Ability of Pharmacy Students, Pharmacists and Pharmacy Support Staff to Manage Childhood Fever via Simulation

Objective. To ascertain how pharmacy students (novices) and pharmacy staff (experts) respond to a childhood fever scenario. Methods. Data were collected from 65 second year students and 51 fourth (final) year students in an over-the-counter fever scenario during assessment tasks. Data from pharmacy staff were collected via mystery shopping conducted over nine weeks between March and October 2015. All encounters were immediately scored by the trained simulated client, and immediate feedback was provided for pharmacy staff and fourth year students. Questioning scores and proportions of competent participants were collected in all groups. Statistical comparative analyses were made between fourth year students and pharmacy staff. Pharmacy staff scores were also tracked over time. Results. Second year students performed well, achieving a median questioning score of 100%. Conversely, pharmacy staff scored 22%. A large proportion of the fourth year students and pharmacy staff achieved appropriate outcomes (92% and 65%, respectively); however, a smaller proportion of second year students performed well (52%). The pharmacy staff achieved statistical improvements over time for median questioning scores. Conclusion. Protocol compliant questioning appears to decline with experience. However, experienced counselors are more likely to provide appropriate patient advice. Further improvements in outcomes can also occur when staff are provided feedback and coaching. Mystery shopping simulations can be used as a valuable educational tool.

The effectiveness of an online training programme to prepare teachers to provide asthma first aid

AIM

Asthma is prevalent in our primary (elementary) school population. Training in asthma management for school staff should be relevant and focused on the recognition and management of an acute severe exacerbation of asthma. Evidence suggests that online training can be as effective as face-to-face training for medical education; however, there is little information regarding the effectiveness of online asthma education.

METHODS

University students in the final year of their primary education degree completed the asthma first aid (AFA) knowledge questionnaire before undertaking a 1-h online training course in asthma management. After 3 weeks, participants underwent a second AFA knowledge questionnaire followed by an AFA scenario-based skills assessment. This skills assessment required the student to describe and demonstrate how they would manage a child having a severe exacerbation of asthma using the AFA equipment provided. Skills scores were further analysed to establish AFA competency.

RESULTS

AFA knowledge scores improved significantly after the asthma online training (64-79%), z = -6.11 (P < 0.001). The mean AFA skills score after the training was 20.5 (79%); however, the proportion of students who achieved a level of competency sufficient to save the life of a child having a severe exacerbation of asthma was only 29%.

CONCLUSION

This research has revealed that online asthma management training was effective in increasing the knowledge needed for AFA. This knowledge did not translate into effective AFA skills, with only 29% of participants deemed competent to save the life of a child in an asthma emergency.

Community pharmacy modifications to non-prescription medication requests: A simulated patient study

BACKGROUND

Self-care, and hence self-medication, is becoming an increasingly popular practice worldwide. Community pharmacies are an important destination for those seeking non-prescription medicines, and pharmacists and their staff are in a prime position to facilitate appropriate and safe self-medication.

PURPOSE

To determine what modifications (for example, a change in brand, change in drug, or non-supply) pharmacy staff make when presented with a request for a non-prescription medicine, and to determine what factors influence whether a modification is made.

METHODS

Sixty-one third year Bachelor of Pharmacy students from The University of Sydney were trained as mystery shoppers to make 9 visits once a week to 36 community pharmacies in the metropolitan region of Sydney, Australia from March-October 2015. Students presented to a different, pre-allocated pharmacy once a week with a direct product request for a non-prescription medicine relating to a common ailment (e.g. asthma, insomnia, allergic rhinitis) for 9 weeks. Student mystery shoppers audio-recorded each visit and collected the details of the interaction and product sold. Descriptive statistics, chi-squared analyses, and binary logistic regression were performed to find factors influencing modifications made by pharmacy staff to the simulated patient initial request.

RESULTS

Of 540 completed visits, 497 were eligible for analysis. Modification (change in brand, intra/interclass change, companion sale, or no product supplied) occurred in 49% (n = 245) of visits. Whether the product requested was deemed "not appropriate" given the scenario outline was the only significant predictor of whether a modification to the request occurred (42% modification, "appropriate" scenarios vs. 57% modification, "not appropriate" scenarios; χ² = 8.90; p < 0.01).

