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Objective. To assess empathy longitudinally in student pharmacists and describe how it changes during their four years of pharmacy education. Methods. The Jefferson Scale of Empathy Health Professions Student version (JSE-HPS) was completed by a cohort of student pharmacists at the beginning and end of their first year of pharmacy school (P1), then at the end of their second, third, and fourth years of pharmacy school (P2, P3, P4). Demographic data and information about students’ previous pharmacy work experience and experience interacting with patients were also collected. Results. Student pharmacists’ empathy scores were relatively high at the beginning of P1, comparable to scores reported for medical and other health professions students. Empathy scores declined over the first two years of the pharmacy curriculum but increased during both P3 and P4, recovering to the level observed at the beginning of P1. Factor analysis identified three factors, namely “perspective taking,” “compassionate care,” and “walking in a patient’s shoes” that accounted for 26%, 19%, and 7% of the variance, respectively, and supported the construct validity of the JSE-HPS. Conclusion. Student pharmacists’ empathy decreased during the early, primarily didactic years of the pharmacy curriculum but increased during the latter years that emphasize clinical experiences.

Oral squamous cell carcinoma (OSCC) patients suffer from poor survival due to metastasis or locoregional recurrence, processes that are both facilitated by perineural invasion (PNI). OSCC has higher rates of PNI than other cancer subtypes, with PNI present in 80% of tumors. Despite the impact of PNI on oral cancer prognosis and pain, little is known about the genes that drive PNI, which in turn drive pain, invasion, and metastasis. In this study, clinical data, preclinical, and in vitro models are leveraged to elucidate the role of neurotrophins in OSCC metastasis, PNI, and pain. The expression data in OSCC patients with metastasis, PNI, or pain demonstrate dysregulation of neurotrophin genes. TrkA and nerve growth factor receptor (NGFR) are focused, two receptors that are activated by NGF, a neurotrophin expressed at high levels in OSCC. It is demonstrated that targeted knockdown of these two receptors inhibits proliferation and invasion in an in vitro and preclinical model of OSCC, and metastasis, PNI, and pain. It is further determined that TrkA knockdown alone inhibits thermal hyperalgesia, whereas NGFR knockdown alone inhibits mechanical allodynia. Collectively the results highlight the ability of OSCC to co-opt different components of the neurotrophin pathway in metastasis, PNI, and pain.

Objective: To examine severity of dysphagia and outcomes following iatrogenic high vagal nerve injury. Methods: Retrospective chart review of all patients with iatrogenic high vagal nerve injury that were seen at a tertiary referral center from 2012 to 2020. Results: Of 1304 patients who met criteria for initial screening, 18 met all inclusion criteria. All 18 required intervention to address postoperative dysphagia. Eleven required enteral feeding tubes with 7 eventually able to advance to exclusively per oral diets. Fourteen underwent vocal fold injection and 6 underwent laryngeal framework surgery. Sixteen pursued swallowing therapy with speech language pathology. Patients lost a mean of 8.6 kg of weight in the 6 months following the injury. Swallowing function on the Functional Outcome Swallowing Scale (FOSS) and Functional Oral Intake Scale (FOIS) was 4.4 and 2.4 respectively immediately following the injury and improved to 1.9 and 5.3 at the last follow-up. No patients had complete return of normal swallowing function at last follow up. Conclusion: Iatrogenic high vagal injury causes significant lasting dysphagia which improves with intervention but does not completely resolve. Interventions such as vocal fold injection, medialization laryngoplasty, cricopharyngeal myotomy, or swallowing therapy may be required to reestablish safe swallowing in these patients.

Background Oral squamous cell carcinoma (OSCC) is a capricious cancer with poor survival rates, even for early-stage patients. There is a pressing need to develop more precise risk assessment methods to appropriately tailor clinical treatment. Genome-wide association studies have not produced a viable biomarker. However, these studies are limited by using heterogeneous cohorts, not focusing on methylation although OSCC is a heavily epigenetically-regulated cancer, and not combining molecular data with clinicopathologic data for risk prediction. In this study we focused on early-stage (I/II) OSCC and created a risk score called the REASON score, which combines clinicopathologic characteristics with a 12-gene methylation signature, to predict the risk of 5-year mortality. Methods We combined data from an internal cohort (n = 515) and The Cancer Genome Atlas (TCGA) cohort (n = 58). We collected clinicopathologic data from both cohorts to derive the non-molecular portion of the REASON score. We then analyzed the TCGA cohort DNA methylation data to derive the molecular portion of the risk score. Results 5-year disease specific survival was 63% for the internal cohort and 86% for the TCGA cohort. The clinicopathologic features with the highest predictive ability among the two the cohorts were age, race, sex, tobacco use, alcohol use, histologic grade, stage, perineural invasion (PNI), lymphovascular invasion (LVI), and margin status. This panel of 10 non-molecular features predicted 5-year mortality risk with a concordance (c)-index = 0.67. Our molecular panel consisted of a 12-gene methylation signature (i.e., HORMAD2, MYLK, GPR133, SOX8, TRPA1, ABCA2, HGFAC, MCPH1, WDR86, CACNA1H, RNF216, CCNJL), which had the most significant differential methylation between patients who survived vs. died by 5 years. All 12 genes have already been linked to survival in other cancers. Of the genes, only SOX8 was previously associated with OSCC; our study was the first to link the remaining 11 genes to OSCC survival. The combined molecular and non-molecular panel formed the REASON score, which predicted risk of death with a c-index = 0.915. Conclusions The REASON score is a promising biomarker to predict risk of mortality in early-stage OSCC patients. Validation of the REASON score in a larger independent cohort is warranted.

