Introduction: Doctor of Pharmacy programs are charged with developing students' empathy by the 2016 Accreditation Council for Pharmacy Education (ACPE) Standard 3 and the 2022 Curriculum Outcomes and Entrustable Professional Activities (COEPA). Although empathy is essential to optimal patient care, its subjective nature makes it challenging to teach and therefore literature is lacking on best teaching practices. The authors of this paper describe a novel simulated approach to elicit and assess empathy in a pharmacy classroom. This study evaluated the impact of a decision-making game in a pharmacy skills lab course on the development of students' empathy using a validated empathy scale. Methods: This is a cohort-based quality improvement project in which third year pharmacy students participated in a 3-h classroom empathy game experience that simulated a month in a patient's life including issues related to the cycle of poverty. Prior to the game, students completed a voluntary, anonymous baseline demographics survey. They also completed a preand post-survey of the validated empathy tool, the Kiersma-Chen Empathy Scale (KCES-R), to assess change in the empathy score following the decision-making game. Students also provided narrative comments in the post-survey. Statistical tests used included descriptive statistics for demographic data, Shapiro-Wilk test of normality, and Wilcoxon Signed-Rank test for survey scores (SPSS Version 29). Results: Pharmacy students (n = 37) showed an overall increase in composite KCES-R scores after participating in the empathy game class session (z = -5.071, p < 0.001). The scores of each of the 14 KCES-R items also increased after the learning experience (p < 0.05). Students' narrative comments were all positive and indicated that the activity offered new insights on self-perceived empathy development. Conclusion: The empathy game simulation was a successful approach to increase empathy scores in third-year pharmacy students.

BACKGROUND:A recent study demonstrated that pharmacists presented with multiple estimating equations deviated from recommended dosing guidance more often than pharmacists who were presented with a single estimate on clinical vignettes.OBJECTIVES:To identify characteristics associated with an increased tendency to deviate from approved recommendations.METHODS:Participant data were split into 2 cohorts: pharmacists who chose a dose that was inconsistent with dosing recommendations on at least 1 of the 4 vignettes and pharmacists who did not deviate on a single case. Bivariate analysis of demographic- and practice-related variables were conducted between groups using the χ2, Mann-Whitney U, or Student t-test for nominal, ordinal, and continuous variables, respectively. Statistically different covariates between groups (P < 0.05) were assessed using multivariable linear regression.RESULTS:Survey data from 154 inpatient pharmacists, 71 of whom deviated on at least 1 clinical vignette, were analyzed. On univariate analysis, deviator pharmacists were more likely to have completed postgraduate residency training (68% vs 41%; P < 0.05) and board certification (39% vs 20%; P < 0.05). Deviator pharmacists were also more likely to have been presented with multiple renal estimates as opposed to a single estimate and had differing renal dosing practices at baseline (P < 0.05). Following multivariable regression, residency training, mismatched baseline renal practices, and multiple renal estimates remained independent predictors (P < 0.05) of dosing deviation.CONCLUSION AND RELEVANCE:Higher clinical training, practice variation, and multiple renal estimates may affect renal dosing practices. Prospective, statistically powered studies are needed to verify these hypotheses.

BACKGROUND AND PURPOSE:There has been an increased use of active learning pedagogies in pharmacy curricula. Structured, complex pedagogies such as problem-based learning (PBL) may require rigorous training for students to be successful. We aim to describe the development and implementation of an introductory PBL course for first-year pharmacy students. We describe the theoretical framework for course development, including the educational philosophies informing the course design. Development of PBL skills and professional behavior were evaluated using student self-assessment throughout the course.EDUCATIONAL ACTIVITY AND SETTING:This introductory PBL course was developed using educational philosophies to scaffold student learning of the pedagogy and development of PBL skills. A student self-assessment was administered at two time points throughout the course. The self-assessment contained items related to PBL skills and professional behaviors. Self-assessment scores were compared with facilitator evaluations of student performance to determine reliability of self-assessment results.FINDINGS:Eighty-eight students completed both self-assessments (93.6% response rate). Self-assessment of PBL skills increased significantly. There was no improvement in self-assessed professional behaviors. Self-assessment scores did not correlate with facilitator assessment of student performance in a small group.SUMMARY:Integrating a scaffolded, theoretically sound educational approach to introduce students to the PBL pedagogy improves students' self-assessed PBL skills but not professional behavior.

