulation until treatment was switched from generic to branded warfarin.

Case Summary:

A 53-year-old male with a history of hypertension, coronary artery disease, heart failure, and mild renal insufficiency was diagnosed with atrial fibrillation during a routine examination. Anticoagulation was started with warfarin 5 mg daily. The patient presented to the anticoagulation clinic 2 days later with an international normalized ratio (INR) of 5.4 and no signs or symptoms of bleeding. Warfarin was held for 3 days until the INR was <3. Warfarin was then restarted at 2.5 mg daily. Over the next week his INR rose to 4.8; warfarin was again held and restarted at 1.5 mg/day. Although the warfarin dose was eventually titrated to 6.5 mg/wk, the INR never stabilized and the patient only had consecutive therapeutic INRs twice in 1 year and only one 3-month period with therapeutic INRs not requiring any dosage adjustments. The decision was made to switch from the generic product to Coumadin to try to improve stability. Several dosage adjustments were made over the 6 weeks following the switch before the INR was stabilized with 7 mg/wk. Subsequent INRs ranged from 2.0 to 2.2 in the 3 months after the switch, during which time INRs were measured at least weekly. Over 14 months after the switch, the patient did not have an INR outside of the therapeutic range.

Discussion:

Many patients are able to take generic warfarin without problems. However, case reports have documented occasional patients who have had problems after switching to a generic product. Large cohorts have been switched to generic warfarin without experiencing significant changes in therapeutic control. However, 1 cohort study found that patients who required very low warfarin dosages had significant changes in their INR after switching to a generic product.

Conclusions:

Patients who require very low warfarin dosages to consistently maintain therapeutic anticoagulation may experience less therapeutic stability while on a generic product.
Community Pharmacy Use Patterns of Women with HIV and Women at Risk for HIV in the San Francisco Bay Area
Authors: Cocohoba Jennifer M , Hsu Tracy , Greenblatt Ruth M.
Published: September 2013

Background:

Community pharmacies play a key role in the care of patients when dispensing antiretroviral therapy.

Objective:

To determine factors associated with the use of multiple dispensing pharmacies to obtain medications in a population of HIV-positive and at-risk women and to determine whether use of multiple pharmacies was associated with immunologic or virologic changes for the subset of HIV-positive women.

Methods:

A survey on community pharmacy use was distributed to participants in the Women's Interagency HIV Study, San Francisco site, from 2004–2007. Poisson, linear, and logistic regression methods were used to determine associations between specific patient characteristics and use of multiple dispensing pharmacies and associations between multiple pharmacy use and CD4+ cell count or viral load changes.

Results:

There was a trend toward an association between HIV status and use of multiple pharmacies (IRR 1.23; 95% CI 1.00 to 1.51; p = 0.05). In multivariable analyses of HIV-positive women, use of additional pharmacies (over the primary pharmacy) during the study period was not associated with statistically significant changes in CD4+ count or viral load.

Conclusions:

HIV-positive participants may tend to use multiple pharmacies more frequently than their HIV-negative counterparts do, though this practice does not appear to be associated with poorer immunologic or virologic outcomes. Further studies should be conducted to determine whether different patient patterns of community pharmacy use affect HIV treatment outcomes.
Roles of Intravenous Iron Therapy in Various Patient Settings
Authors: Nguyen Timothy V , Wang Amy , Kim Sara S
Published: September 2013

Objective:

To provide clinical information on intravenous iron products and their role in chronic kidney disease (CKD), dialysis, oncology, critical illness, and heart failure.

Data Sources:

Intravenous iron products information, national clinical practice guidelines, and the latest primary literature available were reviewed. PubMed and MEDLINE databases were searched from January 2000-December 2009.

Study Selection and Data Extraction:

All FDA-approved intravenous iron products information, available national clinical practice guidelines, and primary literature were included.

Data Synthesis:

Iron deficiency is common in patients with CKD, dialysis, oncology, critical illness, and heart failure. Routine supplementation with intravenous iron therapy is indicated in patients with CKD, including those receiving dialysis; however, its role in oncology, critical illness, and heart failure is not clearly defined. Assessing patients for iron deficiency, evaluating their status, and knowing the risks of adverse events are important in determining the roles of intravenous iron therapy in each setting. If patients are initiated on intravenous iron, they must be closely monitored for signs and symptoms of adverse drug reactions, as well as clinical worsening. Additionally, intravenous iron must be discontinued upon resolution of iron deficiency.