CONCLUSIONS

Modification from the original non-prescription medicine request occurred in approximately half the reported requests. A request for a product that was considered "not appropriate" was more likely to elicit a modification than a request for an "appropriate" non-prescription medicine.

Revision of the International Pharmaceutical Federation's Basel Statements on the future of hospital pharmacy: From Basel to Bangkok

PURPOSE

The processes used to revise the 2008 Basel Statements on the future of hospital pharmacy are summarized, and the revised statements are presented.

METHODS

The process for revising the Basel Statements followed an approach similar to that used during their initial development. The Hospital Pharmacy Section (HPS) of the International Pharmaceutical Federation (FIP) revised the 2008 FIP Basel Statements in four phases, including a survey of hospital pharmacists worldwide, an internal review, online forums, and a face-to-face "World Café" workshop in Bangkok, Thailand.

RESULTS

The global survey on the initial Basel Statements included input from 334 respondents from 62 countries. The majority of respondents agreed that most of the initial Basel Statements were acceptable as written and did not require revision. In total, 11 statements were judged by more than 10% of respondents as needing revision or deletion. The FIP HPS executive committee used the survey results to develop 69 initial revised draft statements. After an online discussion with the international hospital pharmacy community, including individuals from 28 countries representing all six World Health Organization regions, a final set of draft statements was prepared for the live discussion involving participants from 20 countries. The final 65 revised Basel Statements were voted on and accepted.

CONCLUSION

Systematic revision of the FIP Basel Statements resulted in an updated reflection of aspirational goals for the future of hospital pharmacy practice. While this revision reflects the development of new goals for hospital pharmacy practice, the core principles of the Basel Statements remain an essential foundation for the discipline.

Magnetic resonance imaging of muscle electroporation injury

Low frequency electrical currents traversing the body during electrical shock can produce tissue damage by effects of electrical forces on cellular organelles and proteins as well as by Joule heating beyond thermotolerance. Treatment for these different injuries are quite distinct. Therefore, it is important to accurately diagnose the form of injury. Here we discuss the use of MRI for this purpose.

Effect of timing of prostaglandin administration, controlled internal drug release removal and gonadotropin releasing hormone administration on pregnancy rate in fixed-time AI protocols in crossbred Angus cows

Two experiments were conducted to investigate the effects of timing of prostaglandin F2(alpha) (PGF2(alpha)) administration, controlled internal drug release device (CIDR) removal and second gonodotropin releasing hormone (GnRH) administration on the pregnancy outcome in CIDR-based synchronization protocols. In Experiment 1, suckled Angus crossbred beef cows (n = 580) were given 100 microg of GnRH+a CIDR on Day 0. Cows in Group 1 (modified Ovsynch-P) received 25 mg of dinoprost (PGF2(alpha)) and CIDR device removal on Day 8 (AM), 100 microg of GnRH 36 h later on Day 9 (p.m.), and fixed-time AI (FTAI) 16 h later on Day 10 (47.5+/-1.1 h after PGF2(alpha)). Cows in Group 2 (Ovsynch-P) received 25mg of PGF2(alpha) and CIDR device removal on Day 7 (p.m.), 100 microg of GnRH 48 h later on Day 9 and FTAI 16 h later on Day 10 (66.6+/-1.2 h after PGF2(alpha)). Pregnancy rates were 56.5% (170/301) for Group 1 and 55.6% (155/279) for Group 2, respectively (P = 0.47). In Experiment 2, beef cows (n=734) were synchronized with 100 microg of GnRH+CIDR on Day 0, 25 mg of PGF2(alpha) and CIDR device removal on Day 7 and either 100 microg of GnRH 48 h later on Day 9 (Ovsynch-P) and FTAI 16 h later on Day 10 (64.9+/-3.3 h from PGF2(alpha)) or 100 microg of GnRH on Day 10 (CO-Synch-P) at the time of AI (63.2+/-4.2 h from PGF2(alpha)). Pregnancy rates were 48.8% (180/369) for Ovsynch-P and 44.7% (163/365) for CO-synch-P groups, respectively (P = 0.11). In both experiments, there was a locationxtreatment interaction (P<0.05); pregnancy rates between locations were different (P < 0.05) in the Ovsynch-P group. In conclusion, in a CIDR-based Ovsynch synchronization protocol, delaying administration of prostaglandin and CIDR removal by 12 h, or timing of the second GnRH by 16 h, did not affect pregnancy rates to FTAI. Therefore, there may be an opportunity to make changes in synchronization protocols with out adversely affecting FTAI pregnancy rates.

