Concussion Recommendations in Children and Adolescents in Sports Related Injuries

In recent years, concussions have made their way into the media more and more. Something that we once thought was a simple injury that could be shaken off is now being thought of as a serious injury.  There are specialists who dedicate their practice to concussions.  This type of injury is commonly associated with sports.  Concussions are a common injury that occurs in sports especially football.  It has been somewhat of a controversy this past decade because the NFL has made changes in their roles and regulations to protect the players from concussion injuries.  Children and adolescents are also affected from these injuries.  This article looked at how providers are supposed to handle young patients that have sustained a head injury.

Within 1 to 2 days of the injury, the patient should be presented to a physical to have symptoms checked.  The patient should not be left unattended within 48 hours of the injury.  Rest for the first 1 to 2 days is critical to the patient’s recovery.  It is not, however, recommended for the patient to have prolonged bed rest.  The notion that patients should rest until there are no longer any symptoms is not the preferred method of treatment anymore.  Patients should return to school and normal activity within a couple weeks to avoid depression and other negative symptoms.  Accommodations can be made but can usually be discontinued within 2 weeks.

A system was developed called SAFE (Symptoms, Assessment, Follow-up, Execute, and return to pay) to help providers decide what actions need to be taken with the patient.  This system was made into a flow chart so that a provider can follow the protocol for each patient.  This system can help determine when a patient should be referred to a specialist and what kind of tests need to be performed.  It also helps figure out back to school and return to play times.  There have been laws passed in all 50 states to help outline when a patient is ok to come to back and play for their sport.  This article shows how important it is to have a standard method of treatment for patients with concussions.  Each patient may be different, but this method could help make sure that the provider is doing their best to follows the protocol treatment for each patient.

ORTHOPEDICS. 2016; 39: 24-30

http://ORTHOPEDICS. 2016; 39: 24-30

Free Prescription Samples Affecting the Prescribing Trend for Acne Vulgaris and Rosacea

Working in a community pharmacy, it is a familiar statement to hear that someone received a sample of a medication from their doctor’s office. There are a high number of samples given to patients to treat acne vulgaris and rosacea.  Although giving patients free samples seems like a generous thing to do, it can also cause problems.  Many patients receive these samples and then are expected to get their refill at their local pharmacy.  Once the patient gets to their pharmacy, they have to deal with higher drug costs associated with these name brand drugs or name brand generics that the provider is prescribing.  Furthermore, there are generic alternatives that are not being prescribed which are normally used for treatment of these two conditions.  This study aimed to look at the relationship between private dermatology offices that have drug representatives that come and give the office free samples against the academic medical center (AMC) that does not get free samples.

The study looked at dermatology offices nationally that receive free prescription samples and the medical center that does not get free samples to see if the influence of free samples increases the cost that a patient can occur down the line.  The cost that they obtained for the study reflected the out of pocket cost of these medications without insurance.  It did not take into account discount cards or pharmacy programs that could work for the prescription.  The study found that brand name and branded generics were prescribed 79% nationally compared to only 17% at the academic medical center.  This correlated to approximately $456 spent on prescriptions from an office visit for acne at a doctor’s office compared to $200 for prescriptions after a visit at the academic medical center.

This study is informative but does not give us all the information we need to make a conclusion.  Although one can conclude from this data that doctors are prescribing the medication that the representatives have agreed to provide we do not know why each prescription is prescribed.  We cannot make assumptions as to why a prescriber chose to prescribe a medication for a patient.  We can however push to inform prescribers about the costs of these medications.  Some providers do not know what a financial burden these prescriptions can have on a patient. It is important to continue to promote conversation between the different professions.  Having open dialogue between the provider and pharmacist, the financial issue with these medications can be brought to the provider’s attention.  This issue is also important for pharmacist because the financial burden of these prescriptions can lead to nonadherence from the patient.  If we understand that cost is the reason that a patient is not getting their medication filled, then we can work towards finding a cheaper alternative and continue that dialogue with the provider.  These free samples can be helpful for someone who has no insurance and is able to use the samples for the duration of the treatment of the condition.  It is important that all of these factors are taken into account before prescribing a medication.


http://JAMA Dermatol. 2014 May 1; 150(5): 487–493.