Background: Numerous equations are used for estimation of renal function, and many electronic medical records report multiple clearance estimates to assist with drug dosing. It is unknown whether the presence of multiple clearance estimates affects clinical decision-making. Objective: To determine whether the presence of multiple renal clearance estimates affects pharmacist drug dosing decisions. Methods: A randomized trial in the form of an electronic survey including 4 clinical vignettes was delivered to hospital pharmacists. Vignettes consisted of a patient presenting with an acute pulmonary embolism requiring enoxaparin therapy. Pharmacists were randomized to receive a single estimate of renal function or multiple estimates for all vignettes. The primary outcome was deviation from approved recommendations on at least 1 vignette. The χ 2 test was used to detect differences in deviation rates between groups. Logistic regression was performed to adjust for the effects of potentially confounding variables. Results: A total of 154 studies were completed (73 in the multiple-estimate group and 81 in the single-estimate group). Pharmacists presented with multiple renal estimates were significantly more likely to deviate from recommended dosing regimens than pharmacists presented with a single estimate (54.7% vs 38.2%; P = 0.04). The results were driven primarily by the 2 vignettes that included discordance among Cockcroft-Gault equation creatinine clearance estimates. Logistic regression identified multiple estimates as the only independent predictor of deviation ( P = 0.04). Conclusion and Relevance: Pharmacists provided with a single renal clearance estimate were more likely to adhere to approved dosing recommendations than pharmacists provided with multiple estimates.

Background: Chronic obstructive pulmonary disease (COPD) guidelines recommend both long-acting and dual bronchodilator therapy. It is unclear if there are differences in efficacy and safety. Objective: This meta-analysis evaluates the efficacy of dual therapy with long-acting β-agonist (LABA) + long acting muscarinic antagonist (LAMA) compared with monotherapy with LAMA for COPD. Methods: We searched PubMed, CINAHL, and Web of Science databases from inception through March 2020 to identify English-language, prospective randomized controlled trials (RCTs) that compared dual therapy with monotherapy in adult patients with COPD. Risk of bias was assessed using the Jadad score. Overall analysis was performed using Review Manager 5.3. Treatment effect was determined with the random-effects model using the Mantel-Haenszel method and was reported as mean difference (MD) with 95% CI. Results: A total of 18 RCTs were included (n = 6086; median Jadad score 5/5) that compared LAMA + LABA with LAMA. There was a greater improvement in forced expiratory volume at 1 s (FEV 1 ) with dual therapy compared with LAMA: MD = 0.08; 95% CI = [0.05, 0.11]. There was no difference in St George Respiratory Questionnaire (SGRQ) scores between groups: OR = −0.85; 95% CI = [−1.83, 0.13]. There were no differences in overall adverse events (OR = 1.00; 95% CI = 0.92, 1.09), serious adverse events (OR = 1.01; 95% CI = 0.86, 1.18), or cardiovascular events (OR = 0.88; 95% CI = 0.58, 1.34). Conclusion and Relevance: Dual therapy improves FEV 1 and is as safe as LAMA. Dual therapy does not improve SGRQ scores more than LAMA.

INTRODUCTION:The objective of this project was to evaluate the effect of adjusting the solution reporting phase of problem-based learning (PBL) while keeping core components of the pedagogy constant.METHODS:A PBL course for third year pharmacy students changed delivery of the problem solution from a written format to a verbal defense. Comparisons were made between the written format and verbal defense groups. The primary outcome was the change in the motivation domain of the Motivated Strategies for Learning Questionnaire (MSLQ). Secondary outcomes included evaluation of the learning strategies domain of the MSLQ, changes in MSLQ scores within each group, exam scores, and themes identified using focus groups.RESULTS:There was no difference in the change of motivation and learning domains between the groups. However, scores in both groups increased significantly from the beginning to the end of the semester for both motivation and learning. There was no difference in exam scores and facilitator confidence between groups. Themes from focus groups who used the written format were appreciation of PBL outcomes, discomfort with the pedagogy, and disconnect of assessments. Themes from the verbal format group were realism, increased confidence, and comments with course logistics.CONCLUSIONS:No difference in motivation and learning was observed between the groups, although both groups improved over the course of the semester. Changes to PBL approach within the confines of the pedagogy may not impact motivation and learning.