Selective lymphoscintigraphy: a necessary adjunct to dye-directed sentinel node biopsy for breast cancer?

BACKGROUND

Dye-directed sentinel node biopsy (SNB) for breast cancer provides accurate staging with low morbidity, but for tumors distant from the axilla, its use has been questioned.

HYPOTHESIS

Can preoperative breast lymphoscintigraphy (BL) applied selectively to medial hemisphere tumors predict a subset of patients who may not require surgical staging of the axilla?

DESIGN

Prospective cohort study.

SETTING

Tertiary, multidisciplinary breast center.

PATIENTS

Thirty-two women with breast tumors located in the medial hemisphere (30) or inframammary crease (2).

INTERVENTION

Peritumoral injection of 500 microCi of technetium Tc 99m sulfur colloid and biplanar imaging. Nonpalpable lesions were localized with ultrasound or mammography. At the time of definitive breast surgery, isosulfan blue dye-directed SNB was performed. Axillary dissection was performed when the SN contained a tumor or could not be identified.

MAIN OUTCOME MEASURES

Regional nodal basins identified by BL; success rate of SNB.

RESULTS

Preoperative BL demonstrated axillary drainage in 28 patients (88%); 2 patients (6%) had isolated internal mammary radionuclide uptake, and 2 patients had no nodal uptake. Dye-directed axillary SNB succeeded in 27 (87%) of 31 patients, including both patients with failed BL. Breast lymphoscintigraphy had predicted isolated internal mammary drainage in 2 of 4 patients whose SNs could not be identified. Metastases were found in 5 patients (16%).

CONCLUSIONS

Axillary radionuclide uptake predicts but does not augment dye-directed SN identification. In those few patients with isolated internal mammary drainage, BL may obviate the need for surgical staging of the axilla.

Antineoplastic agents 430. Isolation and structure of cribrostatins 3, 4, and 5 from the republic of maldives cribrochalina species

Continued investigation of cancer-cell growth-inhibitory constituents of the blue marine sponge Cribrochalina sp. has led to discovery of cribrostatins 3 (4a), 4 (5), and 5 (4b) in 10(-5) to 10(-7) % of the wet weight. The structure of cribrostatin 3 (4a) was determined by results of high field (500 MHz) (1)H and (13)C NMR and HRMS interpretations. The same general approach to the structures of cribrostatins 4 (5) and 5 (4b) was completed by X-ray crystal structure determinations. Cribrostatins 3, 4, and 5 provided significant cancer cell line inhibitory activities. Cribrostatins 1 and 2(2) and the newly isolated cribrostatins 3-5 displayed antibacterial and/or antifungal activities.

Common bile duct stone characteristics: correlation with treatment choice during laparoscopic cholecystectomy