Patient Counseling Increases Reported Side Effects in Patients with Schizophrenia

One of the number one ways that pharmacist can help patients is by counseling them on their medications.  Side effects of a medication is something that almost every patient is concerned about before taking a new medication.  Antipsychotics, treatment for Schizophrenia, have a large side effect profile.  Sedation, sexual dysfunction, and extrapyramidal symptoms are some of the side effects patients can experience from these medications.  This studies aim was to see whether or not the number of patients that reported side effects from their antipsychotic medication increase after being counseled by a healthcare provider.  Nonadherence is a big problem that often leads to hospitalization of a patient.  Nonadherence is often caused by patients experiencing a side effect but they are not counseled as to whether or not they were supposed to expect that side effect.  This leads to the patient discontinuing the medication without properly talking to a provider.

The study was conducted by taking a survey to assess whether or not a patient was experiencing side effect symptoms from their antipsychotic medication.  The patient had to report whether or not they experienced side effects from their medication.  The study was conducted at two inpatient settings in Japan which ae the Sawa Hospital and the Hokuto Clinic Hospital.  The study was conducted with 87 patients.  Before the patients were counseled on their medications, 24 of the 87 patients reported experiencing side effects compared to the 60 patients that had reported that they experienced side effects after the counseling session.  These numbers show that patients do not always know that they are experiencing side effects from their medication.  It is important to counsel patients before they pick up their medication so that they know what to expect.  It is also important to be available to patients all the time so that they can have their unanswered questions answered.  Creating a comfortable trusting environment is also important when it comes to accurate retrieval of information.  This study shows the importance pharmacist have on patients therapy outcomes.

http://Australas Psychiatry. 2016 Feb 24. pii: 1039856216634825.

Pain Intensity Related to Smoking Dependency

It has been proven through previous studies that there is a positive correlation between smoking dependency and pain. It is hard, however, to determine which comes first.  Is it that pain patients turn to smoking or the smoking creates higher levels of pain?  Previous studies identified the correlation between the two, but left out some important parameters we needed to get a closer look at this correlation.  A problem with previous studies is that they specifically looked at patients that were being seen for pain.   If a patient is seeking treatment for pain then it is probably on the more moderate to severe end of the pain scale.  This particular study that I looked into wanted to see how strong this correlation was when comparing smoking dependency in patients that had little to no pain against patients that had moderate to severe pain.

In this study, they wanted to look at how strong the correlation was between patient’s pain and their smoking habits. The best way to measure these two categories was with surveys.  Participants in this study were given multiple surveys to fill out to determine their pain level and smoking dependency.  These surveys include  the “Smoking History Questionnaire” (SHQ) to understand the patients smoking history, the “Fagerstrom Test for Nicotine Dependence” (FTND) that helps determine how depend a patient is to smoking, “The Short –Form Health Survey” which was used to determine the bodily pain in the patient, and the “Positive and Negative Affect Scale” (PANAS) which assessed a patients emotions.  The DSM-IV was also used during the assessment process.

The results of the study showed that there was an increase in smoking dependency in individuals that have a higher intensity of pain.  That being said, the study did have many limitations including diversity issues and relying heavily on self-reporting.  This study was a good step towards trying to figure out whether smoking dependency was associated with increased levels of pain.   This study is helpful because we can use this information to help patients that are trying to quit.  We can try to treat their pain so that we can reduce their dependency.  Further studies would help better understand this correlation and improve treatment of this disease.

http://Psychiatry Res. 2016 Mar 30;237:67-71. doi: 10.1016/j.psychres.2016.01.073. Epub 2016 Feb 3.