Background and purpose Pharmacy education programs use simulation to provide a realistic and safe environment for student learning. We studied whether incorporation of virtual simulation into a required first year self-care therapeutics course impacted frequency of interactions, self-reported student confidence, and preceptor-reported student performance during second-year community pharmacy introductory pharmacy practice experiences (IPPEs). Educational activity and setting Virtual simulation cases using MyDispense were incorporated into a self-care therapeutics course in winter 2017. Students and preceptors were surveyed at the end of the fall semester community pharmacy IPPE. Data from IPPE experiences was compared with students who took the self-care therapeutics course in winter 2016 (control). Findings Students completed 30 virtual simulation cases and three cases as part of the final examination (n = 33). Students in the intervention group reported more patient care interactions during their IPPEs than students who did not complete virtual simulation cases, but there was no difference in self-reported confidence. Preceptors did not report any differences in the ability of students to complete over-the-counter medication interactions during IPPEs. Summary Cases were well received by students although they took longer to complete than initially anticipated. Students in the intervention group reported significantly more patient care interactions during IPPEs than those in the control group; however, there were no differences in self-reported confidence. Incorporation of virtual simulation was a sustainable change as the cases were able to be re-used the following year with minimal edits.

Background Oral squamous cell carcinoma (OSCC) has poor survival rates. There is a pressing need to develop more precise risk assessment methods to tailor clinical treatment. Epigenome-wide association studies in OSCC have not produced a viable biomarker. These studies have relied on methylation array platforms, which are limited in their ability to profile the methylome. In this study, we use MethylCap-Seq (MC-Seq), a comprehensive methylation quantification technique, and brush swab samples, to develop a noninvasive, readily translatable approach to profile the methylome in OSCC patients. Methods Three OSCC patients underwent collection of cancer and contralateral normal tissue and brush swab biopsies, totaling 4 samples for each patient. Epigenome-wide DNA methylation quantification was performed using the SureSelectXT Methyl-Seq platform. DNA quality and methylation site resolution were compared between brush swab and tissue samples. Correlation and methylation value difference were determined for brush swabs vs. tissues for each respective patient and site (i.e., cancer or normal). Correlations were calculated between cancer and normal tissues and brush swab samples for each patient to determine the robustness of DNA methylation marks using brush swabs in clinical biomarker studies. Results There were no significant differences in DNA yield between tissue and brush swab samples. Mapping efficiency exceeded 90% across all samples, with no differences between tissue and brush swabs. The average number of CpG sites with at least 10x depth of coverage was 2,716,674 for brush swabs and 2,903,261 for tissues. Matched tissue and brush swabs had excellent correlation (r = 0.913 for cancer samples and r = 0.951 for normal samples). The methylation profile of the top 1,000 CpGs was significantly different between cancer and normal samples (mean p-value = 0.00021) but not different between tissues and brush swabs (mean p-value = 0.11). Conclusions Our results demonstrate that MC-Seq is an efficient platform for epigenome profiling in cancer biomarker studies, with broader methylome coverage than array-based platforms. Brush swab biopsy provides adequate DNA yield for MC-Seq, and taken together, our findings set the stage for development of a non-invasive methylome quantification technique for oral cancer with high translational potential.

Background Oral squamous cell carcinoma (OSCC) has poor survival rates. There is a pressing need to develop more precise risk assessment methods to tailor clinical treatment. Epigenome-wide association studies in OSCC have not produced a viable biomarker. These studies have relied on methylation array platforms, which are limited in their ability to profile the methylome. In this study, we use MethylCap-Seq (MC-Seq), a comprehensive methylation quantification technique, and brush swab samples, to develop a noninvasive, readily translatable approach to profile the methylome in OSCC patients. Methods Three OSCC patients underwent collection of cancer and contralateral normal tissue and brush swab biopsies, totaling 4 samples for each patient. Epigenome-wide DNA methylation quantification was performed using the SureSelectXT Methyl-Seq platform. DNA quality and methylation site resolution were compared between brush swab and tissue samples. Correlation and methylation value difference were determined for brush swabs vs. tissues for each respective patient and site (i.e., cancer or normal). Correlations were calculated between cancer and normal tissues and brush swab samples for each patient to determine the robustness of DNA methylation marks using brush swabs in clinical biomarker studies. Results There were no significant differences in DNA yield between tissue and brush swab samples. Mapping efficiency exceeded 90% across all samples, with no differences between tissue and brush swabs. The average number of CpG sites with at least 10x depth of coverage was 2,716,674 for brush swabs and 2,903,261 for tissues. Matched tissue and brush swabs had excellent correlation (r = 0.913 for cancer samples and r = 0.951 for normal samples). The methylation profile of the top 1,000 CpGs was significantly different between cancer and normal samples (mean p-value = 0.00021) but not different between tissues and brush swabs (mean p-value = 0.11). Conclusions Our results demonstrate that MC-Seq is an efficient platform for epigenome profiling in cancer biomarker studies, with broader methylome coverage than array-based platforms. Brush swab biopsy provides adequate DNA yield for MC-Seq, and taken together, our findings set the stage for development of a non-invasive methylome quantification technique for oral cancer with high translational potential.