Conclusions:

The importance of intravenous iron therapy is well established in patients with CKD, including those receiving dialysis, who have iron deficiency. Its roles in oncology, critical illness, and heart failure should be assessed on a case-by-case basis.
Sailin' into Savannah…Pharmacy Techs and Beyond: 2010 PTEC Annual Meeting Report
Authors: Sparks Jason P
Published: September 2013

The 2010 Pharmacy Technician Educators Council (PTEC) Annual Meeting was held July 15–17, 2010, in Savannah, GA, at the historic Mulberry Inn. A series of continuing education sessions on the topics of pharmacy technician education, certification, professionalism, legislative involvement, and updates to ASHP-accreditation were hosted. The meeting concluded with the annual banquet, induction of the new board officers, and annual auction. The 2011 PTEC meeting will be held in Memphis, TN, July 14–16.
Overview of Chemotherapy and Nine Commonly Prescribed Chemotherapeutic Medications
Authors: Smith Tara L , Carter Chenita W
Published: September 2013

Objective:

To briefly review cancer treatment and describe 9 commonly prescribed chemotherapeutic agents currently approved by the FDA: anastrozole, bicalutamide, capecitabine, erlotinib, imatinib, imiquimod, lenalidomide, letrozole, and temozolomide.

Data Sources:

Literature retrieval was accessed through PubMed (2000-June 2010) and Ovid (2000-June 2010), using search terms of chemotherapy and chemotherapy safety. Reference citations from publications identified were reviewed. Individual drugs were researched by generic name, using drug-dosing literature as referenced.

Study Selection and Data Extraction:

Articles in English and relating to chemotherapeutic handling and safety were identified and evaluated for content relevant to the drugs being reviewed.

Data Synthesis:

Oral and topical chemotherapy agents are being prescribed more frequently for patients with cancer as part of their out-patient treatment protocols. Since many drugs are dispensed for patients to self-administer at home, it is important for health-care workers—and patients taking these drugs—to know the safest way to handle them. Pharmacy personnel should be familiar with these agents to provide proper patient counseling on how to take the drug, what adverse effects to expect, and other drugs that may need to be taken concomitantly (ie, antiemetics).

Conclusions:

Oral and topical chemotherapy medications are being used more frequently in chemotherapeutic protocols for patients to self-administer at home. It is important to understand how these drugs work as well as important facts that need to be relayed to patients regarding adverse effects, handling, and exposure.
Pharmacists' Perceptions of the Value of Technician Certification through a Nationally Accredited Certification Program
Authors: Desselle Shane P , Schmitt Michael R
Published: September 2013

Background:

There has been considerable debate over the appropriate credentialing of pharmacy technicians; however, there have been no previous attempts to ascribe the value associated with national certification.

Objective:

To assess pharmacists' perceptions of the skills, knowledge, and attitudes gained by technicians from the certification process and toward pharmacy technician certification in general.

Methods:

A self-administered questionnaire was mailed to a random sample of pharmacists from 6 states. These states were selected primarily due to criteria regarding their regulations on technician certification so that pharmacists had the opportunity to work with both certified as well as noncertified technicians. The questionnaire contained items to elicit respondents' perceptions of the impact of certification on technicians' skills, knowledge, and attitudes, as measured on Likert-type scales. There were additional items related to overall perceptions of the certification process. Unpaired t-tests, 1-way analyses of variance, and Wilcoxon ranked-sign tests were conducted.

Results:

Analyses were conducted on 609 usable responses among the 795 returned. Certification was reported to have a moderate contribution toward myriad technician skills, knowledge, and attitudes in ambulatory and acute care settings. Pharmacists in ambulatory care settings, with greater familiarity with the Pharmacy Technician Certification Examination, were more positive (p < 0.01) about the impact of certification. Certification of technicians was viewed as a more valuable source of training and education than prior nonpharmacy work experience, completion of a vocational training program, or a 4-year college degree (p < 0.001) and equal to prior pharmacy work experience in another setting (p = 0.73). A vast majority of pharmacists supported mandatory certification and standardized education requirements to sit for a national certification examination.

Conclusions:

Pharmacists view certification as a valuable means of enhancing technician competence. Combinations of pedagogic approaches and experiential education may further improve technician proficiency and enhance patient care.
Amiodarone-Induced Neuropathies and Related Neurotoxicities
Authors: Slowe Kristen K , Krikorian Susan A
Published: September 2013

Objective:

To report the frequency and symptomatic characteristics of amiodarone-induced neuropathies and related neurotoxicities.

Data Sources:

Literature retrieval was accessed through MEDLINE and PubMed (1950–July 2010), using the terms amiodarone, neuropathy, and neurotoxicity. In addition, reference citations from publications identified were reviewed.

Study Selection and Data Extraction:

All articles published in English retrieved from the data sources were assessed. Case reports, randomized trials, and retrospective medical record analyses were included in the review.

