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Objective: The aim of the present study is to determine similarities between patients with type 2 diabetes not on metformin therapy compared to patients on metformin therapy at a resident-led primary care clinic. Methods: An exploratory, single-center retrospective chart review was performed on patients 18 years and older with a documented diagnosis of type 2 diabetes seen at the University of Arkansas for Medical Sciences Family Medicine Clinic in Little Rock, Arkansas. Of the 2452 patients who met criteria for the study, 1085 patients did not have a documented metformin allergy. A subset of 216 patients who were not currently prescribed metformin and had no documented metformin allergy were further examined and compared to the 869 patients who were prescribed metformin. We sought to determine reasons for nonuse by evaluating their EPIC electronic health record. Information on these patients such as race, gender, hemoglobin A1c (A1c), kidney function, stated metformin intolerance, and comorbid disease states such as neuropathy, chronic kidney disease (CKD), ulcerative colitis, and irritable bowel syndrome were collected. Further examination was performed to determine why patients were not on metformin therapy and potential similarities between metformin intolerant patients. Results: The results of the study indicated a significant difference between metformin users and non-users in relation to body mass index (BMI) and diagnosis of CKD. Metformin non-users were found to have significantly lower mean BMI (30.87 vs. 35.43; p-value <0.0001), and significantly higher rates of CKD (25.93% vs 14.73%; p-value <0.0001) as compared to metformin users. BMI value of patients (coefficient: 0.2033, p value: <0.0001) was found to be significantly and positively correlated with metformin use, and CKD (coefficient: - 0.1191, p-value: <0.0001) was found to be significantly and negatively correlated with metformin use. A1c levels for patients not on metformin therapy were evaluated. Most non-metformin patients fell in prediabetic A1c levels ranging from 5-6.4% (84 patients; 38.89%), and 31 patients (14.35%) should be on insulin therapy according to guidelines. Conclusion: The results demonstrated that patients with lower BMI, CKD, or A1c in the prediabetic range were less likely to be prescribed metformin., (© Individual authors.)

Background: Health literacy is defined as the degree to which individuals have the capacity to obtain, process and understand basic health information needed to make appropriate health decisions. A review of literature revealed few studies that examined pharmacist's knowledge of health literacy. Methods: The Pharmacist Professional Health Literacy Survey was distributed to a convenience sampling of community pharmacists in medically underserved counties of Southwest Georgia. Results: Of 75 pharmacists contacted, 39 completed the survey and were used in the evaluation. Most respondents reported no health literacy training and had never assessed health literacy with a validated questionnaire. More than half of the participants cited lack of knowledge about low health literacy as a major barrier to implementing health literacy screening for their patients. Time and cost were identified as major barriers to participating in health literacy training programs. Conclusion: Most pharmacists from this area had little exposure to evaluating health literacy. Pharmacy education postgraduate programs and continuing education training programs around this topic will heighten health literacy knowledge for the pharmacy profession. There is a need for a quick, easy to use, and effective tool for pharmacists to recognize and assess health literacy in patients.