With over a third of the doctor of pharmacy curriculum relying on experiential education (EE), it is critical that students are assessed and graded in accordance with their actual performance. The objective of this paper is to review advanced pharmacy practice experience (APPE) grading across the Big Ten Academic Alliance to describe how APPE grading occurs at these institutions and highlight differences in approach and outcomes.Experiential directors/deans were asked to import de-identified data (e.g., APPE curriculum, midpoint and final evaluation score and grade, number of preceptors, number of students, number of years of pharmacy school, total hours of APPEs offered, number and duration of APPEs per year, grading scale information). A chi-square test including pairwise comparisons with a Bonferroni p-value adjustment for multiple comparisons was performed.Seven college/schools submitted data from over 3600 students between 2012-2015. The distribution of letter grades differed significantly across all colleges/schools in 2012-2013, 2013-2014 and 2014-2015 (p 0.0001). Similarly, the distribution of letter grades by rotation type varied significantly for all colleges/schools (p 0.0001). Students in acute care, ambulatory care, and other patient care rotation types were less likely to obtain an "A" and more likely to obtain a "B" compared to students in other rotation types.When letter grades are used for APPEs, the trend suggests over 95% of students receive an "A" or "B" grade. Final grades varied by rotation type with more "B" grades observed in patient care rotations than "A" grades over the three-year period.

ObjectivesTo introduce surgical safety checklists and time outs to future physicians through early incorporation of time outs in the first year gross anatomy course.SettingThe Wayne State University School of Medicine Anatomy Lab.ParticipantsApproximately 300 first year medical students per year participated in the intervention.InterventionsAn educational presentation on medical errors focusing on surgical errors was developed. Students in 2017–2018 viewed the presentation and completed two time outs, one with the first anatomy dissection and a second with the last dissection. Preintervention and postintervention surveys were completed and results compared. Students completed a second postintervention survey after the second time out. Students in 2018–2019 were asked to complete the time outs before every dissection. Time out procedure sheets were collected to determine completion rates. The intervention was further modified for academic year 2019–2020 and time out sheets were again collected.Outcome measuresFour domains of learning were surveyed: (1) major components and goals/limitations of universal protocol, (2) medical error lexicon, (3) components of a time out, and (4) confidence in completing time out checklists.ResultsPostintervention surveys demonstrated significant improvement in each domain. Students found time outs easy to complete and developed confidence in performing time outs. Following a successful pilot, time outs were incorporated into every dissection. Students continued to perform this procedure despite absence of adverse consequences for not doing so.ConclusionStudents found the time outs easy to complete and developed the confidence and ability to perform a surgical time out early in their medical education. The new skills, knowledge and attitudes that these medical students have developed will hopefully improve the care they provide to patients, thereby advancing the practice of quality improvement and patient safety in the clinical setting.

Disclaimer In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

Juvenile nasopharyngeal angiofibromas (JNAs) are highly vascular and benign tumors that can expand into the skull base. Delay of treatment can result in intracranial invasion, requiring extensive open approaches such as a facial translocation, maxillary swing, or an orbitozygomatic craniotomy. We describe a single-stage, combined endoscopic and transoral approach on a 14-year-old male with extensive high-stage dumbbell-shaped JNA involving the infratemporal fossa, orbit, buccal space, and intracranial extension into Meckel's cave. Successful resection of the tumor and good postoperative outcome was achieved. A transoral approach allowed for greater access to the infratemporal fossa, where endonasal resection was not possible, allowing for improved visualization, greater traction, and dissection. In select highly staged JNAs with significant lateral extension and intracranial involvement, successful and complete resection may be accomplished with this combined approach. Utilization of this approach avoids the morbidity of more invasive open approaches.