Data Synthesis:

The frequency and characteristics of amiodarone-induced neurologic disturbances are not well established. We reviewed 7 case reports, 8 randomized trials, and 1 retrospective record analysis. Neurologic adverse reactions associated with amiodarone therapy consistently presented as tremor, gait ataxia, peripheral neuropathy, or a combination. Amiodarone dose and duration of exposure ranged from 200 mg/day to 1200 mg/day and 21/2 months to 20 years, respectively, across case reports. Similarly, clinical trials and retrospective analysis demonstrated widely varying rates of neurotoxicity after amiodarone exposure, from 1.6% to 54%. A dose- or duration-dependent nature of amiodarone exposure and its associated neurotoxicity is difficult to substantiate, based on current literature. Nonetheless, the nature of its clinical presentation and mechanism of pathogenesis is better understood.

Conclusions:

A dose- or duration-dependant rise in the frequency of amiodarone-induced neurologic disturbances has not been established, due to variances in dose and duration exposure, differing study definitions of neurotoxicity, and inconsistent criteria for reporting a drug event, across relevant literature.
Evaluation of Anticoagulation Management and Chronic Disease State Control in a Pharmacist-Run Pharmacotherapy/Anticoagulation Clinic
Authors: Sease Julie M , Blake Elizabeth W , Gowan Mollie , Shealy Kayce M
Published: September 2013

Background:

The benefit of pharmacist-run clinics for anticoagulation, dyslipidemia, diabetes, and hypertension has been described in the literature as individual services. We describe a clinic model in which anticoagulation and other chronic disease states are managed concomitantly.

Objective:

To evaluate the control of anticoagulation, hypertension, dyslipidemia, and diabetes in anticoagulation patients enrolled in a pharmacotherapy/anticoagulation clinic.

Methods:

Patients seen in the pharmacotherapy/anticoagulation clinic for management of anticoagulation were included in a retrospective review. Demographic information, blood pressure measurements, and laboratory values were recorded. Initial and final results were compared and statistically analyzed. Benchmark goals were set for each parameter analyzed.

Results:

Between August 2007 and July 2008, 282 patients were enrolled in the clinic. While slightly increasing the average time in therapeutic range from 69.9% to 70.7%, the clinical pharmacists also managed hypertension, dyslipidemia, and diabetes, if present. Systolic (p = 0.0075; 95% CI 0.98 to 6.31) and diastolic (p = 0.004; 95% CI 1.26 to 4.33) blood pressures decreased during the study period such that the number of patients with controlled blood pressure increased to 81%. Low-density lipoprotein cholesterol measurements decreased by an average of 5.9 mg/dL (p < 0.0001; 95% CI 3.121 to 8.789), with an increase in number of patients at goal to 86%. Although not significant, mean hemoglobin A1c (A1C) values decreased an average of 0.12% (p = 0.1138; 95% CI 0.029 to 0.271), with an increase to 59% of those achieving a goal A1C.

Conclusions:

A pharmacotherapy/anticoagulation clinic can be considered a practice model for effective management of anticoagulation patients who require management of other chronic disease states.
Training Community Pharmacy Technicians about Their Roles in the Provision of Medication Therapy Management Services
Authors: Pattin Anthony Jamarr , Powers Mary F , Lengel Aaron J
Published: September 2013

Background:

Although increased patient access and reimbursement opportunities are available through medication therapy management (MTM), strategies must be employed to decrease barriers to providing MTM services in a retail pharmacy.

Objective:

To describe a program for training community pharmacy technicians about their role in the provision of MTM services while evaluating their attitudes about and understanding of MTM.

Methods:

A training program was developed for community pharmacy technicians, aimed at defining MTM and designating nonclinical skills that can be developed to decrease the burden on pharmacists who perform MTM. All pharmacy technicians within a zone of a supermarket chain were invited to participate in the training program. Immediately prior to the training program, participants completed a pretest survey. After the training program, technicians completed a posttest survey. Surveys were designed to capture technicians' understanding of MTM and their attitudes about performing functions in the MTM process.

Results:

Of 150 technicians available in the designated zone, 28 volunteered to complete the MTM training program and surveys. More technicians responded that they believe that they have a role in MTM services after the training program (21.4%) than did before the training program (3.6%). Posttest results, compared with pretest results, indicated that technicians strongly agreed that they can help with MTM services (p < 0.01). Posttest responses showed that more technicians agreed that MTM services are important for patients, compared with pretest responses.

Conclusions:

Participants indicated that they are willing to help pharmacists complete MTM cases by performing nonclinical tasks. The widespread use of MTM training programs for pharmacy technicians is necessary to evaluate effective ways to prepare pharmacy technicians to assist with the MTM process.
The Role of Antioxidant Vitamins in Cardiovascular Disease
Authors: Seefeldt Teresa M , Bennet Lunawati L
Published: September 2013

Objective:

To review the current data on the role of antioxidant vitamins in cardiovascular disease.

Data Sources:

Articles were obtained from a MEDLINE search covering all years. Terms used in the search included combinations of antioxidant, vitamin, vitamin E, vitamin C, beta-carotene, and cardiovascular disease. Reference lists from articles were examined for additional references.

