Neurodevelopmental outcomes in children prenatally exposed to opioid maintenance treatment: A population-based study

BACKGROUND AND OBJECTIVES

Opioid maintenance treatment (OMT), with methadone or buprenorphine, is a key approach for managing opioid use disorder (OUD) during pregnancy. Despite buprenorphine's superior short-term outcomes, its long-term effects remain understudied. This study aims to evaluate the effects of prenatal OMT exposure on the incidence of childhood neurodevelopmental disorders (NDDs) considering timing effect.

METHODS

A retrospective cohort study using Rhode Island Medicaid data linked to vital statistics from 2008 to 2018 was conducted. The study included pregnancies having live birth from 2008 to 2016 with continuous Medicaid insurance and OUD diagnosis within 3 months preceding conception until delivery. At least one buprenorphine dispensing or a claim of methadone was required for exposure definition. Exposure was evaluated during early (0-90 days) or late (>90 days) gestation, or at any pregnancy phase. NDDs, including autism, attention-deficit/hyperactivity disorder (ADHD), learning disabilities, speech/language disorders, developmental coordination disorder, intellectual disability, and behavioral disorders, were identified using validated algorithms. Applying Cox proportional-hazard models with propensity score overlap weighting, adjusted hazard ratios (aHR) were calculated, mitigating potential confounders. Children were followed up from birth until NDD diagnosis, disenrollment, or study end.

RESULTS

Of 416 mother-child dyads with OUD, 40% used methadone and 20% had buprenorphine exposure during pregnancy. NDDs were observed in 36% of children with early methadone exposure compared to 17% in the early buprenorphine exposed group (aHR: 2.75; 95% confidence interval [CI]: 1.42-5.35). Further comparison to late buprenorphine exposure, late methadone exposure was associated with higher NDD risk (aHR: 2.05; 95% CI: 1.09-3.86). Compared to unexposed group, children exposed to methadone during early and late periods showed higher NDD incidences (aHR: 2.33; 95% CI: 1.51-3.60 and aHR: 2.42; 95% CI: 1.54-3.80, respectively).

DISCUSSION

The study suggests that buprenorphine is a good treatment option for OUD during pregnancy due to minimal long-term neurodevelopmental impacts on children. However, further extensive research is necessary to rule-out potential confounding.

Angiotensin Receptor Blockers for Hypertension and Risk of Epilepsy

Importance

Animal and human studies have suggested that the use of angiotensin receptor blockers (ARBs) may be associated with a lower risk of incident epilepsy compared with other antihypertensive medications. However, observational data from the US are lacking.

Objective

To evaluate the association between ARB use and epilepsy incidence in subgroups of US patients with hypertension.

Design, Setting, and Participants

This retrospective cohort study used data from a national health administrative database from January 2010 to December 2017 with propensity score (PS) matching. The eligible cohort included privately insured individuals aged 18 years or older with diagnosis of primary hypertension and dispensed at least 1 ARB, angiotensin-converting enzyme inhibitor (ACEI), β-blocker, or calcium channel blocker (CCB) from 2010 to 2017. Patients with a diagnosis of epilepsy at or before the index date or dispensed an antiseizure medication 12 months before or 90 days after initiating the study medications were excluded. The data analysis for this project was conducted from April 2022 to April 2024.

Exposures

Propensity scores were generated based on baseline covariates and used to match patients who received ARBs with those who received either ACEIs, β-blockers, CCBs, or a combination of these antihypertensive medications.

Main Outcomes and Measures

Cox regression analyses were used to evaluate epilepsy incidence during follow-up comparing the ARB cohort with other antihypertensive classes. Subgroup and sensitivity analyses were conducted to examine the association between ARB use and epilepsy incidence in various subgroups.

Results

Of 2 261 964 patients (mean [SD] age, 61.7 [13.9] years; 1 120 630 [49.5%] female) included, 309 978 received ARBs, 807 510 received ACEIs, 695 887 received β-blockers, and 448 589 received CCBs. Demographic and clinical characteristics differed across the 4 comparison groups prior to PS matching. Compared with ARB users, patients receiving ACEIs were predominantly male and had diabetes, CCB users were generally older (eg, >65 years), and β-blocker users had more comorbidities and concurrent medications. The 1:1 PS-matched subgroups included 619 858 patients for ARB vs ACEI, 619 828 patients for ARB vs β-blocker, and 601 002 patients for ARB vs CCB. Baseline characteristics were equally distributed between comparison groups after matching with propensity scores. Use of ARBs was associated with a decreased incidence of epilepsy compared with ACEIs (adjusted hazard ratio [aHR], 0.75; 95% CI, 0.58-0.96), β-blockers (aHR, 0.70; 95% CI, 0.54-0.90), and a combination of other antihypertensive classes (aHR, 0.72; 95% CI, 0.56-0.95). Subgroup analyses revealed a significant association between ARB use (primarily losartan) and epilepsy incidence in patients with no preexisting history of stroke or cardiovascular disease.

