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Objectives: To examine the extent to which pharmacy students’ attitudes, subjective norm beliefs, and perceived behavioral control beliefs explain gray dispensing decisions, using the theory of planned behavior (TPB) as a framework. Method: Third professional year pharmacy students (n=159) from two academic cohorts were provided three written case scenarios: (1) a dentist prescribing outside of his scope of practice; (2) a physician prescribing for a family member; and (3) a patient who was out of refills on insulin. A brief questionnaire assessed TPB constructs, whether or not the student would dispense the medication, and the number of times the student would dispense in 10 similar situations. Composite scores were calculated for TPB constructs after analyzing internal consistency reliability. Linear regression techniques were used to analyze the influence of the constructs on mean intent to dispense in similar scenarios. Results: The percent of students who indicated they would dispense in each scenario was 68% in scenario 1, 74% in scenario 2, and 81% in scenario 3. For all case scenarios, mean intent to dispense in similar scenarios was explained by attitude scores (p≤0.006). For the insulin refill and family prescribing cases, mean intent to dispense was also explained by subjective norm beliefs (pImplications: Student attitudes consistently predicted intention to dispense across the gray scenarios. These findings can be used to develop and target upstream TPB construct interventions in pharmacy education that influence students’ downstream dispensing decisions. Additional research is warranted to determine if TBP constructs similarly explain the dispensing behaviors of practicing pharmacists.

Objective. To determine the perceptions of junior pharmacy faculty members with US doctor of pharmacy (PharmD) degrees regarding their exposure to residency, fellowship, and graduate school training options in pharmacy school. Perceptions of exposure to career options and research were also sought. Methods. A mixed-mode survey instrument was developed and sent to assistant professors at US colleges and schools of pharmacy. Results. Usable responses were received from 735 pharmacy faculty members. Faculty members perceived decreased exposure to and awareness of fellowship and graduate education training as compared to residency training. Awareness of and exposure to academic careers and research-related fields was low from a faculty recruitment perspective. Conclusions. Ensuring adequate exposure of pharmacy students to career paths and postgraduate training opportunities could increase the number of PharmD graduates who choose academic careers or other pharmacy careers resulting from postgraduate training.

Objectives. To develop and validate an instrument to assess subjective ratings of the perceived value of various postgraduate training paths followed using expectancy-value as a theoretical framework; and to explore differences in value beliefs across type of postgraduate training pursued and type of pharmacy training completed prior to postgraduate training. Methods. A survey instrument was developed to sample 4 theoretical domains of subjective task value: intrinsic value, attainment value, utility value, and perceived cost. Retrospective self-report methodology was employed to examine respondents’ (N=1,148) subjective task value beliefs specific to their highest level of postgraduate training completed. Exploratory and confirmatory factor analytic techniques were used to evaluate and validate value belief constructs. Results. Intrinsic, attainment, utility, cost, and financial value constructs resulted from exploratory factor analysis. Cross-validation resulted in a 26-item instrument that demonstrated good model fit. Differences in value beliefs were noted across type of postgraduate training pursued and pharmacy training characteristics. Conclusions. The Postgraduate Training Value Instrument demonstrated evidence of reliability and construct validity. The survey instrument can be used to assess value beliefs regarding multiple postgraduate training options in pharmacy and potentially inform targeted recruiting of individuals to those paths best matching their own value beliefs.

Excerpt: Interactions between chemotherapy and dietary or herbal supplements can compromise patient care.

Securing and Excelling in a Pharmacy Residency is a practical guide and handbook for pharmacy students seeking a residency, residents currently enrolled in a program, and residency program leadership. This user-friendly text encourages high-quality pharmacy residency training, which elevates the individual, the profession, and ultimately patient care. Answering the need for residency training and improvement raised by the ASHP/ACCP joint 2020 initiative, Securing and Excelling in a Pharmacy Residency uniquely prepares students for the increasingly competitive pharmacy residency market. This one-of-a-kind resource is also helpful to guide individuals currently enrolled in a residency and their mentors. This valuable resource also addresses options after residency training, priceless guidance for both current residents and faculty advisers.