Study Selection and Data Extraction:

Randomized clinical trials were selected and evaluated for study design and data obtained. Observational studies, meta-analyses, and basic science articles were also reviewed for background.

Data Synthesis:

The use of dietary supplements, including vitamins, minerals, and herbal products, is common among patients in the US. Vitamin E, vitamin C, and beta-carotene are all supplements with reported antioxidant activity. Because oxidative stress has been implicated in the development of cardiovascular disease, there has been significant research at the basic science level as well as observational studies and randomized placebo-controlled trials examining the potential impact of vitamin E, vitamin C, and beta-carotene in the prevention and treatment of cardiovascular disease. While basic science data and data from observational studies have identified benefit from antioxidant vitamin supplementation, randomized clinical trials have failed to support a role for antioxidant vitamin supplementation in the prevention or treatment of cardiovascular disease.

Conclusions:

Data from randomized clinical trials do not support the use of antioxidant vitamins in cardiovascular disease. Therefore, antioxidant vitamins should not be recommended to patients for prevention or treatment of cardiovascular disease.
A Review of Commonly Prescribed Antiviral and Antiretroviral Agents
Authors: Mansour Hanine , Inge Lisa Devito , Ferreira Jason , Unger Nathan R
Published: September 2013

Objective:

To review the pharmacologic properties of and uses for the most commonly prescribed antiviral agents.

Data Sources:

A MEDLINE/PubMed search (1966–September 2010) was conducted for English-language articles using the terms HIV, hepatitis, cytomegalovirus (CMV), herpes simplex virus (HSV), antiviral agents, antiretroviral agent, acyclovir, valganciclovir, valacyclovir, interferon, ribavirin, ritonavir, efavirenz, zidovudine, darunavir, lopinavir, tenofovir, raltegravir, lamivudine, atazanavir, and emtricitabine. Book chapters and recent guidelines pertaining to the pathophysiology or pharmacologic properties of antiviral agents were also reviewed.

Study Selection and Data Extraction:

Articles, chapters, and guidelines pertaining to the relevant pharmacologic agents were collected for review.

Data Synthesis:

Viral pathogens affect multiple organs, causing direct and indirect damage by activating an immune response. Unlike bacterial infections, which can be eradicated from the host system, viral infections are not curable. Antiviral treatments are prescribed to reduce morbidity and mortality. There are many antiviral and more than 20 antiretroviral agents currently approved by the FDA. These include acyclovir, valacyclovir, and famciclovir for HSV; ganciclovir, valganciclovir, foscarnet, and cidofovir for CMV; interferon and ribavirin for hepatitis; efavirenz, tenofovir, emtricitabine, atazanavir, darunavir, lopinavir, ritonavir, raltegravir, zidovudine, and lamivudine as first-line agents for HIV.

Conclusions:

Viral illnesses affect a large portion of the population. Given the multitude of drugs available, pharmacists and pharmacy technicians should be educated about common treatment options. Having a strong knowledge of commonly prescribed antiviral drugs allows these frontline professionals to make a significant impact on the quality of care that they provide to their patients and community.
Pharmacy Technicians and Immunizations
Authors: Powers Mary F , Hohmeier Kenneth C
Published: September 2013

Objective:

To provide background on immunizations and community pharmacies and identify opportunities for pharmacy technicians to assist pharmacists in providing community pharmacy-based immunization programs.

Methods:

Articles were identified through searches of MEDLINE/PubMed (1950–July 2010) with the following search terms: vaccination and technician, immunization and technician, vaccination and pharmacist, and immunization and pharmacist. Additionally, immunization resources from the American Pharmacists Association, the American Society of Health-System Pharmacists, and the Centers for Disease Control and Prevention were used.

Results:

Pharmacy technicians can help facilitate immunization programs and help reduce some of the barriers to providing superior services. Specific tasks that can be performed by pharmacy technicians include documentation, billing, assisting in the reporting of adverse events, and facilitating communication. Technicians can also take an active role in pharmacy-based immunization programs by obtaining cardiopulmonary resuscitation training and certification.

Conclusions:

Pharmacy technicians can help facilitate immunization programs and help pharmacists offer more robust and comprehensive immunization services.
PTCB Hosts C.R.E.S.T. Summit
Authors: Mohr Mary E
Published: September 2013

In February 2011, the Pharmacy Technician Certification Board (PTCB) convened a meeting of a group of leaders in the pharmacy profession to discuss the future roles of pharmacy technicians as pharmacists continue to establish themselves in the field of medication therapy management. The C.R.E.S.T Summit (Consumer Awareness, Resources, Education, State Policy, and Testing) began with a timeline of PTCB progress since its inception in 1995 and a directive to discuss and reach consensus on the 5 major issues defining the Summit. Background material included important published works, several insightful presentations, and the results of an online survey with 12,000 responses from various stakeholders in the pharmacy profession. Following open discussions at the general sessions, participants attended roundtable discussions of the specific topics. Consensus was attained in many areas and the PTCB is evaluating the information gathered and will use it to determine directions for the future.
Adverse Drug Reactions in Hospitalized Psychiatric Patients—Comparison of Data
Authors: Bowen Guy T , Sajbel Terrie A
Published: September 2013

Objective:

To compare and contrast adverse drug reaction (ADR) reporting between 2 psychiatric hospitals, as well as preventability and possible reasons that one hospital had more preventable occurrences than the other.