Objective. To determine whether student confidence in their knowledge of ambulatory care pharmacy and ability to contribute to patient care in this setting increased after participating in an ambulatory care introductory pharmacy practice experience (IPPE), and whether it changed student interest in pursuing a career in ambulatory care pharmacy. Methods. Second-year pharmacy students (n=86) completed a required ambulatory care experience which included four hours of didactic work and 13.5 hours of clinic experience with an ambulatory care pharmacist. Before and after the experience, students completed an eight-question survey in which they rated their confidence in their knowledge of ambulatory care practice and in providing patient care in this setting, as well as their interest in a career in ambulatory care. A five-point Likert scale was used to assess student confidence (1=not at all confident, 5=very confident) and interest in ambulatory care (1=not at all interested, 5=extremely interested). The Wilcoxon signed rank test was used to compare pre-post survey responses. Results. Eighty-five pharmacy students completed both the pre- and post-survey. Median scores on the post-intervention test increased from 3 to 4 in seven of the domains assessed. Student interest in a career in ambulatory care remained unchanged. Conclusion. An ambulatory care IPPE increased student confidence in their understanding of ambulatory care pharmacy practice and caring for patients in this setting.

Background:Medullary thyroid carcinoma (MTC) accounts for 1% to 2% of thyroid cancers in the United States. When identified early, total thyroidectomy is most often curative. However, in advanced disease, more aggressive treatment such as laryngectomy and esophagectomy may be indicated. Postsurgical fistula formation and leak is a potential complication in such cases. These fistulas are most likely to occur at the anastomotic site in cases of laryngectomy or esophagectomy. Concomitant chemotherapy and radiation increase this risk. Tyrosine kinase inhibitors (TKI) such as Cabozantinib are used as therapy for metastatic MTC. These drugs have previously been associated with dehiscence of anastomotic sites in the gastrointestinal tract. While previously identified in the bowel, this report represents the first documented case of gastropharyngeal anastomosis leak described in the context of TKI use for head and neck cancer.Case Presentation:We present the case of a 72-year-old male previously diagnosed with MTC. His gastropharyngeal anastomosis status-post laryngopharyngectomy and gastric pull up had been stable for 23 years. Over the past year, he developed back pain and was found to have spinal metastases of MTC. He was subsequently started on Cabozantinib to slow the progression of the disease. Within months of starting this TKI, a bleeding pharyngocutaneous fistula developed at the anastomosis site of the gastric pull up and pharynx. Upon discontinuation of Cabozantinib, the fistula healed with no further complications.Conclusions:To our knowledge, this is the first documented case of gastropharyngeal anastomotic leak related to TKI use. A causal relationship is highly plausible given the previously stable anastomosis and the suspicious advent of complications within months of initiation of this new drug. While previously limited to cases of intraabdominal bowel dehiscence, this report now suggests that wound dehiscence must be considered a known side effect of TKIs throughout the gastrointestinal tract, including the gastropharynx. As such, the risk of anastomotic dehiscence should be discussed with the patient prior to starting a TKI.

Dog bite injuries are common sources of morbidity with an estimated incidence of 4.5 million bites per year with over 350,000 requiring treatment in the emergency room. Children under the age of 14 are most likely to be affected with a peak age of 5-9 years old. We report a case of a 24-month-old female who sustained a large composite facial avulsion injury from a pit bull dog bite. The avulsed tissue involved a substantial portion of the patient's mid-face, including the entire soft tissue of the nose, upper lip, part of the left cheek, and left oral commissure. Artery-only microvascular replantation was performed because no recipient vein could be identified from the facial defect. Medicinal leech therapy was used for eight days postoperatively to prevent venous congestion. The patient experienced significant blood loss due to leech therapy and required nearly 29 L of blood product replacement. At the last follow up of 8 months postoperatively, the patient was recovering well with significant improvement in function and cosmesis of the mid-face. This case describes a successful artery-only replantation of an avulsive bite injury to the face of a young child. Despite the technical difficulty of cases such as this one, microvascular replantation should be attempted because when successful it provides a superior cosmetic and functional result to other reconstructive techniques.

Objective. To determine pharmacy students’ perspectives regarding opioid use, the opioid crisis, and pharmacy education related to both topics. Methods. Students from each professional year at eight participating schools and colleges of pharmacy were invited to participate in focus groups and answer questions about their experiences with the opioid crisis. Faculty and/or staff moderated the focus groups and audio-recorded responses. Recordings were deidentified, transcribed, and analyzed. Results. One hundred fifty students participated in one of 29 focus groups conducted. Responses were categorized according to themes using consensual qualitative research (CQR) methodology. Sources impacting student views on the crisis included school, personal and work experience, and media. Perspective changes since starting school included increased knowledge and awareness and decreased bias/stigma. Conclusion. Conducting focus groups on the opioid crisis provided pharmacy schools with information on what student pharmacists are learning about the crisis, practices they see, and their recommendations to address the crisis. Pharmacy schools can better prepare students to combat the opioid crisis by providing them with training in opioid counseling, use of naloxone, and how to have difficult conversations with patients.

