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Objective Academic programs strive to optimize retention while maintaining a high-quality curriculum. The purpose of this study was to investigate enrollment management strategies of professional pharmacy programs in the context of academic progression and retention. Methods Participants from fully accredited pharmacy programs were asked to complete a survey and submit any program documents describing (a) progression plans, (b) remediation strategies, (c) policies related to academic performance, and (d) description of milestone or progression exams. Documents were reviewed for similar or unique policies and/or strategies related to progression and retention. Results The most common strategies for enrollment management that were identified through the survey included cognitive screening tools (96%), pre-program (91%) and in-program (96%) preventative resources for non-academic problems (91%), course repeat (96%), and faculty development for effective teaching/assessment strategies (91%). The least common strategies were pre-tests for ability placement in coursework (20%) and mastery learning (36%). Review of the supplement documents revealed that enrollment management strategies of professional pharmacy programs varied across admissions, in-program screening, remediation, curricular review, retention, and attrition. Conclusions Our study provides foundational information for schools and colleges to develop or revise their current enrollment management strategies as related to progression and retention. Future studies should evaluate the effectiveness or outcomes of enrollment management plans to better serve the student, the program, and the profession.

Objective:To provide an overview of the safety and tolerability of newer agents used to treat bipolar disorder (BPD) and provide clinicians with management strategies for drug-related toxicity and adverse effects.Data Sources:MEDLINE was searched through July 2005 for BPD treatment, adverse effects, tolerability, safety, emerging agents, atypical antipsychotics, new antiepileptic drugs (AEDs), risperidone, quetiapine, clozapine, ziprasidone, aripiprazole, lamotrigine, topiramate, gabapentin, oxcarbazepine, and olanzapine.Study Selection and Data Extraction:Results from randomized controlled trials, open-label studies, and reviews are described.Data Synthesis:Emerging agents recently approved for BPD include atypical antipsychotics and new AEDs. Safety and tolerability are as Important as efficacy because poor adherence in BPD worsens outcome; metabolic and other comorbidities pose specific challenges; and manic patients often require combination therapy, which increases adverse effects. Most atypical antipsychotics cause fewer extrapyramidal symptoms than conventional antipsychotics, but may cause more weight gain and metabolic complications. The newer AEDs generally cause less weight gain than the older agents, and some even promote weight loss. Several newer AEDs used in BPD also offer the advantages of fewer drug interactions and less need for therapeutic drug monitoring compared with older AEDs.Conclusions:Pending the results of ongoing controlled studies, several emerging agents may be useful additions to the therapeutic arsenal for BPD.

Study Objective. To evaluate the efficacy, safety, and tolerability of extended-release divalproex sodium. Design. Prospective, open-label, 4-week study. Setting. Long-term care facility of the Missouri Department of Mental Health. Patients. Ten hospitalized patients (mean age 39.4 yrs) with mood or thought disorders who were experiencing adverse effects from delayed-release divalproex sodium. Intervention. All participants were switched from delayed-release to extended-release divalproex sodium. Measurements and Main Results. Efficacy was monitored with the Brief Psychiatric Rating Scale (BPRS), and safety and tolerability were monitored with the Systematic Assessment for Treatment Emergent Events (SAFTEE). Frequently reported adverse effects before conversion were sedation, stomach upset, and tremor. At study conclusion, no differences were seen in total BPRS scores or individual BPRS items, although a trend pointed to decreased somatic complaints (p=0.057). The mean serum concentration of valproic acid among participants did not change significantly in the transition from the delayed-release formulation to an equivalent dose-adjusted extended-release formulation (90.5 mg/L vs 95.5 mg/L, p=0.493). At study conclusion, significant decreases in low-density lipoprotein cholesterol (p=0.010) and potassium (p=0.043) levels were identified. Three categories of adverse effects decreased significantly after patients switched to the extended-release form of divalproex sodium: sedation (p=0.022), stomach or abdominal discomfort (p=0.045), and tremor (p=0.004). Conclusion. This preliminary investigation suggests that patients receiving delayed-release divalproex sodium for mood lability can be converted successfully to extended-release divalproex sodium. Moreover, these findings imply that this transition is associated with a reduction in some of the adverse effects associated with divalproex sodium.