Study of the Potential Renal Toxicity of Cefpirome and Cefepime

Fourth- generation cephalosporins are used to treat infections that are drug resistant.  Two of the most common fourth- generation cephalosporins are cefpirome and cefepime.  There was a study conducted to see if there was a prevalence of one of these two drugs to cause damage to renal function.  The study was conducted in vitro and in an in vivo clinical cohort study.  The damage to the kidney was determined by the serum creatinine (SCr) level and whether the SCr reached about 445 μmol/1 which indicates renal failure. The in vitro study was carried out on renal mesangial cells.  The clinical cohort study was on 944 patients that were hospitalized in a third-grade-class-A teaching hospital.  The patients that were included in the study were in the hospital between January 2009 and December 2012.  The patients that were in the study had to have a normal creatinine clearance rate and normal renal function.  The exclusion criteria included anything that would deviate from normal kidney function as well as previous use of aminoglycoside antibiotics or antimicrobial agents while previously on nephrotoxic drugs.  The patients were separated into two group of those that were under 65 and those that were 65 and older.

After the study was conducted, it was shown that both cefepime and cefpirome caused cytotoxicity on the renal mesangial cells.  Cefpirome had a higher maximal inhibitory concentration and could be more renal cytotoxic in comparison to cefepime.  The clinical cohort studied also showed that cefpirome was shown to cause a larger increase in serum creatinine levels among the participants compared to the participants that were given cefepime.  There was also an increase in the number of cases of SCr going higher than 445 μmol/1 which is an indication of renal failure. An increase in these two values during the study seemed to be more prevalent in the 65 and over group.  The conclusion of this study showed that cefpirome could potentially be more likely to contribute to renal damage than cefepime.  With that being said, the study does specify that other studies should be conducted to study the renal function while on these medications as well as to study the adverse effects of these drugs.  They also suggest more animal model studies to have insight as to why there is potential nephrotoxicity.  The take away message from this study is that there may be some thoughts to consider when choosing between these two medications as well as to take careful measures when administering to older adults.

http://Biomed Rep. 2016 Jan; 4(1): 40–44.

The use of Hospital Pharmacists on Antibiotic Choice on Inpatients

With the increase prevalence of antibiotic resistant infections, maintaining the integrity of older antibiotics while using more advanced antibiotics in certain situations has become an important aspect of hospital medicine. Programs such as the Antimicrobial Stewardship (AMS) have risen to help facilitate when these antibiotics should be used.  It is important for an interprofessional team to be assembled to make sure that antibiotics are being used properly.

There was a study conducted at two Australian hospitals to see how pharmacists believe that they can help in the role of managing antibiotic use as well as how they believe they are perceived in this role. The study interviewed 19 pharmacists of varying degrees expertise level as well as varying levels of education beyond the pharmacy degree.  The study also included 12 female and 9 male pharmacists.  The pharmacists were given surveys as well as were interviewed about questions pertaining to how they play a role in the use of antibiotics, how they are perceived in this role, and challenges they face in this role.

The results of these interviews showed that the pharmacist felt that they were experts when it comes to the use of antibiotics since they are specifically trained in medications. They also felt that they had a watchful responsibility over some of the specific antibiotics since they have to be specifically ordered from the pharmacy.  They felt that they were considered major problem solvers when it came to this issue or their profession in general.  They generally believed that they were not always used to the outmost importance by some of the other healthcare providers since they are traditionally seen as a dispenser.  They also are not the ones that ordered the medication therefore they are not seen in the same importance.  This is a major problem when it comes to  interprofessionalism between colleagues in the healthcare field.  Furthermore, by not using the pharmacist, the healthcare team is missing out on information from medication experts.

This study is one very specific example of how pharmacist are trained to make an impact on the prescribing that is going on in a hospital setting but yet how they are not being used to their fullest potential. Interprofessionalism is an important aspect in improving the care of patients. This study should be reproduced in different settings across the world to promote to use of pharmacist as well as increase the rapport between the different healthcare professionals on a healthcare team.

http://BMC Health Serv Res. 2015; 16: 43.