Accommodating pharmacy students with physical disabilities during the experiential learning portion of the Doctor of Pharmacy (PharmD) curriculum can present unique challenges for pharmacy schools. The available literature regarding accommodations for pharmacy students in the experiential learning environment is sparse, leaving programs with little guidance. This commentary from the Big Ten Academic Alliance calls on the Academy to create a community of shared resources and best practice examples and offers practical suggestions for accommodating pharmacy students with mobility, vision, and auditory disabilities during introductory pharmacy practice experiences (IPPEs) and advanced pharmacy practice experiences (APPEs).

Objectives To incorporate a published clinical tool related to heart failure (HF) assessment into advanced pharmacy practice experiences in the community pharmacy setting to provide a meaningful and innovative learning experience for students. Setting Sixteen independent and chain community pharmacies that served as advanced pharmacy practice experience locations. Practice description Sixteen community pharmacy locations served as rotation sites and participated in data collection (8 chain and 8 independent). Practice innovation This was the first study in which pharmacy students used The One-Minute Clinic for Heart Failure (TOM-C HF) tool to assess HF within the community pharmacy setting. Interventions Trained student pharmacists identified patients who may have heart failure by evaluating medication dispensing records, interviewed the patient using the TOM-C HF tool, and made interventions as clinically appropriate. Evaluation The number of students using the TOM-C HF tool, the number and types of interventions made, and student perceptions about the educational and professional value of the patient interaction. Results Thirty-three of 83 (40%) students completed 63 patient assessments. Thirty-five percent of patients (22/63) were candidates for an intervention. Interventions were performed in 9 of 22 patients (41%). More than 65% of students found the patient interaction to have educational and professional value. Conclusion Students were able to assess HF patients and make interventions in a community pharmacy setting. The majority of students also perceived some value in these assessments. The incorporation of a clinical tool in the community setting driven by fourth-year pharmacy students has been shown to be feasible and to provide both a novel advanced practice experience. In addition, it may be expandable to the services offered at community pharmacies.

Fluoroquinolones (FQs) and ciprofloxacin (Cp) are important antimicrobials that pollute the environment in trace amounts. Although Cp has been recommended as prophylaxis for patients undergoing leech therapy to prevent infections by the leech gut symbiont Aeromonas, a puzzling rise in Cp-resistant (Cpr) Aeromonas infections has been reported. We report on the effects of subtherapeutic FQ concentrations on bacteria in an environmental reservoir, the medicinal leech, and describe the presence of multiple antibiotic resistance mutations and a gain-of-function resistance gene. We link the rise of Cpr Aeromonas isolates to exposure of the leech microbiota to very low levels of Cp (0.01 to 0.04 µg/ml), IMPORTANCE The role of subtherapeutic antimicrobial contamination in selecting for resistant strains has received increasing attention and is an important clinical matter. This study describes the relationship of resistant bacteria from the medicinal leech, Hirudo verbana, with patient infections following leech therapy. While our results highlight the need for alternative antibiotic therapies, the rise of Cpr bacteria demonstrates the importance of restricting the exposure of animals to antibiotics approved for veterinary use. The shift to a more resistant community and the dispersion of Cpr-conferring mechanisms via mobile elements occurred in a natural setting due to the presence of very low levels of fluoroquinolones, revealing the challenges of controlling the spread of antibiotic-resistant bacteria and highlighting the importance of a holistic approach in the management of antibiotic use.

While experiential education has been an essential component of pharmacy education for many years, access to experiential education for students with disabilities continues to be a challenge and an evolving topic. Learning disabilities (eg, attention deficit hyperactivity disorder (ADHD), dyslexia

Purpose This study evaluated the impact of an admission medication reconciliation process conducted by student pharmacists during an introductory pharmacy practice experience (IPPE). Methods Patients aged 18 years or older admitted to a general medicine service and who received medication reconciliation from a student pharmacist were included. Data were collected retrospectively from electronic medical records. Results Student pharmacists performed medication reconciliation on 21.8% of 6395 patients admitted to the target service, directly involving the majority of patients/caregivers (78.9%) in the process. Potential medication discrepancies were found in 43.8% of patients; the average number of potential discrepancies found per patient was 1.0 ± 1.6. The most common potential discrepancy was “omitted prescription medication.” Prescribers responded to notification about potential discrepancies by correcting or clarifying 74.9% of all potential discrepancies and 77.2% of discrepancies with the potential to causes severe patient discomfort or clinical deterioration. Conclusion IPPE student pharmacists contributed to patient care by performing medication reconciliation on patient admission to hospital. Student pharmacists identified and facilitated correction of unrecognized medication issues that could have adversely impacted patient well-being.

Objective: This study describes a case of a successful free flap repair using argatroban for local intraluminal irrigation as a substitute to heparin in a patient with heparin-induced thrombocytopenia. Methods: Case report and review of literature. Results: The patient had an uneventful postoperative course, and the free flap survived without complications. Conclusions: The use of argatroban during microvascular surgery is likely to be safe and simple and may be effective in preventing micro-thrombotic complications during microvascular surgery, and it should be considered as an alternative to heparinized saline for local intraluminal irrigation.