Conclusions and Relevance

This cohort study found that ARBs, mainly losartan, were associated with a lower incidence of epilepsy compared with other antihypertensive agents in hypertensive patients with no preexisting stroke or cardiovascular disease. Further studies, such as randomized clinical trials, are warranted to confirm the comparative antiepileptogenic properties of antihypertensive medications.

An Integrative Review of Micro-Credentials and Digital Badges for Pharmacy Educators

Micro-credentials (MCs) and digital badges (DBs) have gained popularity in recent years as a means to supplement traditional degrees and certifications. MCs and DBs can play a significant role in supporting student-centered learning by offering personalized and flexible learning pathways, emphasizing real-world relevance and practical skills, and fostering a culture of continuous learning and growth. However, barriers currently exist within health professions education, including pharmacy education, that could limit the full adoption and implementation of MCs and DBs. Research on the use of MCs and DBs in Doctor of Pharmacy degree programs is sparse. In this integrative review, literature on the use of MCs and DBs in health professions education is reviewed, and perspectives on the benefits, issues, and potential future uses within Doctor of Pharmacy degree programs are presented.

Antibiotics on Demand: Advances in Asynchronous Telemedicine Call for Increased Antibiotic Surveillance

The rapid growth of telehealth services has brought about direct-to-consumer telemedicine platforms, enabling patients to request antibiotics online without a virtual or face-to-face consultation. While telemedicine aims to enhance accessibility, this trend raises significant concerns regarding appropriate antimicrobial use and patient safety. In this viewpoint, we share our first-hand experience with 2 direct-to-consumer platforms, where we intentionally sought inappropriate antibiotic prescriptions for nonspecific symptoms strongly indicative of a viral upper respiratory infection. Despite the lack of clear necessity, requested antibiotic prescriptions were readily transmitted to our local pharmacy following a simple monetary transaction. The effortless acquisition of patient-selected antibiotics online, devoid of personal interactions or consultations, underscores the urgent imperative for intensified antimicrobial stewardship initiatives led by state and national public health organizations in telehealth settings. By augmenting oversight and regulation, we can ensure the responsible and judicious use of antibiotics, safeguard patient well-being, and preserve the efficacy of these vital medications.

Prenatal Exposure to Opioids and Neurodevelopmental Disorders in Children: A Bayesian Mediation Analysis

This study explores natural direct and joint natural indirect effects (JNIE) of prenatal opioid exposure on neurodevelopmental disorders (NDDs) in children mediated through pregnancy complications, major and minor congenital malformations, and adverse neonatal outcomes, using Medicaid claims linked to vital statistics in Rhode Island, United States, 2008-2018. A Bayesian mediation analysis with elastic net shrinkage prior was developed to estimate mean time to NDD diagnosis ratio using posterior mean and 95% credible intervals (CrIs) from Markov chain Monte Carlo algorithms. Simulation studies showed desirable model performance. Of 11,176 eligible pregnancies, 332 had ≥2 dispensations of prescription opioids anytime during pregnancy, including 200 (1.8%) having ≥1 dispensation in the first trimester (T1), 169 (1.5%) in the second (T2), and 153 (1.4%) in the third (T3). A significant JNIE of opioid exposure was observed in each trimester (T1, JNIE = 0.97, 95% CrI: 0.95, 0.99; T2, JNIE = 0.97, 95% CrI: 0.95, 0.99; T3, JNIE = 0.96, 95% CrI: 0.94, 0.99). The proportion of JNIE in each trimester was 17.9% (T1), 22.4% (T2), and 56.3% (T3). In conclusion, adverse pregnancy and birth outcomes jointly mediated the association between prenatal opioid exposure and accelerated time to NDD diagnosis. The proportion of JNIE increased as the timing of opioid exposure approached delivery.

Comparative Safety Analysis of Opioid Agonist Treatment in Pregnant Women with Opioid Use Disorder: A Population-Based Study

INTRODUCTION AND OBJECTIVE

Receipt of opioid agonist treatment during early and late pregnancy for opioid use disorder may relate to varying perinatal risks. We aimed to assess the effect of time-varying prenatal exposure to opioid agonist treatment using buprenorphine or methadone on adverse neonatal and pregnancy outcomes.