Methods:

A 3-year retrospective analysis was conducted comparing ADRs previously reported in a study from Maryland Psychiatric Hospital that were classified as probable and definite according to the modified Naranjo probability scale versus probable and definite ADR reports from the Colorado Mental Health Institute at Pueblo (CMHIP). The same study period (July 1, 2006–June 30, 2009) was used for the retrospective analysis of ADRs at both institutions. We compared the most frequently reported classes of medications and examined the number of reactions, types of reactions, and preventability.

Results:

Psychiatric medications were responsible for 98/145 (67.6%) ADRs at CMHIP, while 47 (32.4%) ADRs were caused by nonpsychiatric medications. At Maryland Psychiatric Hospital, 48.4% of ADRs were caused by psychiatric medications and 51.6% were caused by nonpsychiatric medications. Of the 145 ADRs reported at CMHIP, only 1 (0.7%) was classified as preventable, versus 19 (20.4%) preventable ADRs reported in Maryland Psychiatric Hospital. The classes of medications most frequently associated with ADRs at Maryland Psychiatric Hospital were cardiovascular agents, antiepileptic drugs, and second-generation antipsychotic medications; at CMHIP the medications most commonly associated with ADRs were second-generation antipsychotics, conventional antipsychotics, and mood stabilizers. Proposed reasons for differences in numbers, types, and preventability of ADRs between the institutions are that different reporting mechanisms and pharmacy medication monitoring programs, in conjunction with quality assurance programs, were used at the 2 institutions.

Conclusions:

Differences between 2 comparable hospitals in the number and preventability of ADRs and the classes of medications reportedly responsible for them may be due to different reporting mechanisms and monitoring programs. Pharmacy intervention programs may lead to prevention of ADRs.
Amlodipine-Induced Gingival Hyperplasia in a Child: Case Report and a Review of the Literature
Authors: Ahmad Nazia , Mullakary Jacquline , El-Chaar Gladys M
Published: September 2013

Objective:

To increase awareness of amlodipine-induced gingival hyperplasia in children, as well as review whether a dose-related relationship exists.

Case Summary:

A 9-year-old girl with a past medical history of membranous nephropathy and hypertension presented with failure to thrive and inability to gain weight. She had a history of allergy to enalapril. On admission, she was found to have gingival hyperplasia. A review of her medication profile found amlodipine and azathioprine to be possible agents for this adverse reaction. The child's mother noticed this adverse effect after an increase in amlodipine dosage. We recommended substituting the angiotensin receptor blocker losartan for amlodipine; however, the nephrologist feared a cross-reactivity with enalapril and decided to continue amlodipine therapy. A follow-up call after hospital discharge revealed that the patient could no longer eat by mouth and that her gums bled upon brushing.

Discussion:

We reviewed the possible role of azathioprine in causing our patient's gingival hyperplasia. Due to the timeliness of this occurrence and the possibility of a dose-related response, we selectively reviewed the literature associated with amlodipine in children. A PubMed search and subsequent review of the literature revealed 1 study in rats that showed a relationship between amlodipine dose/plasma concentration and gingival hyperplasia. In humans, this relationship was reported with other calcium channel blockers, but not with amlodipine and not in a child. The Naranjo probability scale revealed a possible adverse reaction of gingival hyperplasia associated with amlodipine.

Conclusions:

To our knowledge, this is the first report of a possible dose-related occurrence of gingival hyperplasia in a child receiving amlodipine.
Warfarin Inhibition in a Patient Taking Complementary and Alternative Medicine Products
Authors: Pence Alicia , Gregory Philip J
Published: September 2013

Objective:

To report a case of a decreased international normalized ratio (INR) in a patient taking warfarin in addition to multiple complementary and alternative medicine (CAM) products.

Case Summary:

A patient on warfarin with a target INR of 2–3 presented to the clinic with an INR of 1.1. Approximately 3 months earlier, the patient had started taking several CAM products, including omega-3 fatty acids, butcher's broom, and hawthorn berry; aloe vera juice was added approximately 6 weeks later. She was not asked to discontinue these products; instead, the warfarin dose was increased to eventually achieve a stable INR of 2.5.