Introduction: Budd Chiari Syndrome (BCS) is a very rare disease affecting approximately 1 in 100,000 people in the general population. It is caused by an obstruction of the hepatic veins leading to blood backing up in the liver. Treatment options to improve hepatic blood flow and relieve ascites are well documented. However, there are no established guidelines or treatment preferences for pain associated with BCS while patients are awaiting other treatment options., Case: A 22-year-old African American female was diagnosed with Budd Chiari Syndrome. The initial attempt at a transjugular intrahepatic portosystemic shunt (TIPS) procedure failed. While awaiting a second attempt at the procedure, the patient presented to her primary care provider complaining of abdominal and right upper quadrant pain. Treatment guidelines were searched for acute pain management options; however, no BCS pain management guidelines exist., Discussion: Individuals with BCS often present with abdominal pain, however, no guidelines outlining analgesic options in BCS exists. Acetaminophen, NSAIDs, and opioids are commonly used prescription medications for moderate to severe pain. Acetaminophen use was not considered due to acute liver injury and portal venous thrombosis. Anticoagulation with apixaban prevented concurrent use with NSAIDs. Opioid medications combined with acetaminophen were excluded to minimize exacerbating the liver injury. Tramadol 25 mg was chosen due to its lower abuse profile than other opioid analgesics, and was initiated for pain management., Conclusion: The patient reported adequate pain control with tramadol, tolerated the medication with no complications, and underwent a successful TIPS procedure one month later.  Abdominal pain is a common symptom of BCS and needs to be effectively managed. Guidelines on treating pain associated with BCS in the outpatient setting would improve quality of life for patients and provide guidance to primary care providers requiring direction on how to address pain associated with Budd Chiari Syndrome safely and adequately., Competing Interests: We declare no conflicts of interest or financial interests that the authors or members or their immediate families have in any product or service discussed in the manuscript, including grants (pending or received), employment, gifts, stock holdings, or options, honoraria, consultancies, expert testimony, patents, andxroyalties. Acknowledgment:  The authors would like to thank Letevia Herlong, FNP-C for consulting us for treatment options for this patient and providing pertinent information related to the case. Conflicts of Interest: NoneConflicts of Interest: None, (© Individual authors.)

Objective: To review and summarize studies on the changes in bone mineral density (BMD) and fracture risk following discontinuation of teriparatide therapy., Data Sources: A search of PubMed (1966-May 2016) and International Pharmaceutical Abstracts (1970-May 2016) was conducted using the Medical Subject Headings terms teriparatide, osteoporosis, and withholding treatment. Free text searches included drug holiday, discontinuation, and drug discontinuation., Study Selection and Data Extraction: These searches yielded 79 articles. There were 7 articles reviewed that addressed the effects of teriparatide discontinuation on markers of overall bone health and fracture risk., Data Synthesis: Teriparatide is a recombinant human parathyroid hormone that is indicated for a lifetime maximum of 24 months in the United States for the treatment of osteoporosis in men and women at high fracture risk. There is inconsistent evidence regarding retained skeletal integrity resulting from increased bone resorption. Study analyses have shown that female patients seem to have more reduction in BMD upon teriparatide discontinuation. Several studies evaluating teriparatide discontinuation were follow-up studies with small patient populations, limiting the generalizability and statistical rigor associated with assessing these outcomes. In addition, the majority of patients were receiving bisphosphonate therapy, and the true effect of discontinuing teriparatide remains unknown., Conclusion: Independent patient risk factors should be taken into consideration when weighing the risk-vs.-benefit of initiating and discontinuing teriparatide therapy. Additional randomized control trials should be conducted to determine long-term effects of discontinuing teriparatide in the presence and absence of other bone-strengthening agents.

Background. The Cardiovascular Risk Reduction Clinic (CRRC) in Perry County, Alabama, provides free pharmacist-led services. Clinic goals include improving health outcomes and reducing cardiovascular risk factors. Objective. To investigate the effectiveness of the CRRC in rural Perry County, Alabama. The reduction of the modifiable cardiovascular risk factors, blood pressure and body mass index, was evaluated to measure a decrease from baseline to last clinic date. Methods. This retrospective chart review identified 130 patients with at least two blood pressure and BMI measurements from baseline to June 30, 2010. The patients' paper files were used to collect baseline data and most recent measurements, which were recorded on a data collection sheet. Results. There was a statistically significant reduction in systolic blood pressure of 4.08 mmHg, 3.25 mmHg reduction in diastolic blood pressure, and 0.42 kg/m(2) reduction in mean BMI. At their last visit prior to June 30, 2010, 59% of hypertensive patients and 35% of diabetic patients were meeting their blood pressure goals. Conclusion. Pharmacist-led management of patients with cardiovascular risk factors significantly reduced blood pressure and allowed more patients to meet their hypertension treatment goals. Despite being modest, reductions in blood pressure and BMI help reduce overall cardiovascular risks.