METHODS

We conducted a retrospective cohort study of pregnant women with opioid use disorder using Rhode Island Medicaid claims data and vital statistics during 2008-16. Time-varying exposure was evaluated in early (0-20 weeks) and late (≥ 21 weeks) pregnancy. Marginal structural models with inverse probability of treatment weighting were applied.

RESULTS

Of 400 eligible pregnancies, 85 and 137 individuals received buprenorphine and methadone, respectively, during early pregnancy. Compared with 152 untreated pregnancies with opioid use disorders, methadone exposure in both periods was associated with an increased risk of preterm birth (adjusted odds ratio [aOR]: 2.52; 95% confidence interval [CI] 1.07-5.95), low birth weight (aOR: 2.99; 95% CI 1.34-6.66), neonatal intensive care unit admission (aOR, 5.04; 95% CI 2.49-10.21), neonatal abstinence syndrome (aOR: 11.36; 95% CI 5.65-22.82), respiratory symptoms (aOR, 2.71; 95% CI 1.17-6.24), and maternal hospital stay > 7 days (aOR, 14.51; 95% CI 7.23-29.12). Similar patterns emerged for buprenorphine regarding neonatal abstinence syndrome (aOR: 10.27; 95% CI 4.91-21.47) and extended maternal hospital stay (aOR: 3.84; 95% CI 1.83-8.07). However, differences were found favoring the use of buprenorphine for preterm birth versus untreated pregnancies (aOR: 0.17; 95% CI 0.04-0.77), and for several outcomes versus methadone.

CONCLUSIONS

Methadone and buprenorphine prescribed for the treatment of opioid use disorder during pregnancy are associated with varying perinatal risks. However, buprenorphine may be preferred in the setting of pregnancy opioid agonist treatment. Further research is necessary to confirm our findings and minimize residual confounding.

Maternal Complications and Prescription Opioid Exposure During Pregnancy: Using Marginal Structural Models

INTRODUCTION

Prescription opioids are frequently used for pain management in pregnancy. Studies examining perinatal complications in mothers who received prescription opioids during pregnancy are still limited.

OBJECTIVES

The aim of this study was to assess the association of prescription opioid use and maternal pregnancy and obstetric complications.

METHODS

This retrospective cohort study with the Rhode Island (RI) Medicaid claims data linked to vital statistics throughout 2008-2015 included pregnant women aged 12-55 years with one or multiple live births. Women were excluded if they had cancer, opioid use disorder, or opioid dispensing prior to but not during pregnancy. Main outcomes included adverse pregnancy and obstetric complications. Marginal Structural Cox Models with time-varying exposure and covariates were applied to control for baseline and time-varying covariates. Analyses were conducted for outcomes that occurred 1 week after opioid exposure (primary) or within the same week as exposure (secondary). Sensitivity studies were conducted to assess the effects of different doses and individual opioids.

RESULTS

Of 9823 eligible mothers, 545 (5.5%) filled one or more prescription opioid during pregnancy. Compared with those unexposed, no significant risk was observed in primary analyses, while in secondary analyses opioid-exposed mothers were associated with an increased risk of cesarean antepartum depression (HR 3.19; 95% CI 1.22-8.33), and cardiac events (HR 9.44; 95% CI 1.19-74.83). In sensitivity analyses, results are more prominent in high dose exposure and are consistent for individual opioids.

CONCLUSIONS

Prescription opioid use during pregnancy is associated with an increased risk of maternal complications.

A systematic review of integrative medicine for opioid withdrawal

INTRODUCTION

The United States has been battling an opioid epidemic for decades. As substance use disorders have grown, so too has investigation into treatment options, including integrative medicine approaches, for managing opioid withdrawal symptoms (OWS).

OBJECTIVES

This systematic review sought to assess the use of integrative medicine approaches for the alleviation of OWS in patients dependent on opioids and to summarize the available data.

METHODS

The authors searched using synonyms for opioids, substance use disorder, and integrative medicine and standardized searches in Embase, PubMed, and Cochrane Library. We also hand searched references for systematic reviews. This review did not include articles that could not be obtained as full-text publications via interlibrary loan. The review also excluded studies with interventions involving acupuncture because multiple systematic reviews on this approach already exist. In addition, we also excluded studies of therapy for opioid maintenance. We evaluated studies for inclusion based on the Jadad criteria. We compared opioid withdrawal outcomes of the studies to determine the efficacy of integrative medicine approaches.