Eulerian Video Magnification (EVM) can enhance subtle changes in videos to reveal what was once invisible to the naked eye. In this proof of concept study, we investigated using EVM as a novel form of free flap monitoring. Free flaps with skin paddles were filmed in the operating room with manipulation of their pedicles. In a representative 77-year-old female who received a latissimus dorsi-serratus-rib composite free flap, EVM was able to detect blockage of arterial or venous supply instantaneously, providing a visible representation through degree of color change in videos. EVM has the potential to serve as a powerful free flap monitoring tool with the benefit of being noninvasive, sensitive, easy-to-use, and nearly cost-free.

Background: Antimicrobial prophylaxis is commonly administered to patients undergoing left ventricular assist device (LVAD) surgeries to prevent infectious complications. However, optimal surgical infection prophylaxis (SIP) for LVAD surgeries is not well defined. Methods: We conducted an electronic survey to characterize LVAD SIP used at different centers performing LVAD implantation. Results: Responses were received from 23 of 85 centers (27%). Of 21 centers that provided usable data about their LVAD SIP regimens for nonpenicillin allergic patients, 42.9% reported using a four-drug regimen (three antibiotics plus fluconazole), 23.8% reported using a three-drug regimen (three antibiotics or two antibiotics plus fluconazole), 23.8% reported using a regimen of two antibiotics, and 9.5% reported using vancomycin alone. A similar pattern was observed among SIP regimens for penicillin-allergic patients. Criteria for discontinuation of SIP and use of decolonization strategies also varied widely across centers. Conclusions: Our results demonstrate wide variability in LVAD SIP regimens and underscore the lack of consensus regarding best practice. (J Card Surg 2011;26:440-443)

[Figure][1] The standards of the Accreditation Council for Pharmacy Education (ACPE) for doctor of pharmacy programs require pharmacy curricula to provide students with introductory pharmacy practice experiences (IPPEs), which are defined as “practice experiences offered in various

Tough economic times are forcing governments to review the costs and benefits of the goods and services they offer to the public. However, dollars and cents are more easily attached to the costs of many of these programs than the benefits. The 1981 Canadian Census of Agriculture is no exception — it cost $7.5 million. Yet. to this point, no quantitative value has been attributed to its benefits. This paper shows that the value of only one of the benefits covers the entire cost of conducting the Census of Agriculture. This should serve as an indicator of the value of agricultural statistics.

Purpose Fluoroquinolone and tetracycline antibiotics are routinely used for the treatment of a variety of bacterial infections. A disadvantage with their oral administration is the potential for a drug interaction leading to decreased absorption when coadministered with oral supplements containing polyvalent cations. The objective of this study was to evaluate the impact of several inservices aimed at educating nursing staff on reducing this drug interaction. Methods To assess the impact of the educational interventions, a retrospective chart review was conducted in two phases to determine the incidence of the drug interaction. Phase 1 was conducted before implementation of the educational inservices. Following the educational inservices, phase 2 was conducted to determine their impact on reducing coadministration. Results This interaction occurs frequently in hospitals; we found that these antibiotics were given within 2 hours of polyvalent-cation containing supplements in 72.5% of patients before inservices. An inservice involving multiple approaches significantly reduced the frequency of the drug interaction to 10%; P < 0.001. Conclusion Educational inservices directed toward nursing staff were successful in significantly reducing the incidence of this drug interaction.

To evaluate the effectiveness of a multidisciplinary practice model consisting of medical providers, clinical pharmacists, and social workers on reducing 30-day all-cause readmissions.Retrospective cohort study.This study included adults 60 years or older discharged from a large academic medical center. Patients were grouped as either receiving the primary care-based transitional care program (intervention group) or usual care (control group) after an index hospitalization. Only 1 index hospitalization was included per patient. All-cause 30-day readmission rates between propensity score matched study groups were analyzed by intention-to-treat, per protocol, and as-treated methods. Secondary outcomes included time to readmission, subgroup analysis, process measures, and cost avoidance influence of covariates on chance of readmission measured by logistic regression.Over 27 months, 19,169 unique patients had 18,668 index hospitalizations and 572 interventions scheduled after discharge. Among matched subjects, 30-day readmission rates were not significantly different between those scheduled for the intervention and those never scheduled (21% vs 17.3%, respectively; P = .133). However, when those completing the intervention (n = 217) were examined, readmission rates were significantly reduced (11.7% vs 17.3%, respectively; P.001). Likewise, time to readmission was significantly longer among those receiving the intervention (18 ± 9 days compared with 12 ± 9 days with usual care; P = .015) and potential cost avoidance was observed only when the intervention was completed.A community-based multidisciplinary transitional care program may reduce hospital readmissions among older adults.