Cost containment measures within hospital systems push for earlier discharges on stable patients. Due to patient placement difficulties and costs associated with skilled facilities, antibiotic use in home health care settings is becoming a common occurrence. This trend will likely increase as care continues to shift to outpatient areas. Lack of sufficient serum drug concentrations needed in severe infections and increasing resistance to many of the oral options often necessitates the use of the intravenous (IV) route. Home health care practitioners may have minimal information on patients or limited experience with IV antibiotics that may impact quality of care. This review summarizes key points relevant to IV antibiotics routinely used by home health prescribers, nurses, technicians, and care managers. This review will focus on antibacterial agents including vancomycin, aminoglycosides, beta-lactams, daptomycin, tigecycline, and telavancin. Appropriate dosing, indications, adverse events, monitoring parameters, and feasibility of using IV antibiotics are discussed.

Echinacea is an herbal supplement commonly used as an immune system stimulant to prevent infections, such as the common cold or flu. Echinacea has been documented as a cyctochrome P450 (CYP) 3A4 inhibitor in vitro, but no formal studies have been conducted in humans. Etoposide is a cytotoxic, topoisomerase II inhibitor, chemotherapeutic agent used in the treatment of lung cancer. Etoposide is primarily metabolized by CYP 3A4. We report the first possible drug–herbal interaction between Echinacea and etoposide. A 61-year-old gentleman newly diagnosed with nonsmall cell lung cancer began concurrent chemoradiation with cisplatin and etoposide. He was admitted to the hospital on day 8 of his first cycle and found to be thrombocytopenic. His platelet count eventually reached a nadir of 16 × 103/L, requiring platelet transfusion support. Upon admission, it was discovered he was taking Echinacea, which was discontinued. He received his next cycle of chemotherapy without taking Echinacea. His platelet count decreased to a nadir of 44 × 103/L, but he did not require platelet transfusions. Echinacea likely contributed to this patient's profound thrombocytopenia and should be avoided in patients receiving etoposide and possibly other chemotherapeutic drugs that are CYP 3A4 substrates.

Purpose: Cetuximab is a monoclonal antibody with a known risk of hypersensitivity reactions. Early studies showed hypersensitivity reaction rates of 3%, but there appears to be a higher incidence in the southeastern United States. To confirm the findings from nearby institutions that cetuximab-associated hypersensitivity reactions occur in approximately 20% of patients in the southeastern United States. Methods: A retrospective chart review was conducted at Johnson City Medical Center in Johnson City, Tennessee. Each patient’s first infusion was analyzed for hypersensitivity reaction, as well as for demographic information such as allergy and smoking history, pre-medications, and malignancy type. Results: Data from the first infusion of cetuximab were collected for a total of 71 patients with various malignancies. The overall rate of grade 3 or higher hypersensitivity reaction was 1.4%, and total rate of hypersensitivity reaction was 8.5%. These findings more closely correlate to the early clinical trials and package insert. Both severe (p = 0.001) and any-grade (p = 0.002) hypersensitivity reaction occurred less frequently in one Southeastern Appalachian medical center compared to academic medical centers directly to the east and west. Conclusions: Patients in southern Appalachia may be less likely to develop cetuximab hypersensitivity reactions compared to surrounding areas in the Southeastern U.S. These results lend support to the theory that exposure to lonestar ticks (Amblyomma americanum) may be responsible for the development of IgE antibodies to cetuximab that cause hypersensitivity reactions. The development of quick and reliable bedside predictors of cetuximab hypersensitivity reactions may aid clinicians considering the use of cetuximab.

The advent of effective oral, molecular-targeted drugs in oncology has changed many incurable malignancies such as chronic myeloid leukemia into chronic diseases similar to coronary artery disease and diabetes mellitus. Oral agents including monoclonal antibodies, kinase inhibitors and hormone receptor blockers offer cancer patients incremental improvements in both overall survival and quality of life. As it is imperative to recognize and manage side effects of platelet inhibitors, beta blockers, statins, HIV drugs, and fluoroquinolones by all healthcare providers, the same holds true for these newer targeted therapies, patients may present to their generalist or other subspecialist with drug-related symptoms. Cardiovascular adverse events are among the most frequent, and potentially serious, health issues in outpatient clinics, and among the most frequent side effects of targeted chemotherapy. Data support improved patient outcomes and satisfaction when primary care and other providers are cognizant of chemotherapy side effects, allowing for earlier intervention and reduction in morbidity and health care costs. With the implementation of accountable care and pay-for-performance, improved communication between generalists and subspecialists is essential to deliver cost-effective patient care.