RESULTS

The authors identified a total of 382 unique publications initially for possible inclusion through systematic searches. After applying inclusion and exclusion criteria, five studies met Jadad criteria. The authors identified an additional two studies for inclusion via hand searching. A total of seven studies included interventions consisting of passionflower, weinicom, fu-yuan pellet, jinniu capsules, tai-kang-ning, dynorphin, and l-tetrahydropalmatine. Analyzing the articles was difficult given the varied scoring methods they used to quantify opioid withdrawal symptoms and the small sample sizes in the trials. Most showed evidence that supported integrative medicine approaches for OWS, although the strength of evidence was limited because of sample sizes.

CONCLUSIONS

This review found evidence of multiple integrative medicine approaches for opioid withdrawal symptoms. Well-designed randomized controlled trials should assess the efficacy of integrative medicine for improvement in OWS.

Association of Gestational Opioid Exposure and Risk of Major and Minor Congenital Malformations

IMPORTANCE

The rapid increase of opioid-related overdoses and deaths has become a public health concern in the US. Use of prescription opioids in pregnant women has increased; results from teratogenicity studies remain controversial.

OBJECTIVE

To evaluate the association between maternal prescription opioid use (excluding opioid use disorders) during pregnancy and the incidence of congenital malformations.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective population-based cohort study evaluated linked Rhode Island Medicaid claims and vital statistics data of live births from January 1, 2008, to December 31, 2016. Data analysis was conducted from May 1, 2019, to May 31, 2020. Women who had a live birth during the study period, but no cancer or opioid use disorder, were followed up from 3 months before pregnancy to the end of pregnancy.

EXPOSURES

Data on the mother's prescription opioid exposure were obtained through pharmacy claims and exposure was defined as dispensing of at least 1 prescription opioid during the first, second, or third trimester.

MAIN OUTCOMES AND MEASURES

The primary outcome was overall major or minor congenital malformations, defined as 1 or more major or minor congenital malformation. Secondary outcomes were defined as 10 specific categories of congenital malformations classified by organ systems using International Classification of Diseases diagnosis codes.

RESULTS

Of 12 424 included pregnancies, 891 mothers (7.2%) received prescription opioids during pregnancy and 3153 infants (25.4%) were diagnosed with major or minor congenital malformations. Comparing prescription opioid exposure vs nonexposure, no excess risk was observed for major birth defects in infants with opioid exposure in trimester 1 (adjusted relative risk [aRR], 1.40; 95% CI, 0.84-2.34), and higher risks were found for overall minor birth defects in trimester 3 (aRR, 1.26; 95% CI, 1.04-1.53) and minor birth defects in the musculoskeletal system in trimester 2 (aRR, 1.50; 95% CI, 1.10-2.03) and trimester 3 (aRR, 1.65; 95% CI, 1.23-2.22). Significant dose responses in selected minor malformations and effects of specific opioids were also identified. Hydrocodone in trimester 2 (aRR, 3.01; 95% CI, 1.80-5.03) and oxycodone in trimester 3 (aRR, 2.43; 95% CI, 1.37-4.02) were associated with plagiocephaly, polydactyly, and other specified congenital deformities of the hip.

CONCLUSIONS AND RELEVANCE

The findings of this study suggest a higher risk of minor congenital malformations associated with use of prenatal prescription opioids in trimester 3, which seems to be dose-dependent. Further investigation is needed to establish causality and explore the physiologic plausibility of the association.

Intranasal Ketamine for Acute Pain

OBJECTIVES

The aim was to review current evidence regarding the off-label use of intranasal ketamine for acute pain presenting in the setting of the emergency department, and secondary to pediatric limb injuries, renal colic, digital nerve block, and migraines.

RESULTS

In all 5 indications reviewed, ketamine demonstrated efficacy in reducing pain. However, when compared with other agents, ketamine did not demonstrate superiority over opioids in pediatric limb injuries or renal colic and was not as efficacious as standard therapy for migraine relief. Ketamine was also associated with a greater incidence of transient adverse reactions, such as dizziness, bitter aftertaste, fatigue, and vomiting than opioid therapies.

DISCUSSION

The current body of evidence is insufficient to support the use of intranasal ketamine over other standard therapies for acute pain. However, current evidence can be used when developing dosing strategies, preparing for adverse reactions, and generating hypotheses for future, more robust research.