Purpose. The relationship between medication use and falls among hospitalized elderly patients was studied. Methods. Sixty-two patients 65 years of age or older who fell during hospitalization were randomly selected from incident reports of falls and matched for age, sex, and discharge date with 62 patients who did not fall. Data on demographic characteristics, vital signs, laboratory test variables, drug therapy, and the presence of other known risk factors for falls were collected retrospectively and compared between the groups. Results. Nonsteroidal antiinflammatory drug (NSAID) use was more frequent in patients who fell than in control patients. NSAID use was a significant predictor of falls and was associated with a 10-fold increase in the likelihood of falling. Opioid analgesics were given more frequently to control patients and were not associated with falls. Dementia, the only non-medication-related independent predicator of falls, was associated with a 21-fold greater risk of falling. Conclusion. In hospitalized elderly patients, there was a significant association between NSAID use and falls, an effect largely accounted for by low-dose aspirin.

The developing prefrontal cortex receives a dense serotonergic innervation, yet little is known about the actions of serotonin [5-Hydroxytryptamine (5-HT)] in this region during development. Here, we examined the developmental regulation of 5-HT receptors controlling the excitability of pyramidal neurons of this region. Using whole-cell recordings inin vitrobrain slices, we identified a dramatic shift in the effects of 5-HT on membrane potential during the postnatal developmental period. In slices derived from young animals [postnatal day (P) 6 to P19], administration of 5-HT elicits a robust depolarization of layer V pyramidal neurons, which gradually shifts to a hyperpolarization commencing during the third postnatal week. This progression is the result of coordinated changes in the function of 5-HT7and 5-HT2Areceptors, which mediate different aspects of the depolarization, and of 5-HT1Areceptors, which signal the late developing hyperpolarization. The loss of the 5-HT7receptor-mediated depolarization and the appearance of the 5-HT1Areceptor-mediated hyperpolarization appears to reflect changes in receptor expression. In contrast, the decline in the 5-HT2Areceptor depolarization with increasing age was associated with changes in the effectiveness with which these receptors could elicit a membrane depolarization, rather than loss of the receptors per se. Together, these results outline coordinated changes in the serotonergic regulation of cortical excitability at a time of extensive synaptic development and thus suggest a key role for these receptor subtypes in the postnatal development of the prefrontal cortex.

A growing body of evidence demonstrates that untreated pain is associated with adverse consequences that can compromise clinical and developmental outcomes in children but that these adverse consequences can be prevented or attenuated by appropriate analgesic therapy. Thus, effective treatment of acute pain must be a clinical priority for children of all ages. Over the past 20 years, extensive pediatric research exploring pain assessment, developmental pharmacology of analgesics, and the clinical use of analgesics has dispelled many myths and misconceptions about pain management in pediatric patients; proven that analgesics can be used safely in neonates, infants, and children; and provided a framework for the development of pediatric pain management guidelines. This article reviews guidelines recommended for managing acute pain in pediatric patients and the treatment options for children experiencing acute pain. Contemporary issues regarding acetaminophen, nonsteroidal anti-inflammatory agents, and opioids are discussed.

This study was designed to evaluate the long-term results using the technique of canal wall reconstruction (CWR) tympanomastoidectomy with mastoid obliteration in the treatment of chronic otitis media with cholesteatoma.Institutional review board-approved retrospective case review.Tertiary referral center.Retrospective review was performed on consecutive patients undergoing CWR tympanomastoidectomy with mastoid obliteration at a single institution from 1997 to 2011.Status of tympanic membrane and ear canal anatomy, preoperative and postoperative audiometry, residual cholesteatoma at second look surgery, postoperative complications, recurrence rate, and location.Two hundred eighty-five ears in 273 patients underwent CWR tympanomastoidectomy with a mean age of 35 years with average follow-up of 4.29 years (median, 3.16 yr). A second-look ossiculoplasty was performed in 253 (89%). Recurrent retraction pocket formation occurred in 34 ears (13%). A secondary endaural atticotomy only was required to improve access for debridement in 16 of these 34 ears (5.8% of total ears). Only 7 ears (2.6%) required a revision open cavity mastoidectomy (n = 5) or subtotal petrosectomy (n = 2) for recurrent cholesteatoma. Those undergoing second-look ossiculoplasty demonstrated a small improvement in preoperative versus postoperative air-bone gap (ABG), 28 dB versus 23 dB, respectively. Postoperative infection occurred in 16 patients (5.6%) with 1 patient requiring conversion to open cavity mastoidectomy.A CWR tympanomastoidectomy provides excellent intraoperative exposure of the middle ear and mastoid without the long-term disadvantages of a canal wall down mastoidectomy. Long-term follow-up demonstrates that there were only 2.6% failures requiring conversion to an open cavity or subtotal petrosectomy.4.