Objective: To evaluate and summarize the data on erythropoietin (EPO) use to prevent anemia in intensive care unit (ICU) patients. Data Sources: A literature search was performed using MEDLINE (1966–December 2003) using the key words erythropoietin, intensive care unit, anemia, and critically ill. Data Synthesis: Attempts to decrease the complications associated with anemia in ICU patients have recently focused on EPO use. Two comprehensive studies found that EPO significantly reduced the cumulative number of blood transfusions as compared to that of placebo. The assessing outcomes found no difference between the groups with respect to mortality rates, ventilation days, or length of stay. Conclusions: Available trials demonstrate reduced blood transfusions in ICU patients when EPO is administered. However, this result has not carried over as a defined clinical benefit. EPO use should be reserved for patients with longer hospital stays who are at risk for frequent blood transfusions as a comprehensive blood conservation strategy in the ICU.

In spring 2000, the Missouri Department of Mental Health mandated that its psychiatric inpatient facilities convert patients from trade-name to generic clozapine. The pharmacy department at our facility was encouraged to develop a conversion program to oversee and assess the efficacy and tolerability of the change. A protocol to monitor the conversion of patients to generic clozapine hospitalwide was developed. The primary objective was to determine whether therapeutic response and level of tolerability were the same with generic versus trade-name clozapine. The secondary objective was to determine whether changes in monitoring white blood cell and absolute neutrophil counts were necessary after conversion. Our results showed that most patients did not experience changes greater than a mean of 5 points in their scores on the Brief Psychiatric Rating Scale (BPRS). However, a statistically significant difference was seen in 22 patients who had a mean reduction or an increase of less than 5 points (p=0.0139) in BPRS scores compared with two patients who had a mean increase greater than 5 points. Assessment of percentage change in BPRS scores indicated that 14 (58%) converted patients had a 1-50% decrease in mean BPRS scores, and 10 (42%) had a 1-40% increase. However, of those with a mean BPRS increase, five (50%) had an increase of 10% or less. Our clozapine conversion program resulted in the successful conversion of all 24 patients.

Biomedical Communications and Informatics Reviews Section Editor Peter D. Anderson, PharmD, BCPP, DABFE, FASCP Clinical Pharmacist MedManagement, Inc. Massachusetts and Massachusetts Eye and Ear Infirmary Adjunct Associate Professor of Pharmacy University of Rhode Island Clinical Assistant Professor Northeastern University, School of Pharmacy Boston, Massachusetts E-mail: PAnder7291@aol.com Founding Editor James T. O’Donnell, PharmD, MS, ABCP, CNS, FACN Assistant Professor of Pharmacology Rush Medical College

OBJECTIVE: To report a case of extrapyramidal reaction associated with a dosage increase of clozapine. CASE SUMMARY: A 44-year-old white man with a 20-year history of chronic paranoid schizophrenia was admitted to an inpatient psychiatric facility. His prior medications restarted on admission were clozapine 650 mg at bedtime, haloperidol 10 mg at bedtime, clonazepam 2 mg/d, and aspirin 325 mg/d. Two days after admission (hospital day 3), clozapine and clonazepam were discontinued, and he was prescribed haloperidol 5 mg every morning and 10 mg every evening. Stabilization occurred over the following 24 days, with progressively lower dosages of haloperidol and increasing dosages of clozapine. Haloperidol was discontinued on day 24. On day 47, the patient was agitated and making bizarre statements; thus, the morning dose of clozapine was increased by 50 mg (total 450 mg/d). On day 48 at 2200, a dystonic reaction was diagnosed; he received intramuscular diphenhydramine 50 mg, which caused the reaction to subside. At the time of the adverse reaction, he was prescribed clozapine 450 mg/d, vitamin E 400 IU three times daily, aspirin 325 mg/d, and acetaminophen, milk of magnesia, and Maalox as needed. DISCUSSION: Although the risk of extrapyramidal symptoms (EPS) is significantly lower with clozapine than with conventional agents, elevated clozapine blood concentrations have been reported to cause EPS; other reports have cited severe dystonias and dyskinesias on abrupt clozapine withdrawal. Considering the medications prescribed at the time and the discontinuation of haloperidol 24 days before the event, clozapine was the most likely cause of the extrapyramidal reaction. CONCLUSIONS: Regardless of anticipated safety associated with novel antipsychotics such as clozapine, reports of dystonic reactions must be taken into account and patients monitored appropriately.