Complementary and Alternative Medicine in Hospice and Palliative Care: A Systematic Review

CONTEXT

The aim of palliative care is to improve quality of life for patients with serious illnesses by treating their symptoms and adverse effects. Hospice care also aims for this for patients with a life expectancy of six months or less. When conventional therapies do not provide adequate symptom management or produce their own adverse effects, patients, families, and caregivers may prefer complementary or alternative approaches in their care.

OBJECTIVES

The objectives of this study were to evaluate the available evidence on the use of complementary or alternative medicine (CAM) in hospice and palliative care and to summarize their potential benefits.

METHODS

A defined search strategy was used in reviewing literature from major databases. Searches were conducted using base terms and the symptom in question. Symptoms included anxiety, pain, dyspnea, cough, fatigue, insomnia, nausea, and vomiting. Studies were selected for further evaluation based on relevancy and study type. References of systematic reviews were also assessed. After evaluation using quality assessment tools, findings were summarized and the review was structured based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

RESULTS

Out of 4682 studies, 17 were identified for further evaluation. Therapies included acupressure, acupuncture, aromatherapy massage, breathing, hypnotherapy, massage, meditation, music therapy, reflexology, and reiki. Many studies demonstrated a short-term benefit in symptom improvement from baseline with CAM, although a significant benefit was not found between groups.

CONCLUSION

CAM may provide a limited short-term benefit in patients with symptom burden. Additional studies are needed to clarify the potential value of CAM in the hospice or palliative setting.

Atezolizumab for the First-Line Treatment of Non-small Cell Lung Cancer (NSCLC): Current Status and Future Prospects

Purpose: Atezolizumab is a programmed death ligand 1 (PDL-1) blocking antibody that was approved for metastatic non-small cell lung cancer (NSCLC) in patients with disease progression. Various studies have been initiated to explore the effectiveness of atezolizumab among different patient cohorts and disease statuses, including as first-line therapy. The purpose of this paper is to identify and summarize the trials that use atezolizumab as a first-line agent in chemotherapy-naïve patients with NSCLC. Methods: A database search was performed on Pubmed, Embase, and Wiley Cochrane Library-Central Register of Controlled Trials to identify clinical trials using atezolizumab as first-line therapy in NSCLC. Additionally, ClinicalTrials.gov and the International Clinical Trials Registry Platform (ICTRP) were searched to identify relevant clinical trials. Conference abstracts from the American Society of Clinical Oncology, the European Society for Medical Oncology, and the American Association for Cancer Research were hand-searched. Any trial in which atezolizumab was used as first-line therapy in chemotherapy-naive patients with NSCLC was included. Results: Fifteen studies were ultimately included, all of which are current and ongoing. Of the 15 studies, 5 have reported results. When given in the first-line setting, atezolizumab had higher rates of objective response, progression-free survival, and overall survival, compared to the second and third-line settings. Among the 15 studies, atezolizumab is used as monotherapy (n = 5), in combination with chemotherapy (n = 6), in combination with targeted therapy such as bevacizumab (n = 1), as neoadjuvant/adjuvant therapy (n = 3), in combination with stereotactic body radiation therapy (n = 1), and in combination with or following chemoradiation (n = 1). Conclusion: Available evidence shows promising safety and efficacy with the use of atezolizumab as first-line therapy in NSCLC. Atezolizumab is currently being studied in a variety of treatment settings. If clinical benefits are shown, atezolizumab may deem to be a useful first-line agent in NSCLC.

A pharmacist-driven academic detailing program to increase adult pneumococcal vaccination

OBJECTIVES

To describe our statewide, pharmacist-led education campaign to increase knowledge and awareness of pneumococcal immunization recommendations.

SETTING

Immunization providers and residents in the state of Rhode Island.

PRACTICE DESCRIPTION

A clinical pathway (i.e., decision-support tool) was developed to educate health professionals about appropriate indications, administration schedules, and frequently asked questions for the 2 different adult pneumococcal vaccines. Academic detailing and distribution of the clinical pathway to health professionals was conducted across Rhode Island. Community outreach activities included radio ads as well as distribution of patient handouts and wallet cards at community events.

PRACTICE INNOVATION

To our knowledge, this was the first statewide, pharmacist-driven academic detailing and community outreach campaign to promote adult pneumococcal vaccination.

EVALUATION

Academically detailed immunization providers received a 6-question survey. Pneumococcal disease rate differences between the study periods were evaluated with the use of Fisher exact tests, whereas changes in vaccination were assessed with the use of chi-square tests.