The authors declare no conflicts of interest.

Objective: Cannabinoid hyperemesis syndrome (CHS) is characterized by cyclic vomiting, abdominal pain, and alleviation of symptoms via hot showers in chronic cannabinoid users. Capsaicin is recommended as a reasonable first-line treatment approach for CHS despite limited clinical evidence regarding its use. The objective of this study is to systematically review the efficacy data for capsaicin in CHS. Data Sources: A literature search using keywords related to cannabinoids, emesis, and capsaicin was performed in MEDLINE, CINAHL, and EMBASE from inception through March 31, 2019. Study Selection and Data Extraction: Studies and published abstracts in which capsaicin was used for CHS and clinical outcomes were reported were eligible for inclusion. Data Synthesis: A total of 241 articles were screened, of which 5 full-text articles and 6 conference abstracts were included. Full-text case reports (n = 3) and case series (n = 2) found capsaicin to be effective in a total of 18 patients. Published abstracts were in the form of case reports (n = 1), case series (n = 3), and retrospective cohort studies (n = 2). Relevance to Patient Care and Clinical Practice: Capsaicin use was described as beneficial in all case series and case reports; however, both retrospective cohort studies were unable to find a significant benefit for capsaicin on primary outcomes (emergency department length of stay). Conclusion: Current data for capsaicin efficacy in CHS is of low methodological quality. However, the limited data on alternative antiemetic therapies and capsaicin’s favorable risk-benefit profile make it a reasonable adjunctive treatment option.

Objective. To validate a problem-based learning (PBL) evaluation checklist to assess individual Doctor of Pharmacy (PharmD) students' performance in a group. Methods. In 2013, a performance checklist was developed and standardized. To evaluate the reliability and discriminant validity of the checklist, pharmacy students' evaluation scores from 2015-2016 were assessed along with overall program grade point averages (GPA), and scores on knowledge and problem-solving examinations. Predictive analysis software was used to analyze the data. Results. Seventy facilitators generated 1506 evaluation reports for 191 (90 third-year and 101 second-year) students over eight PBL cases. The mean (SD) total score was 40.6 (2.5) for P3s and 39.1 (2.7) for P2s out of a possible 44.2 points. Students' scores improved each semester. Interrater reliability based on intraclass correlation coefficient for all cases was 0.67. Internal reliability as determined by Cronbach alpha was >0.7 for all binary checklist items across all cases. Discriminant validity assessed using Pearson correlation coefficient showed that the total score from the checklist did not correlate with knowledge or problem-solving examination scores. Conclusion. This unique PBL checklist proved to be a reliable and valid tool to assess student performance in small group sessions in a PharmD curriculum.

Objective: To review the mechanism and association of infectious risk among the tumor-necrosis factor α (TNF-α) antagonists used in inflammatory bowel disease. Data Sources: A PubMed literature search was performed using the following search terms: infliximab, adalimumab, certolizumab, golimumab, inflammatory bowel disease, crohn’s, ulcerative colitis, adverse effects, adverse events, safety, and infection. Study Selection and Data Extraction: Meta-analyses and cohort studies with outcomes pertaining to quantitative infectious risk were reviewed. Case reports and case series describing association between TNF-α inhibitors and infection were also reviewed. Data Synthesis: A total of 7 recent meta-analyses of randomized trials demonstrate inconclusive association of infection with TNF-α antagonists. Registry data suggest that medications carry an independent risk of opportunistic infections. Risk factors for infection include older age, malnutrition, diabetes, and possibly combination therapy. Reported infections vary widely but include intracellular and granulomatous bacteria, viruses, and fungi. Conclusion: TNF-α antagonists are associated with an increased risk of opportunistic infection, although this risk has not been demonstrated conclusively in randomized controlled trials. Knowledge of concomitant risk factors, mechanism of infectious risk, and available treatment options can improve patient care in the clinical setting.