Hyperprolactinemia is a well-known consequence of conventional antipsychotic therapy. The atypical antipsychotic clozapine is reported to lack this effect. We describe a case of attenuated serum prolactin levels after conversion to clozapine therapy in an adolescent. A 13-year-old female patient developed hyperprolactinemia with galactorrhea and amenorrhea while receiving thioridazine 300 mg daily. These symptoms continued throughout 3 years of treatment with haloperidol 10 mg daily and then fluphenazine 10 mg daily. Subsequently, after an incomplete improvement in her psychiatric symptoms and hyperprolactinemia on thioridazine 150 mg and bromocriptine 15 mg daily, the patient was changed to clozapine at age 16. Clozapine 150 mg twice daily improved her psychiatric status and corrected her serum prolactin concentrations after 2 weeks; bromocriptine was able to be discontinued. We recommend systematic evaluation of atypical neuroleptics as alternative treatments for refractory hyperprolactinemia induced by conventional antipsychotics.

Women have the right to decide when and if they chose to bear children. Women with mental illness have special contraceptive needs because of the potential impact of their disease on insight and judgment. risk to the fetus from psychotropics and potential for drug interactions between anticonvulsants and hormonal birth control methods. The 1990s have seen the introduction of Norplant and Depo-Provera. both injectable, long-acting progesterone only products. These products provide reliable contraception without the need to take a pill daily and are an option in women sensitive to estrogen. Irregular menses and possibly amenorrhea are the primary adverse effects of injectable contraceptives. Desogestrel and norgestimate are new progesterones found in combination oral contraceptive products. They are less androgenic and antiestrogenic than older progesterones and have little effect on the lipid profile and carbohydrate metabolism. They also carry a low risk of acne and hirsuitism. They recently have been associated with an increased risk of venous thromboembolic disease. making their use controversial. Triphasic combination products have overall low concentrations of both hormones. but are vulnerable to failure from interacting medications, or if a dose is missed. With the wide range of birth control options available. a woman can have safe and effective contraception that suits her individual needs.

Abuse of the centrally acting anticholinergic agents is a phenomenon occasionally reported in the medical literature. Anticholinergics, most often used in psychiatry to treat antipsychotic-induced extrapyramidal symptoms, are also used by some patients for their mood altering and psychedelic effects. The changes in sensorium can range from mild euphoria and increased sociability to hallucinations and toxic psychosis.

OBJECTIVE: To evaluate whether initiating lithium with predictive dosing compared with empiric dosing improves outcome in patients with manic symptoms. DESIGN: The study was a randomized, single-blind design and used the Modified Slattery predictive method. SETTING AND PARTICIPANTS: Eighteen inpatients at an urban psychiatric hospital with a Mania Rating Scale (MRS) score greater than or equal to 24 were enrolled. OUTCOME MEASURES: The study endpoint was defined as an MRS rating less than or equal to 14 or discharge from the hospital. Assessments (MRS, Brief Psychiatric Rating Scale, Clinical Global Impression, Systematic Assessment for Treatment of Emergent Events Scale, quality of life measures) were completed at baseline, on days 3 or 4 and 7 or 8, and weekly thereafter. RESULTS: The predictive group achieved a therapeutic concentration significantly sooner than did the empiric group (p=0.004); however, the mean serum lithium concentration at discharge did not differ between the groups. The predictive group was taking significantly higher dosages of antipsychotics in chlorpromazine equivalents on day 3 or 4 (p=0.05). Significantly fewer gastrointestinal/genitourinary adverse effects on day 3 or 4 were reported by patients in the predictive group (p=0.04). No difference was found between groups with any rating scale or other pharmacokinetic or medication item. Even though the difference did not meet statistical significance, the predictive group's length of stay in the acute unit was three days shorter than that of the empiric group, which may represent significant cost savings. CONCLUSIONS: The preliminary data do not suggest that patient outcome is improved by using Modified Slattery predictive dosing; however, the suggestion of a shorter length of stay in a restrictive unit merits further evaluation.