Discussion:

An objective causality assessment suggests that this interaction was probably related to use of one of the CAMs. However, it is unclear which of these caused the decreased INR. The most likely causative agent was aloe.

Conclusions:

Patients do not need to discontinue CAM products while taking warfarin. However, these products need to be taken in consistent doses. Any substantial changes in intake of these substances can necessitate a change in anticoagulant therapy.
Cerebrovascular Events and Use of NuvaRing
Authors: Wilhoite Jessica E , Place Amanda J
Published: September 2013

Objective:

To report 2 cases, occurring within 1 month at a single institution, in which young women experienced a cerebrovascular event while using the hormonal contraceptive product NuvaRing (etonogestrel/ethinyl estradiol vaginal ring).

Case Summary:

The first patient presented to the emergency department (ED) with a 10-day history of right frontal headache. A computed tomography (CT) scan and magnetic resonance imaging showed evidence for right postcentral and cortical venous thrombosis. A hypercoagulable workup identified a heterozygous factor V Leiden mutation. The second patient presented to the ED with a same-day history of left frontotemporal headache extending into her left jaw and neck, numbness and clumsiness of right hand and right foot, and inability to make a comprehensible sentence. A CT angiogram showed occlusion of the internal and external carotid arteries. A hypercoagulable workup indicated no evidence of a thrombophilic disorder and a transesophageal echocardiogram indicated no cardioembolic source, resulting in a final diagnosis of a spontaneous carotid artery dissection. Both patients reported recent use of NuvaRing. The medication was discontinued during the hospital stay.

Discussion:

The use of hormonal agents for contraception carries a well-known risk of venous thrombosis; however, the impact this therapy has on the risk of arterial thrombosis and ischemic brain events is less understood. We found no previous reports of an ischemic brain event in association with NuvaRing use. The Naranjo probability scale indicated a possible relationship between the ischemic events and NuvaRing exposure in both patients.

Conclusions:

Risk factors should be evaluated appropriately prior to initiating any form of combined hormonal contraceptives, oral or vaginal, in young women.
Comparison of Pediatric Levalbuterol and Albuterol Exposures Reported to Texas Poison Centers
Authors: Forrester Mathias B
Published: September 2013

Background:

Levalbuterol is R-albuterol, which is the active isomer and accounts for the therapeutic activity of albuterol. The effects of S-albuterol are often the opposite of those of levalbuterol, and the effects of levalbuterol may be diminished in the presence of S-albuterol.

Objective:

To compare exposures among young children to levalbuterol and albuterol that were reported to poison centers.

Methods:

Cases included levalbuterol and albuterol exposures among patients age 0–5 years reported to Texas poison centers during 2000–2009. The distribution of total cases for each medication was determined for selected characteristics. For cases not involving other substances and where a final medical outcome was known, the distribution of each medication was determined for outcome and management site of the exposure and most common clinical effects and treatments. Comparisons were made by calculating the rate ratio (RR) and 95% confidence interval.

Results:

There were a total of 1,012 levalbuterol and 4,338 albuterol exposures. Other substances were involved in 11.8% of levalbuterol and 6.6% of albuterol exposures (RR 1.77, 95% CI 1.42 to 2.20). No effect was reported in 84.0% of levalbuterol and 71.9% of albuterol exposures (RR 1.17, 95% CI 1.03 to 1.32), and 91.7% of levalbuterol and 73.1% of albuterol exposures were managed on site (RR 1.26, 95% CI 1.11 to 1.41). The most common adverse clinical effects were reported more frequently among albuterol exposures. The most frequent treatments of levalbuterol and albuterol exposures were, respectively, dilution 59.5% and 42.0% (RR 1.42, 95% CI 1.22 to 1.64), food 18.9% and 12.8% (RR 1.48, 95% CI 1.12 to 1.94), single-dose activated charcoal 0.3% and 10.1% (RR 0.03, 95% CI 0.00 to 0.15), and cathartic 0.0% and 4.6% (RR 0.00, 95% CI 0.00 to 0.22).

Conclusions:

Among exposures involving children aged 0–5 years that were reported to Texas poison centers, levalbuterol was more likely to include other substances, have less serious outcomes, and be managed on site when compared to albuterol.
Drug Shortages and the Role of the Pharmacy Technician: A Review
Authors: Mangan Michelle N , Powers Mary F
Published: September 2013

Objective:

To increase pharmacy technicians' awareness of national drug shortages, enabling them to understand why drug shortages occur and how they can help ameliorate the effects that a drug shortage may have in their workplace.

Data Sources:

Articles were identified through searches of MEDLINE and PubMed (1950 through July, 2011) using the following search terms: drug shortages, drug shortages and legislation, drug shortages and law, and drug shortages and safety. Additionally, resources on drug shortages from the American Society of Health-System Pharmacists, the FDA, and the Institute for Safe Medication Practices were used.