Determining the most appropriate management approach for patients with unsuspected choledocholithiasis may be difficult because of the subjective nature of this decision in the absence of clinical data. Treatment of incidental choledocholithiasis during laparoscopic cholecystectomy was reviewed during a 25-month period. Operative cholangiograms were analyzed retrospectively to determine if associations exist between common bile duct stone characteristics and the intraoperative treatment selected by the operating surgeon. Cholangiographic data included quantification of common bile duct stones, stone dimension, position, and presence of radiopaque contrast flow into the duodenum. Two hundred thirty-six laparoscopic cholecystectomy patients underwent operative cholangiography; 25 (11%) demonstrated choledocholithiasis. Seven patients were converted to open common bile duct exploration (group I), 16 patients were referred for postoperative endoscopic retrograde cholangiopancreatography (group II), and two patients were observed (group III). Evaluation of the operative cholangiograms revealed multiple common bile duct stones (>1) in 86% (6 of 7) in group I, 25% (4 of 16) in group II, and none in group III. All patients in group I had at least one stone larger than 5 ml in greatest diameter, whereas only 33% (6 of 18) in groups II and III combined had stones larger than 5 ml. Group I had significantly (P = 0.027) more representation of delayed or no contrast flow during operative cholangiography compared to groups II and III. The intraoperative decision to proceed with laparoscopic cholecystectomy and rely on postoperative endoscopic retrograde cholangiopancreatography for stone retrieval rather than open common bile duct exploration was associated with (1) a single common bile duct stone, less than or equal to 5 ml in size on operative cholangiogram and (2) normal contrast flow into the duodenum. Open common bile duct exploration was more frequently associated with the demonstration of multiple or large (>5 ml) stones. A periampullary stone did not discriminate among treatment choices.

Distributing working versions of published mathematical models for biological systems via the Internet

Mathematical models are useful tools for investigating complex systems. By representing physiological systems as models, theories can be tested quantitatively against data from the system. Models can be used to explore new theories prior to experimentation and to design studies to optimize experimental resources. They can also be used as teaching tools to illustrate physiochemical principles. In spite of their usefulness and the time invested in developing models, published models are often underused due to the difficulty in obtaining working versions of the model. To address this problem we have designed a library for mathematical models of biological systems on the Internet. The library contains published models of biological systems in formats compatible with several modeling packages, from the fields of physiology, metabolism, endocrinology, biochemistry, and chemistry. The models can be viewed graphically, model solutions can be viewed as plots against data, and models can be downloaded to be run with software on the user's own system. The address of the library is: http://biomodel.georgetown.edu/model/ Investigators are invited to submit working versions of published models to the library. Models can be submitted electronically at the time a manuscript is accepted for publication. As journals go online, articles containing models can be linked to working versions of the models in the library. By increasing access to working versions of models, more of the investment in kinetic studies and model development can be realized.

Partial portacaval shunt for variceal hemorrhage: longitudinal analysis of effectiveness

OBJECTIVE

To determine rates of survival, long-term patency, and recurrent variceal hemorrhage among patients with alcoholic cirrhosis treated by partial portacaval shunt.

DESIGN

Single-institution cohort follow-up study of 72 consecutive patients who underwent small-diameter portacaval H-graft shunt with collateral ablation during a 10-year period (1981 through 1990). Subjects were enrolled and followed up for up to 15 years. Shunt patency was assessed by portography and/or ultrasonography. We performed 7-year Kaplan-Meier analyses of survival (in 65 patients in Child classes A and B), shunt patency, and absence of variceal bleeding.

SETTING

Tertiary academic referral center of the US Department of Veterans Affairs.

PATIENTS

Patients with alcoholic cirrhosis were considered for operation after at least 1 proven episode of variceal hemorrhage. Patients with portal vein thrombosis were excluded; patients in Child class C underwent operation only for compelling indications. Of the 72 who underwent partial shunting, 38 were in Child class A, 27 were in class B, and 7 were in class C.

INTERVENTIONS

Partial portacaval shunt (6-, 8- or 10-mm polytetrafluoroethylene H-graft with collateral ablation) and serial follow-up.

MAIN OUTCOME MEASURES

Study end points were death, recurrent variceal hemorrhage, and unavailability for follow-up. Other measures included graft patency and nonvariceal rebleeding.

RESULTS

Cumulative probability of 7-year patency for grafts at risk was 95%. The 7-year probability for absence of variceal bleeding in patients at risk was 92%. In 65 patients in Child classes A and B, operative mortality was 7.7% and the cumulative probability of 7-year survival was 54%.

CONCLUSION

For variceal bleeding associated with alcoholic cirrhosis, the small-diameter polytetrafluoroethylene portacaval H-graft with collateral ablation affords durable patency and protection against variceal rebleeding.