Personalized medicine uses a patient's individual data to make decisions tailored to their specific wants and needs. In the The Decision Tree, Thomas Goetz describes how patients can be taught to make their own personal health strategy based on the “best practices of genetics, behavioral medicine, information technology and each other.”1 An increased desire by patients to be true partners in their health care decisions and the shift towards encounters and disease monitoring taking place outside the doctor's office or hospital are advancing personalized medicine initiatives. The Innovators Prescription describes a solution to decrease health care costs and increase access by using wireless medical devices, wellness programs, telehealth, medical homes, and retail clinics to deliver health care.2 So how do we prepare pharmacy students to partner with their patients in a decentralized, technology-driven, and more-personalized environment, while keeping a human touch? Fortunately, pharmacy accreditation standards already mandate that graduates be able to provide patient-centered and population-based care. 3 However, strategies to deliver that care are changing and curriculums must keep pace. This viewpoint focuses on 2 areas for consideration as we continue to prepare students for new models of health care delivery.

To design and implement a demonstration project to teach interprofessional teams how to recognize and engage in difficult conversations with patients.Interdisciplinary teams consisting of pharmacy students and residents, student nurses, and medical residents responded to preliminary questions regarding difficult conversations, listened to a brief discussion on difficult conversations; formed ad hoc teams and interacted with a standardized patient (mother) and a human simulator (child), discussing the infant's health issues, intimate partner violence, and suicidal thinking; and underwent debriefing.Participants evaluated the learning methods positively and a majority demonstrated knowledge gains. The project team also learned lessons that will help better design future programs, including an emphasis on simulations over lecture and the importance of debriefing on student learning. Drawbacks included the major time commitment for design and implementation, sustainability, and the lack of resources to replicate the program for all students.Simulation is an effective technique to teach interprofessional teams how to engage in difficult conversations with patients.

Objective. To create, implement, and evaluate a pharmacy course on motivational interviewing. Design. A 3-hour elective course was created to train doctor of pharmacy (PharmD) students in brief patient-centered motivational interviewing counseling strategies that have proven effective with the types of health issues most commonly addressed in pharmacy settings. Students were assisted in developing their skills through required readings, interactive lectures, in-class demonstrations and practice sessions, out of class skills practice, one-on-one supervision provided by doctoral level clinical health psychology students, and written reflections on each class session. Assessment. Students demonstrated significant improvement in motivational interviewing skills and a high level of motivation for and confidence in using these skills in their future practice. Students overall assessment of the course and supervision process was highly positive. Conclusion. This patient-centered counseling skills course was feas...

The management of bipolar disorder has seen significant evolution in terms of the number of treatment options now approved for both the acutely manic phase and the maintenance stages of the illness. In addition, new formulations of traditional agents are available for clinicians to use in their treatment approach. One such example is carbamazepine, which has approval by the United States Food and Drug Administration for the treatment of acute and mixed mania in an extended-release formulation that uses a three-bead delivery system. Although the parent compound has been available for decades, its approval for bipolar disorder is recent despite numerous clinical trials that have supported its use in both the acute and maintenance phases of bipolar disorder. Advantages of the new formulation include less fluctuation in plasma concentration and, in general, improved tolerability. However, issues remain with regard to cytochrome P450 drug-related interactions and the need for therapeutic drug monitoring (e.g., drug concentrations, epoxide metabolite concentrations, hematology, and liver function tests) as part of the treatment and monitoring process. We review the current body of literature describing the use of carbamazepine in bipolar disorder during both the acute and maintenance phases of the disorder, including trials of both monotherapy and combination therapy, as well as findings from trials that included patients with rapid cycling and mixed episodes.

Sir: My colleagues and I thank Dr. Chung for his views; he makes several important points about our article.1 I would like to point out that some of his data, although interesting, reflect dosing in diseases not covered directly in our article. My colleagues and I do appreciate the update of data that was unavailable when we wrote this article.2,3

Selective serotonin reuptake inhibitors (SSRIs) are widely prescribed to treat depression. Although these drugs presumably have the same mechanism of action, they vary in several clinically important ways, including how long they remain in the body and the extent to which they interfere with the metabolism of other medications. This article reviews the pharmacologic differences among SSRIs and how these differences may affect various aspects of treatment, such as dosing, administration, and discontinuation. Understanding the distinct properties of SSRIs may help primary care physicians to design the most appropriate therapeutic plan for individual patients.