RESULTS

From November 2013 through July 2015, our academic detailers visited and distributed our vaccination pathway materials to more than 400 practice sites across Rhode Island, including 68% of community pharmacies and all adult acute care hospitals. Of the 413 surveys completed, 92% of respondents agreed that their knowledge of the pneumococcal conjugate vaccine, 13-valent and pneumococcal polysaccharide vaccine, 23-valent had improved. Pneumococcal vaccination increased significantly (absolute difference 3.9%, percentage change in proportion 5.4%; P = 0.01), and pneumococcal disease decreased significantly between the preintervention and intervention periods (-2.74/10,000 discharges [95% CI -5.15 to -0.32], P = 0.02). Invasive pneumococcal disease decreased by 21 cases per 1,000,000 population per year between the preintervention and postintervention periods (-42.25 to 0.14, P = 0.05).

CONCLUSION

Our statewide, pharmacist-driven pneumococcal vaccination educational outreach program resulted in favorable provider feedback relative to knowledge change and perceptions. Vaccination increased and pneumococcal disease decreased during the study period.

Daptomycin-induced eosinophilic pneumonia - a systematic review

PURPOSE

Eosinophilic pneumonia comprises a group of lung diseases in which eosinophils appear in increased numbers in the lungs and sometimes in the bloodstream. Several case reports link daptomycin use to this phenomenon.

SUMMARY

We performed a systematic literature review to identify cases of eosinophilic pneumonia associated with daptomycin use. Relevant studies were identified by searching Pubmed/Medline, EMBASE, Google Scholar, Cochrane Database of Systematic Reviews, and Clin-Alert from inception to May 2016, and manual searches of reference lists. All case reports that include information regarding patient age, indication, clinical and objective findings, treatment and outcome were evaluated. Abstracts from conference proceedings as well as case reports not in English were excluded. Descriptive statistics were used to analyze the data. Thirty-five patient-cases were included in the final analysis. Patients most likely to be identified with daptomycin-induced eosinophilic pneumonia were male (83%) and elderly (mean age 65.4 ± 15 years). The dose for daptomycin ranged from 4 to 10 mg/kg/day, but included a large number of patients with renal dysfunction. The average duration of daptomycin therapy upon onset of EP symptoms was 2.8 ± 1.6 weeks. Majority of patients presented with dyspnea (94%), fever (57%) and were also found to have peripheral eosinophilia (77%) and infiltrates/opacities of CT/CXR (86%). Symptom improvement was seen after daptomycin discontinuation (24 h to 1 week). The majority of patients were also prescribed treatment with corticosteroids (66%).

CONCLUSION

Clinicians should be aware of daptomycin-induced eosinophilic pneumonia and its symptoms along with its presentation and treatment.

Promoting Safe Use of Medications: Providing Medication Education to Seniors Receiving Meals on Wheels

STUDY OBJECTIVES

To assess whether pharmacist-provided medication education and counseling to Meals on Wheels (MOW) participants decreases medication-related preventable harm and improves adherence.

DESIGN

Prospective, quasi-experiment.

SETTING

Ambulatory congregrate dining centers.

PATIENTS

Persons 60 years of age and older participating in MOW receiving prescription, nonprescription, or complementary products were eligible. In total, 42 patients consented. Five patients did not complete the first visit, and 13 patients did not complete the six-month follow-up visit.

INTERVENTIONS

Pharmacists provided comprehensive medication education about prescription, nonprescription, and complementary products at baseline. Additional resources to enhance adherence and avoid medication-related preventable harm were provided and discussed.

MAIN OUTCOME MEASURES

Medication-related preventable harm and medication adherence were assessed before pharmacist intervention and six months after intervention. Adherence was assessed and compared with baseline using the Morisky scale and pill counts.

RESULTS

Women constituted the majority of participants (94.4%) with an average age of 74.5 ± 8.2 years. Mean difference in Morisky score from baseline to six months was 0.28 (-0.11 to 0.56). After adjustment for age and living situation, the change in Morisky score was associated with a 14% improvement in adherence. Mean differences in drug-drug and drug-supplement interactions, and medication-related harm were not significantly reduced from baseline to study end.

CONCLUSION

Pharmacist intervention with MOW participants appeared to improve medication adherence rates but had limited effect on medication-related preventable harm. No findings reached statistical significance as the sample size was inadequate. Larger studies are needed to confirm these findings.