The evolution of a policy disallowing patients' use of alternative therapies in a health system is described. The pharmacy and therapeutics (P&T) committee at Children's Hospital of Michigan, a part of the Detroit Medical Center (DMC), was asked to review the appropriateness of allowing inpatients to bring in and use alternative therapy products during their hospitalization. Recognizing the interest of consumers in alternative medicines and patients' growing involvement in their own care, the committee drafted a policy that allowed patients to continue taking dietary supplements after being admitted to the hospital. If the physician had no concerns about potential toxicities or drug interactions for a particular product, he or she would write a medication order allowing it to be used. Purchasing and administering the products were deemed the responsibility of the patient or the family. However, many issues concerning supplements remained unresolved, including questions about safety, efficacy, dosing, drug interactions, ethical conflicts, and liability. Ultimately, the P&T committee decided that the potential risks associated with alternative therapies outweighed potential benefits and adopted a policy disallowing the use of alternative therapies by hospitalized patients. The policy was eventually implemented at all eight DMC hospitals. A health system responded to patients' desire to continue their use of alternative therapies during hospitalization by drafting a policy allowing such use. However, concerns related to safety, efficacy, ethics, and liability led to the abandonment of the liberal policy and implementation of a highly restrictive one.

We reviewed the frequency and duration of vancomycin use during 93 left ventricular assist device placements. Vancomycin prophylaxis was administered for a mean duration (± standard deviation) of 10.5 ± 11 days. Empirical vancomycin use was frequent, with a mean duration (± standard deviation) of therapy of 9.8 ± 9 days (median, 8 days) given during 81 (87%) of the implantations. The most common indications for empirical vancomycin treatment were isolated leukocytosis or driveline drainage. Strategies to improve vancomycin use during left ventricular assist device support should be considered.

We attempted to determine the responsiveness and validity of the Quality of Well-Being (QWB) scale in 20 consecutive children and adolescents with cystic fibrosis. The QWB score was determined for 6-day periods immediately before and after hospital admission, and at 6- and 12-month follow-up. With the instrument's scale of zero-1, responsiveness was indicated by significant changes in QWB score (0.09), physical (0.019), social (0.021), and symptom-problem complexes (0.04) domains, and all pulmonary function tests from before to after treatment of an acute exacerbation. Only the symptom-problem complex domain significantly changed from after treatment to 6- and 12-month follow-up. Validity was shown by significant correlations between before and after QWB scores and forced vital capacity (r=0.476), residual volume total lung capacity ratio (r=0.452), forced expiratory volume in 1 second (r=0.358), and forced expiratory flow between 25% and 75% of vital capacity (r=0.35).

Proton-pump inhibitors (PPIs) remain the leading evidence-based therapy for upper gastrointestinal disorders, including gastroesophageal reflux disease, dyspepsia, and peptic ulcer disease. The effectiveness of PPIs has led to overutilization in multiple treatment arenas, exposing patients to an increasing number of potential risks. The overutilization of PPIs in ambulatory care settings is often a result of failure to re-evaluate the need for continuation of therapy, or insufficient use of on-demand and step-down therapy. PPI overutilization in the inpatient setting is often a result of inappropriate stress ulcer prophylaxis (SUP) in nonintensive care unit patients, and failure to discontinue SUP prior to hospital discharge. Potential consequences of prolonged PPI therapy include hypergastrinemia, enterochromaffin-like cell hyperplasia, and parietal cell hypertrophy, leading to rebound acid hypersecretion. PPIs have been linked via retrospective studies to increased risk of enteric infections including Clostridium difficile-associated diarrhea, community-acquired pneumonia, bone fracture, nutritional deficiencies, and interference with metabolism of antiplatelet agents. Reducing inappropriate prescribing of PPIs in the inpatient and outpatient settings can minimize potential for adverse events, and foster controllable cost expenditure.

Objectives/Hypothesis: To examine the changing microbiology of pediatric neck abscesses over a 10-year period with particular interest in methicillin-resistant Staphylococcus aureus (MRSA) infections and their associated antibacterial-resistance patterns, including resistance to clindamycin, a frequently used antibiotic for Staphylococcus aureus. Study Design: Retrospective chart review at a tertiary academic medical center. Methods: One hundred and twenty-two consecutive pediatric patients managed between January 2000 and June 2010 with incision and drainage of a proven neck abscess. Results: Seventy-four patients with 76 abscesses were identified. A microorganism was found in 65 (85%) of the 76 abscesses. Forty-three percent grew Staphylococcus aureus (SA), 12% were methicillin-resistant Staphylococcus Aureus (MRSA), and 31% were methicillin-susceptible Staphylococcus aureus (MSSA). There was a significant increase in the incidence of MRSA infections during the study period, with only one case of MRSA diagnosed in the first half of the study (from 2000–2004) compared with seven in the second half (from 2005–2010) (P = 0.023). The second most common bacterial etiology or isolate was Streptococcus pyogenes in 27%, while the remaining 30% grew mixed oral flora and other microorganisms. Conclusions: These findings demonstrate a statistically significant rise in the proportion of MRSA neck infections in pediatric patients in Iowa. Resistance to clindamycin was highest among MSSA isolates. Clindamycin-resistant S. aureus and Streptococcus pyogenes are established pathogens in neck infections. In communities with similar microbiology patterns, empiric treatment with combination therapy of a beta lactam and vancomycin or trimethoprim/sulfamethoxazole should be initiated until culture results are available. Laryngoscope, 2013