Study Selection and Data Extraction:

Articles describing drug shortages, drug shortages and legislation, and managing drug shortages in the health care setting were included.

Data Synthesis:

The effects of drug shortages on pharmacy departments and the health care system as a whole can place significant strain on pharmacists. Pharmacy technicians can play a key role in the initial management of a drug shortage by being responsible for such tasks as validating shortage details and duration with manufacturers, determining the institution's current stock and history of use of a medication, and remaining up-to-date on current drug shortages to help keep patients and other health care professionals informed.

Conclusions:

Pharmacy technicians are a valuable resource for pharmacists in the management of drug shortages and can work with pharmacists to perform operational and assessment tasks after a drug shortage has been identified.
Osteoporosis and Vitamin D Deficiency in HIV-Positive Patients
Authors: Segarra-Newnham Marisel , Soffler Sarah L
Published: September 2013

Objective:

To review the epidemiology and pathophysiology of osteoporosis in patients with HIV infection and discuss vitamin D deficiency and the treatment of HIV-positive patients with osteoporosis.

Data Sources:

A search of PubMed (1980–June 2011) was conducted using the terms osteoporosis, HIV, vitamin D deficiency, and treatment.

Study Selection and Data Extraction:

Epidemiologic studies, clinical trials, and meta-analyses published in English were included. A manual review of the bibliographies of available literature was conducted and relevant articles were reviewed for inclusion.

Data Synthesis:

Patients with HIV infection are living longer with the use of potent antiretroviral therapy (ART) and are at increased risk for osteoporosis. Several studies have shown that HIV infection can affect bone health and increase the risk for osteoporosis. In addition, ART, and tenofovir in particular, may affect bone turnover. Studies and meta-analyses have shown an increased prevalence of osteopenia and osteoporosis in HIV-positive patients compared to noninfected controls. Recent reports also show increased prevalence of fractures and low vitamin D concentrations in HIV-positive patients. Osteoporosis treatments used in patients with HIV infection are similar to treatments for noninfected patients. HIV-positive patients should be monitored and treated to prevent the progression and complications of osteoporosis.

Conclusions:

HIV-positive patients are at increased risk for osteoporosis and vitamin D deficiency due to disease and treatment influences on bone health. These patients should be identified and treated to prevent the morbidity and mortality associated with osteoporosis.
Approved Uses of Dabigatran Etexilate as an Anticoagulant
Authors: Darnell Joshua B , Kleppinger Erika L
Published: September 2013

Objective:

To review, analyze, and critique dabigatran etexilate's approved uses as an anticoagulant.

Data Sources:

Literature searches were performed via MEDLINE, International Pharmaceutical Abstracts, and Google Scholar through February 2011, using the term dabigatran. Additional data were obtained from tertiary sources and prescribing information.

Study Selection and Data Extraction:

All published Phase 3 anticoagulation trials investigating dabigatran for currently approved indications were selected. Information from other anticoagulation trials investigating dabigatran was used for critiquing Phase 3 studies.

Data Synthesis:

Dabigatran etexilate has been evaluated in multiple clinical trials as an alternative to enoxaparin for prevention of venous thromboembolism in total hip and knee replacement surgeries. It has also been evaluated as an alternative to warfarin in stroke and systemic embolism prevention in patients with atrial fibrillation. Results have generally been positive, with few exceptions. The standard adult dose of dabigatran 150 mg twice daily, approved for use in the US for stroke prevention in nonvalvular atrial fibrillation, was found to be superior to warfarin in regard to occurrence rates of stroke or systemic embolism and hemorrhagic stroke. The occurrence rates of intracranial bleeding, life-threatening bleeding, and major or minor bleeding were lower with dabigatran 150 mg twice daily than with warfarin; however, the occurrence of gastrointestinal bleeding was significantly higher.

Conclusions:

With its numerous benefits, and despite its drawbacks, dabigatran remains a promising option for oral anticoagulation therapy.
Addressing the Controversial Use of Antipsychotic Drugs for Behavioral and Psychological Symptoms of Dementia
Authors: Ibrahim Farrah , Knight Seth R , Cramer Richard L
Published: September 2013

Objective:

To review relevant background information on behavioral and psychological symptoms of dementia (BPSD) and the antipsychotic drugs used to treat it, describe benefits versus risks of antipsychotic drugs for treatment of BPSD, and describe the latest management guidelines for patients with BPSD.

Data Sources:

A PubMed literature search (1998–October 2011) was conducted using the following MeSH search terms: dementia, elderly, antipsychotics, behavioral symptoms, and psychological symptoms. Tertiary references and prescribing information for included medications were used for pharmacology, adverse effects, and cost.

Data Selection and Data Extraction:

English-language reviews, tertiary references, and guidelines were reviewed; only articles that used pharmacotherapy in human models were included.