. Botulinum Toxin use in Migraine Headaches

Chronic Headaches are a debilitating condition that is characterized by having a 15 or more headaches a month for more than three months.  These headaches have to occur on more than 8 days in the month.  Migraines are characterized by distinct pain patterns as well as unique symptoms such as nausea and photosensitivity.  Approximately 28 million Americans are affected by migraines and cost Americans about 1 million dollars a year in medical costs. There are two types of chronic daily headaches.  The first type is chronic migraines and the second type is chronic tension-type headaches.  Traditionally, there are severe medications used to treat migraines such as triptans or ergots, analgesics, and opioids for use when the pain is occurring.  The use of beta blockers, calcium channel blockers, anticonvulsants, NSAIDS, antidepressants, and serotonin antagonist are also used for preventative measures.  Although these medication may work, patients are sometimes not compliant with an everyday regimen and side effects are also a reason patient discontinue treatment.

There are seven different types of botulinum toxins and they all work to inhibit the release of acetylcholine.  Botulinum toxin type A is the type that is studied the most for the use in migraines.  A common name for this type of botulinum toxin is Botox.  Botulinum works by binding on the motor and sympathetic nerve terminals.  While in the terminals, it blocks acetylcholine release, which in turn blocks neuromuscular transmission at the neuromuscular junction.  The end effect of this is reduced localized muscle activity.

Multiple double-blind, randomized, placebo- controlled studies were conducted to study the efficacy and safety of the botulinum type A toxin in migraine suffers.  Doses ranging 155 U to 195 U were administered in 31 different injection sites.  This study showed there was a mean decrease in frequency of headache days and episodes.  There also seemed to be an improvement in patients functioning and symptoms.  The study seemed to be somewhat unclear.  With only 300 participants, the study showed that there was not a significant improvement between the control and the migraine suffering patients after 60 days of treatment, although there was over a 50 percent decrease in chronic tension type headaches in patients after 90 to 120 days of treatment.  The take away message from this trial is that it is worthwhile to continue to investigate the use of botulinum in migraine suffering patients.  The treatment has minimal side effects such as flu like symptoms, rash, pain, or asymmetry.  With that being said, with minimal side effects and a positive outlook on successful treatment, it is worthwhile to continue studying this treatment.

http://Semin Neurol 2016; 36(01): 092-098


Mortality and Readmission Rates between VA and Non-VA Hospitals

I looked at an article that detailed the research of whether there was an increased risk of readmission or mortality depending on whether the patient was admitted to a Veteran Affairs (VA) hospital or a non-VA hospital for heart failure, acute myocardial infarction, and Pneumonia. The study was conducted between 2010 to 2013 and included males that were 65 and older and on Medicare. The study was conducted in metropolitan areas that included both the VA and non-VA hospitals in question.  The study was over a 30 day period to assess mortality rates and the readmission rates of discharged patients at these hospitals.

The study looked at 1513 non-VA hospitals and 104 VA hospitals.  The study was conducted in 92 metropolitan areas. The results found that the VA hospitals had lower mortality rates for acute myocardial infarction (-0.2%) and heart failure by (-0.5%), but a slightly higher mortality risk for pneumonia (+0.4%).  Readmissions rates were higher in all three conditions of anywhere between +0.62% – +0.97%.  The percentage of readmissions and mortality rates were so small that they are almost negligible.  The rates of readmission could have been increased in the VA hospital population for multiple reasons such as the distance needed to travel to a VA hospital or the incentives given to non-VA hospitals to reduce readmission.  VA hospitals are trying to find ways to decrease there readmission rates.  This study also only looked at a small population of males that are 65 and older and also only included three disease states.

This study is not only important to all healthcare providers, but has a specific interest for pharmacists.  Many pharmacy interventions can occur to reduce readmissions into a hospital whether it is a VA or non-VA hospital.  Programs that increase adherence at community pharmacies can help reduce the readmission rates that are seen in the VA hospitals.  I chose this article specifically for the reason of the stigma that comes with VA hospital care in the community setting.  I believe there is a need for more in-depth research that shows the equality of care between VA hospitals and non-VA hospitals so that patients will chose to utilize these facilities.


http://JAMA. 2016;315(6):582-592. doi:10.1001/jama.2016.0278.