The pharmacology, efficacy, and adverse effects of atypical antipsychotic agents when used to treat schizophrenia and other disorders are reviewed. Atypical antipsychotic agents were developed in response to problems with typical agents, including lack of efficacy in some patients, lack of improvement in negative symptoms, and troublesome adverse effects, especially extrapyramidal symptoms (EPSs) and tardive dyskinesia CTD). Atypical antipsychotics differ from typical psychotics in their "limbic-specific" dopamine type 2 (D2)-receptor binding and high ratio of serotonin type 2 (5-HT2)-receptor binding to D2 binding. In clinical trials in patients with non-treatment-resistant schizophrenia, risperidone and olanzapine were superior to placebo for positive and negative symptoms. Risperidone and olanzapine were superior to haloperidol on some measures. Quetiapine was better than placebo but was not better than typical antipsychotics. Head-to-head comparisons of atypical antipsychotics in non-treatment-resistant schizophrenia have been inconclusive. Clozapine remains the standard agent for treatment-resistant schizophrenia. Atypical agents are substantially more expensive than their typical antipsychotic counterparts. To fully determine the overall efficiency of these drugs, other potential benefits, such as improved quality of life, need to be factored in. Atypical antipsychotics are associated with a decreased capacity to cause EPSs, TD, neuroleptic malignant syndrome, and hyperprolactinemia. Clozapine carries a risk of agranulocytosis; the white blood cell count must be monitored. Atypical antipsychotics are increasingly being used for indications other than schizophrenia, such as the management of aggression, mania, and depression. Atypical antipsychotics are often considered first-line agents for treating schizophrenia and are promising treatment alternatives for other psychiatric and neurologic conditions.

Based on the discussion of NMS, certain conclusions may be reached in regard to this patient. In the psychiatric setting, agitation and confusion alone are not suggestive of NMS. However in this patient, the symptoms of agitation, the rapid development of EPS symptoms unresponsive to anticholinergic therapy, autonomic changes (tachycardia, diaphoresis, and incontinence), and elevated CPK, met most of the diagnostic criteria described in Table VI. However, this case may have described an atypical presentation of NMS because of the absence of temperature increases during the onset of symptoms and the 7-week hospitalization for NMS. The patient's later onset of temperature elevations was a result of an aspiration pneumonia. Pneumonia and renal failure significantly increased the morbidity and extended the course of the illness. As a result, the diagnosis and specific treatment of NMS were delayed because of atypical symptoms and complications. In this patient, treatment of NMS with bromocriptine did not start until 10 days into hospitalization. A delay in pharmacologic therapy in this patient may have contributed to persistence of symptoms. The patient showed signs of improvement on day 21 during combination bromocriptine, benztropine, and dantrolene therapy. Moreover, this case exemplifies the rigorous need for supportive therapy and adjunctive pharmacologic therapy for primary and secondary complications resulting from NMS. In conclusion, because of the wide range of risk factors and variations of NMS, a systematic approach to diagnosing and treating NMS is critical to a successful outcome. Discontinuation of antipsychotics, maintenance of supportive therapy aimed at preventing dehydration, hemodynamic, and electrolyte imbalances, and pharmacotherapy are essential in the treatment of NMS.