Jehovah’s Witnesses (JW) represent a complex patient population due to their refusal to accept blood transfusions on religious grounds. Pharmacologic management of anemic JW patients is limited to stimulation of hematopoiesis by iron and erythropoietin supplementation and reduction of blood loss by prothrombin complex concentrates (PCCs). Hemoglobin-based oxygen carriers (HBOCs) represent the only pharmacologic modality for JW patients capable of acutely increasing a patient’s oxygen carrying capacity in the setting of organ failure, yet clinical safety and efficacy data are lacking in this population. We report 3 cases in which the HBOC, PEGylated carboxyhemoglobin bovine (Sanguinate®), was requested under emergent circumstances for severely anemic (hemoglobin <5 g/dL) JW patients who refused blood transfusions. Two patients received PEGylated carboxyhemoglobin infusions for severe anemia, while the third patient died prior to receiving the medication. One patient who received Sanguinate died after 5 units of medication. The other patient’s hemoglobin recovered and she was discharged in stable condition. This series demonstrates the complex nature of the critically anemic JW population and highlights the clinical considerations of using HBOCs in clinical practice and the critical need for further research before they can be broadly recommended.

IntroductionCreatinine‐based equations used to estimate renal function are inaccurate in certain clinical contexts; however, there are limited resources to guide pharmacists in these situations.ObjectivesTo assess current renal function estimation and subsequent drug dosing practices among American College of Clinical Pharmacy (ACCP) members via an electronic survey.MethodsA 21‐item survey was emailed to the listservs of four ACCP Practice‐Research Networks: Adult Medicine, Nephrology, Critical Care, and Infectious Diseases. The survey included pharmacist demographics, practice site information, and case‐based clinical application scenarios requiring the respondent to choose a renal function estimate for overweight, underweight, and elderly patients (≥65 years). Four patient cases captured respondents' enoxaparin dosing decisions in patients with an estimated creatinine clearance of around 30 mL/min. Estimates of renal function were provided based on Cockcroft‐Gault (C‐G), Modification of Diet in Renal Disease, and Chronic Kidney Disease Epidemiology equations.ResultsThere were 299 survey responses. The majority of respondents were pharmacists (98%) who practiced in the hospital setting (96%) as clinical specialists (69%). The C‐G equation was chosen to estimate renal function most commonly (85%). Total and adjusted body weights were used in C‐G estimates most commonly in patients who were underweight (80%) and overweight (75%), respectively. Given an elderly patient with low serum creatinine (Scr), 34% of respondents used actual Scr, 30% rounded Scr to 0.8, and 29% rounded Scr to 1.0 for use in C‐G. Enoxaparin renal dose adjustment differed based on clinical indication. Respondents chose more frequent (every 12 hour) dosing in patients with pulmonary embolism vs atrial fibrillation. Of the 79% of respondents whose practice site utilizes pharmacist‐driven renal dose adjustment policies, 94% indicated they deviated from the policy.ConclusionLarge variation exists among clinical pharmacists in the application of renal function estimating equations which may impact dosing strategies and patient care.

Enoxaparin is a low molecular weight heparin commonly used in the treatment of venous thromboembolisms (VTEs); however, evidence on optimal empiric dosing recommendations are lacking in patients with morbid obesity. Utilization of an absolute dose cap, anti-Xa monitoring, and reduced empiric dosing are among the techniques used in this population. We describe a case of a morbidly obese man (body-mass index, BMI: 68.2 kg/m2, total body weight: 236 kg) who required therapeutic enoxaparin for suspected pulmonary embolism (PE) and critical limb ischemia as a bridge therapy during warfarin initiation. An initial empiric dose of 200 mg Q12 hours (0.85 mg/kg) resulted in an anti-Xa level of 1.01 IU/mL following the fifth dose, and no dose modification was deemed necessary. He experienced no adverse effects from treatment. This report adds to a growing body of evidence illustrating the need for reduced empiric weight-based doses of enoxaparin in the morbidly obese population and raises the question of whether dose capping is an appropriate practice in the clinical setting of morbidly obese patients with acute VTE.