Data Synthesis:

There are no FDA-approved medications for treatment of BPSD; several classes of drugs are prescribed off-label, including selective serotonin reuptake inhibitors and certain anticonvulsants. Antipsychotics, particularly those from the atypical class, are also commonly used by clinicians as a pharmacologic intervention for dementia. Yet, since these are drugs with a wide array of potentially serious adverse effects, including increased risk for cerebrovascular accidents, clinicians treating patients with dementia must be especially cognizant of the benefits and risk of their use.

Conclusions:

Nonpharmacologic treatments should be first-line therapy for BPSD. When these approaches do not produce the desired results, clinicians must weigh the risks versus benefits of continued psychological disease and dangerous behavior with the use of an antipsychotic drug regimen.
Patient Perceptions of Pharmacist-Managed Clinics: A Qualitative Analysis
Authors: Gonzalvo Jasmine D , Papineau Emily C , Ramsey Darin C , Vincent Ashley H , Walton Alison M , Weber Zachary A , Wilhoite Jessica E
Published: September 2013

Background:

Pharmacist-managed clinics have consistently demonstrated improvement in patient outcomes. Quantitative research offers the benefit of objective outcomes to track progress toward therapeutic goals at pharmacist-managed clinics. While quantitative studies are readily available in the literature, there is a paucity of qualitative studies to capture the patients' perspectives of pharmacy services.

Objective:

To assess through the use of qualitative research methods patient perceptions of pharmacist-managed services within ambulatory care clinics that operate under a collaborative practice agreement.

Methods:

A semi-structured interview questionnaire was developed, pilot tested, and revised using a focus group of clinical pharmacists. The questionnaire was used to conduct face-to-face patient interviews at 6 pharmacist-managed clinics in central Indiana. English-speaking patients with a minimum of 2 visits with the clinical pharmacist were included in this study. Pharmacist-managed clinics without established collaborative practice agreements were excluded. Patient interviews were conducted by a trained research assistant, audio-recorded, and transcribed verbatim. The interview transcripts were analyzed to identify cross-cutting themes without predetermined definitions via inductive qualitative analysis. Four study investigators independently identified themes using a sample of the transcripts. Additional themes were identified and defined in a series of independent reviews and investigator meetings using the remaining transcripts until theme saturation. All themes were assigned to segments of the interview transcripts according to the consensus definitions.

Results:

A total of 30 interviews were conducted across the clinics. Ten themes from the interview transcripts emerged, including disease state management expertise, patient alliance, practice novelty, accessibility, increased sense of patient well-being, and compassion.

Conclusions:

Patient perceptions from qualitative interviews revealed that pharmacists are viewed as medication experts who provide patient-centered care. This study highlights unique in-depth perspectives from the patient that further support maintenance and expansion of pharmacist-managed services.
Rifabutin-Induced Thrombocytopenia from Concurrent Use of High-Dose Fluconazole
Authors: Frumin Jane , Yunker Nancy
Published: September 2013

Objective:

To report a case of—and review the literature supporting—rifabutin-induced thrombocytopenia from concurrent use of high-dose fluconazole.

Case Summary:

A 34-year-old man with AIDS, on a stable regimen that included rifabutin and fluconazole for the previous 3 months, was admitted to the hospital with symptoms of oropharyngeal candidiasis. He was treated with increased doses of fluconazole 200 mg to 800 mg daily over a 9-day hospital admission. During this time, his platelet count decreased from 441,000 cells/mm3 to 24,000 cells/mm3, with no signs of bleeding. He was discharged on day 9 and instructed to omit 1 dose of rifabutin and continue fluconazole 200 mg daily. On day 12, his platelet count was 118,000 cells/mm3. About 1 month after discharge, his platelet count was 151,000 cells/mm3.

Discussion:

Rifabutin is known to cause thrombocytopenia. Results from initial studies evaluating various doses of rifabutin were not conclusive as to whether rifabutin-induced thrombocytopenia is a dose-dependent effect. With increased use of rifabutin, often in combination with potentially interacting medications, reports of thrombocytopenia have gained frequency. One study showed that patients on higher doses of rifabutin experienced thrombocytopenia significantly more often than did those on lower doses. When rifabutin is administered with fluconazole, there is a clear pharmacokinetic interaction, showing a 76–82% increase in the rifabutin area under the concentration curve, with only uveitis and leukopenia reported. An objective causality assessment of this case classified the interaction between fluconazole and rifabutin, resulting in thrombocytopenia, as probable. Other causes of thrombocytopenia in our patient, including AIDS, Mycobacterium avium complex, fluconazole, famotidine, and ritonavir, are less likely.

Conclusions:

We describe the first case of rifabutin-induced thrombocytopenia from concurrent use of high-dose fluconazole. There is evidence to support this interaction and practitioners should be aware of this potential adverse effect.