2010-11 COS ADMINISTRATIVE BOARD Sudip Das, Immediate Past Chair (Butler) Irish Marken, Chair, (UMKC) Shane Desselle, Chair-Elect (OU) Cindy Koh-Knox, Secretary (Purdue) 2011-2012 COS ADMINISTRATIVE BOARD Trish Marken, Immediate Past Chair (UMKC) Shane Desselle, Chair (Oklahoma) Denise Soltis, Chair-Elect (Drake) Steve Stoner, Secretary (UMKC) COS Activities 1. Denise Soltis (Drake) was elected Chair Elect of the COS and Steve Stoner was elected as Secretary. 2. Final reports for 2010-2011 task forces: Preceptor Development (Chair: Denise Soltis, Drake) Poster accepted for AACP--The Current State of Preceptor Development: Results of a Survey by Preceptor Development Task Force * Denise A Soltis, Maryann Z. Skrabal, Nora Stelter, Bob Talbert, Meri Hix, Michelle Katsiyiannis, Mariana Lapidus, Irena Bond, Christina Seeger, and Trish Marken on behalf of the Preceptor Development Task Force, Council of Sections, American Association of Colleges of Pharmacy. Compounding (Chairs Bill Shrewsbury, UNC) * Compounding in Schools of Pharmacy: A Report of the AACP COS Task Force on Compounding, has been accepted for the 2011 AACP Annual Meeting in San Antonio (Robert P. Shrewsbury, University of North Carolina at Chapel Hill, Primary Author) * Post executive summary to COS site on AACP website * Paper in preparation for AJPE Primer for New Faculty (Chair: Bill Fassett, Washington State) * Shane Desselle will reappoint for 2011-2012 New Pharmacy Faculty Research Awards Program REVISION Task Force (Sudip Das, Chair) * COS Committee will present recommendations for revised procedures and number for COS vote on 7/9/11 and forward the results to the Board of Directors for action Abstract Task Force (Cynthia P Koh-Knox, Chair) * COS will consider the following recommendations from the Abstract Review Task Force at Annual Meeting. Final recommendations will be forwarded to AACP for action. ** Remove the option of Accept or Reject from the options for evaluating abstracts and instead reviewers assign scores only *** Use a minimum cut score for poster acceptance vs. the accept/reject process used now ** Expand the definition of Work In Progress so authors can better determine whether their project is ready for consideration at this year's meeting ** Add evaluation criteria for Work in Progress to rubrics ** Monitor performance of the changes in review process during 2011-12 cycle COS Programming (Julie Szilagyi, Chair) The committee was charged with establishing the Council's programming for the 2011 AACP Annual Meeting and Conference. The committee chair and section representatives communicated initially via conference call and, thereafter, via ongoing email messages. Progress regarding identification of topics, emphasis and speakers was shared at requested intervals and as needed. This resulted in a productive dialogue among the committee members and a good selection of topics for presentation at the July meeting. The committee members would like to suggest that the Programming Committee membership be composed of the Chair-Elects of each Section. The rationale is that these individuals are already responsible for Section programming. Therefore, it is reasonable that they also participate on the Programming Committee SECTION UPDATE (FEB-JUNE 2011) Biological Sciences Section Update (Stephen A. O'Barr--Western University) The Section has been working on ways to include more biological science faculty in the SIG by offering expanded services, which is part of the strategic plan. Part of the new initiative has been by working with the new Graduate Education SIG on enhancing research oriented programming. …

The recent surge in the use of cocaine has imposed increased financial burdens on society in terms of cocaine-related crimes, and funding for hospitalization/medical treatment and long-term rehabilitation programs. Unfortunately, healthcare costs secondary to chronic cocaine use are likely to increase in the future as drug research into cocaine abuse and effective treatment programs are severely lacking. This article reviews existing literature on treatment of cocaine abuse and is intended to serve as a practical guide to the general clinician involved in drug management of cocaine abuse. Antidepressant agents and the dopamine agonists are emphasized because most of the studies showing benefit have used these agents. Advantages and disadvantages of various interventions are objectively assessed. Additionally, specific implications for both acute and chronic management of cocaine abuse are given along with discussion and recommendations regarding comorbidity.

Elevated serum cholesterol is a risk factor in the development of coronary artery disease. Magnesium has been reported to decrease total serum cholesterol, low density lipoprotein, and very low density lipoprotein, and increase high density lipoprotein. A randomized, double-blind, placebo-controlled, crossover study was completed to determine if supplemented magnesium, in the form of magnesium oxide, would produce changes in the lipid profile. Fifty normal volunteers received placebo or magnesium oxide, 400 mg capsules, twice a day for 60 days, then switched to the alternate treatment. Weight, height, blood pressure, serum potassium, serum magnesium, and a lipid profile were determined initially and after each treatment. Analysis of variance (ANOVA), comparing the mean of each component of the lipid profile at baseline and after each treatment, showed no significant difference. In conclusion, supplemental magnesium oxide did not produce statistically significant changes in the lipid profile in this group of healthy volunteers.