OBJECTIVE:To determine the pharmacological treatment methods available to anemic Jehovah's Witnesses (JW).DATA SOURCES:MEDLINE and PubMed were searched from inception through February 2018 using the search terms Jehovah's Witnesses, treatment, erythropoietin, hemoglobin-based oxygen carrier, Sanguinate, Hemopure, bleeding, and anemia.STUDY SELECTION AND DATA EXTRACTION:All clinical trials, cohort studies, case-control studies, and observational trials involving pharmacotherapy in anemic JW patients were evaluated. Case reports and bibliographies were also analyzed for inclusion.DATA SYNTHESIS:Two studies involving the use of erythropoietin (EPO) and one study involving recombinant factor VIIa were included. Information was also included from other pharmacotherapeutic modalities that had case report data only. Current published evidence is limited with regard to evidence-based management of JW patients. High-dose EPO, intravenous iron supplementation, and hemostatic agents have demonstrated good clinical outcomes in case reports. EPO doses as high as 40 000 units daily have been advocated by some experts; however, pharmacokinetic studies do not support dose-dependent effects. Hemoglobin-based oxygen carriers (HBOCs) are currently not Food and Drug Administration approved. They are available through expanded access programs and may represent a lifesaving modality in the setting of severe anemia.CONCLUSIONS:There are currently not enough data to make definitive recommendations on the use of pharmacological agents to treat severe anemia in the JW population. Further evidence utilizing EPO and HBOCs will be beneficial to guide therapy.

PreviousNext No AccessPharmacotherapyFirst: A Multimedia Learning ResourceNausea and Vomitinghttps://doi.org/10.21019/pharmacotherapyfirst.nv_overviewAuthors:Pramodini Kale-Pradhan, PharmDSheila Wilhelm, PharmD, FCCP, BCPSSean McConachiePharmDPramodini Kale-PradhanSearch for more papers by this author, Sheila WilhelmSearch for more papers by this author, Sean McConachieSearch for more papers by this author SectionsAboutFull TextePUBReferences ToolsAdd to favoritesDownload CitationsTrack Citations ShareFacebookTwitterLinkedInRedditEmail Quick Facts1. Singh P, Yoon SS, Kuo B. Nausea: A review of pathophysiology and therapeutics. Ther Adv Gastroenterol. 2016;9(1):98–112. Crossref, Medline, Google Scholar, 2. McQuaid K. Approach to the patient with gastrointestinal disease. In: Goldman L, Schafer AI, eds. Goldman’s Cecil Medicine, 24th ed. Philadelphia, PA: Elsevier Saunders. 2012;e828–e844. Crossref, Google Scholar, 3. Gravatt L, Donohoe KL, DiPiro CV. Nausea and Vomiting. 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Google Scholar, PreviousNext Session Activity Recently Viewed Nausea and Vomiting Pramodini Kale-Pradhan, Sheila Wilhelm and Sean McConachie Recently Searched No search history FiguresReferencesRelatedDetails Published: 10 September 2019 Copyright & Permissions© 2017 by the American Pharmacists Association. All rights reserved© 2017 by the American Pharmacists Association. All rights reserved Publisher American Pharmacists Association HistoryPublished: 10 September 2019 Citation Information Pramodini Kale-Pradhan, Sheila Wilhelm, and Sean McConachie, (2017), "Nausea and Vomiting," PharmacotherapyFirst: A Multimedia Learning Resource https://doi.org/10.21019/pharmacotherapyfirst.nv_overview Loading ...

Purpose: The Global Initiative for Chronic Obstructive Lung Disease guidelines provide recommendations to manage chronic obstructive lung disease (COPD) exacerbations. This study assessed the management of inpatient COPD exacerbations at an urban teaching hospital. Methods: A retrospective cohort analysis of adults admitted between December 2010 and August 2012 with a COPD exacerbation was conducted. Patient demographics, length of stay (LOS), Charlson comorbidity score, inpatient pulmonary medications, and 30-day readmission were collected. Descriptive statistics characterized guideline adherence and readmission. Results: 94 patients were included with median LOS of 3 days (interquartile range [IQR]: 1-5 days) and median Charlson comorbidity score of 6 (IQR: 5-8). All patients received an inhaled short-acting beta agonist, and 52 (55.3%) also received an inhaled short-acting anticholinergic. Seventy-eight (83%) received systemic corticosteroids, of which 3 received guideline-recommended doses. Sixty-four (68.1%) received antibiotics for a pulmonary indication, of which 71.9% received appropriate antibiotics per indication. Of the 94 patients, 2 were managed in complete adherence with GOLD recommendations. A total of 24 (25.5%) patients were readmitted within 30 days of discharge, 9 of these for COPD. Conclusion: COPD exacerbation treatment deviated from GOLD recommendations. This provides opportunities for further optimization of treatment of COPD exacerbations.