Clinical implications of vancomycin heteroresistant and intermediately susceptible Staphylococcus aureus

Staphylococcus aureus (S. aureus) has proven to be a major pathogen with the emergence of methicillin-resistant S. aureus (MRSA) infections and recently with heteroresistant vancomycin-intermediate S. aureus (hVISA) and vancomycin-intermediate S. aureus (VISA) infections. Although vancomycin is traditionally a first-line and relatively effective antibiotic, its continued use is under question because reports of heteroresistance in S. aureus isolates are increasing. Both hVISA and VISA infections are associated with complicated clinical courses and treatment failures. The prevalence, mechanism of resistance, clinical significance, and laboratory detection of hVISA and VISA infections are not conclusive, making it difficult to apply research findings to clinical situations. We provide an evidence-based review of S. aureus isolates expressing heterogenic and reduced susceptibility to vancomycin.

Assessment and revision of clinical pharmacy practice internet web sites

BACKGROUND

Health care professionals, trainees, and patients use the Internet extensively. Editable Web sites may contain inaccurate, incomplete, and/or outdated information that may mislead the public's perception of the topic.

OBJECTIVE

To evaluate the editable, online descriptions of clinical pharmacy and pharmacist and attempt to improve their accuracy.

METHODS

The authors identified key areas within clinical pharmacy to evaluate for accuracy and appropriateness on the Internet. Current descriptions that were reviewed on public domain Web sites included: (1) clinical pharmacy and the clinical pharmacist, (2) pharmacy education, (3) clinical pharmacy and development and provision for reimbursement, (4) clinical pharmacists and advanced specialty certifications/training opportunities, (5) pharmacists and advocacy, and (6) clinical pharmacists and interdisciplinary/interprofessional content. The authors assessed each content area to determine accuracy and prioritized the need for updating, when applicable, to achieve consistency in descriptions and relevancy. The authors found that Wikipedia, a public domain that allows users to update, was consistently the most common Web site produced in search results.

RESULTS

The authors' evaluation resulted in the creation or revision of 14 Wikipedia Web pages. However, rejection of 3 proposed newly created Web pages affected the authors' ability to address identified content areas with deficiencies and/or inaccuracies.

CONCLUSIONS

Through assessing and updating editable Web sites, the authors strengthened the online representation of clinical pharmacy in a clear, cohesive, and accurate manner. However, ongoing assessments of the Internet are continually needed to ensure accuracy and appropriateness.

Curriculum and Instructional Methods for Drug Information, Literature Evaluation, and Biostatistics: Survey of US Pharmacy Schools

BACKGROUND:

The drug information curriculum in US colleges of pharmacy continues to evolve. The American College of Clinical Pharmacy (ACCP) Drug Information Practice and Research Network (DI PRN) published an opinion paper with specific recommendations regarding drug information education in 2009. Adoption of these recommendations has not been evaluated.

OBJECTIVE:

To assess which recommendations made in the ACCP DI PRN opinion paper are included in US pharmacy school curricula and characterize faculty qualifications, educational methods, and recent changes in drug information education.

METHODS:

An electronic survey was designed using the ACCP DI PRN opinion paper and the Accreditation Council for Pharmacy Education standards and guidelines for accreditation of PharmD programs in the US. Survey questions addressed curricular content within the following categories: drug information, literature evaluation, and biostatistics. A letter including the online survey link was sent via email to the dean of each US college/school of pharmacy (N = 128). Recipients were instructed to forward the email to the individual at their institution who was the most knowledgeable about the content and methodology used for didactic drug information education.

RESULTS:

Sixty-four responses were included in the final analysis. Of the 19 ACCP DI PRN minimum core concepts, 9 (47%) were included in curricula of all responding institutions; 14 of 19 (74%) were included in curricula for all but 1 institution. In contrast, 5 of 16 concepts (31%) were not formally taught by a number of institutions. Many respondents noted an increased focus on evidence-based medicine, medication safety, and informatics.

CONCLUSIONS:

Although a survey of drug information curricula documented substantial inclusion of the essential concepts presented in the ACCP DI PRN opinion paper, room for improvement remains in drug information curricula in US colleges of pharmacy.

The depiction of illness and related matters in two top-ranked primetime network medical dramas in the United States: a content analysis

The effectiveness of entertainment-education is evidenced in previous research; nevertheless, content analytic research on the health content in such programs has been relatively meager in comparison to the large amount of content analyses of health content in news or ads in print media or on television. To address this issue, the current study content analyzed the portrayals of illnesses and related matters in 127 episodes aired from 2000 to 2007 of two top-ranked television medical dramas in the United States (Grey's Anatomy and ER). Results indicated that the two shows portrayed a wide range of illnesses and diseases, with injury, cardiovascular disease, and cancer being the top three most frequently portrayed. Moreover, equal numbers of men and women patient characters were portrayed, Caucasians and African Americans were the top two portrayed races, and the elderly were underrepresented. Last, the shows framed illness and health mainly from a medical perspective in references to the illness's causes, diagnosis, treatment, and prevention. Theoretical and practical implications are discussed.