Modeling of arterial and cardiopulmonary baroreflex control of heart rate

We evaluated R-R interval changes (delta R-R interval) in 13 subjects (27 +/- 6 yr; 7 men and 6 women) as a function of blood pressure changes at the carotid sinus and aortic arch and central venous pressure changes at the cardiopulmonary receptors. Neck chamber pressure and suction were used to change pressure at the carotid sinus while lower body negative pressure, phenylephrine infusion, and nitroprusside infusion were used to change pressure at the carotid sinus (delta CSP), aortic arch (delta AAP), and cardiopulmonary receptors (delta CPP). Random effects regression analysis showed a significant linear relationship for delta R-R interval (-1.75 + 1.64 delta CSP + 15.40 delta AAP + 29.02 delta CPP + error), and the correlation (r) between the observed and predicted delta R-R interval was 0.82 (P < 0.00001). Sixty-seven percent of the delta R-R interval variability observed in the study is explained by the model. delta AAP accounts for approximately 63%, delta CSP for 14%, and delta CPP for 23% of the explained delta R-R interval.

Portacaval shunt for portal hypertensive gastropathy

Portal hypertensive gastropathy is a vascular disorder of the gastric mucosa distinguished by ectasia of the mucosal capillaries and submucosal veins without inflammation. During 1988 to 1993, 12 patients with biopsyproven cirrhosis (10 alcoholic, 2 posthepatitic) were evaluated and treated prospectively by portacaval shunt for active bleeding from severe portal hypertensive gastropathy. Eleven patients had been hospitalized for bleeding three to nine times previously, and one was bleeding uncontrollably for the first time. Requirement for blood transfusions ranged from 11 to 39 units cumulatively, of which 8 to 30 units were required specifically to replace blood lost from portal hypertensive gastropathy. Admission findings were ascites in 9 patients, jaundice in 8, severe muscle wasting in 10, hyperdynamic state in 9. Child's risk class was C in 7, B in 4, A in 1. Ten of the 12 patients had previously received repetitive endoscopic sclerotherapy for esophageal varices, which has been reported to precipitate portal hypertensive gastropathy. Eight patients had failed propranolol therapy for bleeding. Portacaval shunt was performed emergently in 11 patients and electively in 1, and permanently stopped bleeding in all by reducing the mean portal vein-inferior vena cava pressure gradient from 251 to 16 mm saline. There were no operative deaths, and two unrelated late deaths after 13 and 24 months. During 1 to 6.75 years of followup, all shunts remained patent by ultrasonography, the gastric mucosa reverted to normal On serial endoscopy, and there was no gastrointestinal bleeding. Recurrent portal-systemic encephalopathy developed in only 8% of patients. Quality of life was generally good. It is concluded that portacaval shunt provides definitive treatment of bleeding portal hypertensive gastropathy by eliminating the underlying cause, and makes possible prolonged survival with an acceptable quality of life.

Managing choledocholithiasis in the laparoscopic era

BACKGROUND

Management options for common bile duct stones have explained in the era of laparoscopic cholecystectomy (LC), and selecting the most appropriate method for each patient can be problematic due to the difficulty of predicting accurately which patients have choledocholithiasis (CDL). In order to improve selection of appropriate treatment for CDL, treatment options were analyzed for outcome retrospectively during a 25-month period beginning June 1, 1992.

PATIENTS AND METHODS

Four hundred four patients underwent LC; 48 (12%) had CDL identified at preoperative endoscopic retrograde cholangiopancreatography (ERCP) or intraoperative cholangiogram (IOCG). Forty-seven patients were referred for preoperative ERCP for suspected CDL, 23 (49%) of whom had proven duct stones and underwent endoscopic sphincterotomy and stone retrieval with an 87% success rate.

RESULTS

Of 357 patients scheduled for LC without preoperative ERCP, 236 had IOCG, of which 25 (11%) demonstrated CDL. Seven patients had open common bile duct exploration (CBDE). Sixteen patients had postoperative ERCP after positive IOCG, 7 (44%) of which were positive for CDL and whose stones were removed with 100% success. Two patients were observed, anticipating spontaneous passage of a small stone.