Drug information: from education to practice

Drug information is a specialty area within the realm of clinical pharmacy that has evolved as technology and clinical practice have changed. Drug information specialists are trained individuals who have clinical knowledge and skills that allow them to provide clear, concise, and accurate recommendations regarding drug use. The constant changing culture of drug information and health care in general has prompted the need for continual growth and refinement of the standards that govern drug information practice. This article outlines specific standards to help ensure that the education and practice of drug information will continue to meet the needs of the health care community. This opinion paper is divided into two sections: Education and Training, and Practice Areas. The Education and Training section is organized to describe the role of drug information and that of the drug information specialist in the training of all pharmacy students and advanced trainees, as well as to describe the role of focused training for those individuals wishing to specialize in drug information. This article also affirms the recommendations for the standards-based approach to drug information education and specialty training. The Practice Areas section is organized to describe the role of the drug information specialist within various practice settings, to identify some of the challenges faced by the drug information specialist within those settings, and to provide recommendations for the different practice areas. The areas found within this section include academia, institutional health systems, managed care, industry, medical writing, and informatics.

Prevalence of and risk factors for dysglycemia in patients receiving gatifloxacin and levofloxacin in an outpatient setting

STUDY OBJECTIVES

To assess the prevalence of dysglycemia (hypoglycemia or hyperglycemia) associated with oral levofloxacin and gatifloxacin therapy in an outpatient setting, and to determine the characteristics of patients who developed dysglycemia while receiving either fluoroquinolone.

DESIGN

Retrospective medical record review.

SETTING

Outpatient clinic of a Veterans Affairs teaching hospital.

PATIENTS

A total of 1573 patients who received oral levofloxacin (343 patients), gatifloxacin (589 patients), or azithromycin (as a control, 641 patients) between June 1, 2004, and May 31, 2006.

MEASUREMENTS AND MAIN RESULTS

Dysglycemia occurred in 33 patients: 13 (2.2%), 9 (2.6%), and 11 (1.7%), respectively, of those in the gatifloxacin, levofloxacin, and azithromycin groups. Of 13 patients who experienced a hyperglycemic event, 11 (84.6%) had diabetes mellitus. After adjustment for confounding factors, neither levofloxacin nor gatifloxacin were associated with increased odds of developing a dysglycemic event compared with azithromycin. Multivariate analysis demonstrated that lack of downward dosage adjustment based on creatinine clearance (odds ratio [OR] 10.3, 95% confidence interval [CI] 3.8-27.6), presence of diabetes (OR 17.1, 95% CI 3.1-94.9), or treatment with insulin (OR 5.3, 95% CI 1.8-15.7) or sulfonylureas (OR 3.6, 95% CI 1.3-10.4) independently increased dysglycemia risk. Obesity (body mass index > or = 30 kg/m(2)) was independently protective (OR 0.22, 95% CI 0.09-0.55) against dysglycemic events.

CONCLUSION

Levofloxacin and gatifloxacin were not significantly associated with increased dysglycemic events compared with azithromycin. Lack of downward fluoroquinolone dosage adjustment for renal function, presence of diabetes, and treatment with insulin or sulfonylureas each independently increased the risk of dysglycemia. Obesity was independently protective against dysglycemia. More data are needed on the contributing effects of diabetes, fluoroquinolone dosage, and concomitant drug therapy so that an appropriate risk-management strategy can be developed.

Oritavancin – an investigational glycopeptide antibiotic

Antibiotics save countless lives each year; however, increasing rates of drug-resistant bacteria have limited antibiotic selection. Currently, there are few available options for treating resistant Gram-positive organisms. Oritavancin, a novel glycopeptide antibiotic with bactericidal activity, has been developed and recently completed the first round of Phase III clinical trials for the treatment of complicated skin and skin structure infections. Investigations into oritavancin's efficacy will be explored in catheter-related bacteraemia and nosocomial pneumonia. Oritavancin demonstrates similar activity to vancomycin but possesses extended activity against vancomycin-resistant Staphylococcus and Enterococcus. The pharmacokinetics and pharmacodynamics of oritavancin appear to be favourable and once-daily dosing is likely. The incidence of multi-drug resistant bacteria is increasing and explorations into additional treatment options are essential. Further development of oritavancin is necessary to determine clinical efficacy.