CONCLUSIONS

Preoperative ERCP should be applied selectively. For the large majority of patients without preoperative evidence of CDL, we recommend routine IOCG; if CDL is demonstrated, an intraoperative decision can be made to proceed to postoperative ERCP in the usual case or to open CBDE for very large or multiple stones. Observation in anticipation of spontaneous passage may be appropriate for small, solitary common duct stones. Continuing advances in laparoscopic CBDE are likely to reduce further the need to rely on ERCP in managing CDL.

Surgical management of breast masses in pregnant women

OBJECTIVE

The goal of this study was to review the outcomes of breast biopsies in pregnant women in order to plan optimum management strategies for pregnant women with breast masses.

STUDY DESIGN

From January 1990 to October 1992, 17 pregnant women underwent breast biopsy at a university hospital. Parameters evaluated were (1) trimester at presentation, (2) timing of biopsy, (3) mode of anesthesia, (4) requirements for tocolytics, and (5) histology of the lesion.

RESULTS

Antepartum biopsy was performed on all 11 patients who presented in the first or second trimester. Biopsy was accomplished postpartum in four of five patients presenting in the third trimester. Only one patient required tocolysis (associated with biopsy followed by immediate mastectomy). Histologic diagnosis was predominantly lactating adenoma (13 of 17 patients).

CONCLUSION

These results demonstrate that breast biopsy can be safely performed on pregnant women. We recommend that women presenting with breast masses in the first or second trimester undergo antepartum biopsy. We recommend postpartum excision for masses presenting in the latter half of the third trimester. For those presenting in the first half of the third trimester, fine needle aspiration biopsy may be a suitable alternative, particularly for the mass suspicious for cancer.

Collateral ablation improves portal perfusion after partial portacaval shunt

Small-diameter portacaval H-grafts (partial shunts) effectively abolish bleeding from esophageal varices. Goals are 1) to prevent variceal hemorrhage by subtotal portal decompression, and 2) to minimize postshunt encephalopathy by maintaining substantial residual pressure and prograde flow in the portal vein. To reduce spontaneous shunting of portal blood away from the liver, we advocate ablation of collateral vessels after partial shunts. Others have performed partial shunts without collateral ablation. We postulated that ablation of collateral vessels would augment portal perfusion pressure and preserve prograde portal flow after partial shunts. In 15 patients undergoing 8 or 10 mm portacaval H-grafts, portal pressure was measured intraoperatively before and after ligation of principal venous collaterals. In another 13 patients, collateral embolization was performed during postoperative portography. The degree of portal perfusion was scored. Pressure measurements demonstrated a mean rise in portal pressure of 2.8 cm saline after ligation (P = 0.025). Angiographic perfusion scores after embolization improved by a mean of 0.57 points on a 4 point scale (P = 0.032). We conclude that intraoperative collateral ligation augments residual portal pressures and that postoperative collateral embolization improves portal flow patterns. Since both observed effects have been associated with decreased postshunt encephalopathy rates, ablation of collateral vessels must be an integral component of the partial portacaval shunt.

Surgical management of portal hypertension

Portal hypertension is frequently complicated by upper gastrointestinal tract bleeding and ascites. Hemorrhage from esophageal varices is the most common cause of death from portal hypertension. Medical treatment, including resuscitation, vasoactive drugs, and endoscopic sclerosis, is the preferred initial therapy. Patients with refractory hemorrhage frequently are referred for immediate surgical intervention (usually emergency portacaval shunt). An additional cohort of patients with a history of at least 1 episode of variceal hemorrhage is likely to benefit from elective shunt operations. Shunt operations are classified as total, partial, or selective shunts based on their hemodynamic characteristics. Angiographically created shunts have been introduced recently as an alternative to operative shunts in certain circumstances. Devascularization of the esophagus or splenectomy is done for specific indications. Medically intractable ascites is a separate indication for surgical intervention. Liver transplantation has been advocated for patients whose portal hypertension is a consequence of end-stage liver disease. In the context of an increasingly complex set of treatment options, we present an overview of surgical therapy for complications of portal hypertension.