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J Andrew Woods,1 James S Wheeler,1 Christopher K Finch,2 Nathan A Pinner3 1School of Pharmacy, Wingate University, Wingate, NC, USA; 2Department of Pharmacy, Methodist University Hospital, Memphis, TN, USA; 3Harrison School of Pharmacy, Auburn University, Auburn, AL, USA Background: Chronic obstructive pulmonary disease (COPD) is a chronic and progressive disease that affects an estimated 10% of the world's population over the age of 40 years. Worldwide, COPD ranks in the top ten for causes of disability and death. Given the significant impact of this disease, it is important to note that acute exacerbations of COPD (AECOPD) are by far the most costly and devastating aspect of disease management. Systemic steroids have long been a standard for the treatment of AECOPD; however, the optimal strategy for dosing and administration of these medications continues to be debated. Objective: To review the use of corticosteroids in the treatment of acute exacerbations of COPD. Materials and methods: Literature was identified through PubMed Medline (1950–February 2014) and Embase (1950–February 2014) utilizing the search terms corticosteroids, COPD, chronic bronchitis, emphysema, and exacerbation. All reference citations from identified publications were reviewed for possible inclusion. All identified randomized, placebo-controlled trials, meta-analyses, and systematic reviews evaluating the efficacy of systemic corticosteroids in the treatment of AECOPD were reviewed and summarized. Results: The administration of corticosteroids in the treatment of AECOPD was assessed. In comparison to placebo, systemic corticosteroids improve airflow, decrease the rate of treatment failure and risk of relapse, and may improve symptoms and decrease the length of hospital stay. Therefore, corticosteroids are recommended by all major guidelines in the treatment of AECOPD. Existing literature suggests that low-dose oral corticosteroids are as efficacious as high-dose, intravenous corticosteroid regimens, while minimizing adverse effects. Recent data suggest that shorter durations of corticosteroid therapy are as efficacious as the traditional treatment durations currently recommended by guidelines. Conclusion: Systemic corticosteroids are efficacious in the treatment of AECOPD and considered a standard of care for patients experiencing an AECOPD. Therefore, systemic corticosteroids should be administered to all patients experiencing AECOPD severe enough to seek emergent medical care. The lowest effective dose and shortest duration of therapy should be considered. Keywords: chronic obstructive pulmonary disease, exacerbation

Background: Sustainable career advancement opportunities for pharmacy technicians will be a critical part of patient-centered community pharmacy environments as the role of the pharmacist provider expands., Objective: (1) To determine the impact of a Pharmacy Technician Certification Board (PTCB) pharmacy certification on career advancement and professional growth metrics; (2) To assess technicians' role in advanced pharmacy services before and after certification; and (3) To identify changes in pharmacist services when a certified pharmacy technician (CPhT) was added to the provider team., Methods: A 73-question web-based survey was distributed to all PTCB CPhT in the United States, Washing DC, Puerto Rico, Guam, and the US Virgin Islands. The survey was distributed by PTCB in April 2021 with a 28-day collection period. The survey included multiple choice, rating scale, and free text questions centered on 5 domains: practice experience, career aspirations, compensation, pharmacy practice motivations, and impact of COVID-19 pandemic., Results: A total of 23,007 CPhTs completed the survey. Respondents were primarily females (85.5%), age 30-39 (32.8%), and ≥10 years CPhT experience (42.8%). The majority of respondents cited improvement of patient health (77.4%), career advancement opportunities (53.5%), the ability to expand their role during emergencies (e.g., COVID-19) (52.6%), and future career advancement opportunities (51.7%) as benefits of CPhT certification. Increases in job responsibility after certification included changes occurring in roles related to clinical pharmacy services, patient education, preventive health services, provider communication, and staff training. Respondents agreed that PTCB-certification allowed for the expansion of pharmacists' services where they practiced, including clinical services (18.5%), patient education (18.3%), and preventive health services (18.1%)., Conclusion: CPhT's value certification for its benefits on career advancement, personal growth, and salary enhancement. Affirmation of skill and training through certification is also recognized to positively influence patient care and the pharmacy's ability to provide advanced patient care and services., Competing Interests: Disclosure The authors declare no relevant conflicts of interest or financial relationships., (Copyright © 2024 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.)

Purpose: Ensuring pharmacy technicians are adequately trained and prepared to enter the workforce is an important first step in addressing technician staff shortages. How pharmacy technician learners perceive their experiences after completion of a training program remains unknown. This study evaluated participant outcomes and self-efficacy ratings for common technician competencies after completion of a pharmacy technician training program., Methods: Between December 2021 and March 2023, we distributed a survey to participants who successfully completed the program approximately 3 months after their estimated completion date. The survey assessed 6 domains: enrollment and academic progression, utilization of educational resources, self-perceived proficiency on core competencies of a pharmacy technician, employment information, program recommendations, and student demographics., Results: Thirty-six participants completed the survey, corresponding to a 60% response rate. Participants were attracted to the pharmacy technician program due to its affiliation with a college of pharmacy, online format, and affordability. Half of respondents were actively employed as pharmacy technicians, and the self-reported certification exam passage rate slightly exceeded national averages (78% vs 70% to 71%). Participants' self-efficacy ratings for pharmacy technician competencies were high (mean rating of 4.12 out of 5). Overwhelmingly, 97% of participants agreed that the program prepared them well for becoming a pharmacy technician., Conclusion: A pharmacy technician training program housed within a college of pharmacy presents one potential solution in addressing pharmacy technician workforce shortages. Participants positively viewed their training experience, with high self-efficacy ratings for pharmacy technician competencies. Moreover, national certification exam results were slightly better than national averages., (© American Society of Health-System Pharmacists 2024. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Background: The burden from medication costs for treating heart failure can be financially toxic for uninsured/underinsured patients and their families. Prescription discount cards, which offer cash price reductions, may decrease out-of-pocket costs for patients without prescription benefits, but the degree to which they offer financial relief remains unclear. Our objective was to assess the financial burden for uninsured/underinsured patients prescribed a drug from each of the 4 standard classes of medications for heart failure with reduced ejection fraction. A second objective assessed whether discounts varied across economically and geographically diverse regions in Tennessee., Methods: This was a cross-sectional pricing analysis of guideline-directed medical therapy heart failure with reduced ejection fraction regimens utilizing prescription discount cards. Between February 9 and March 31, 2022, we conducted searches on 3 discount card websites (GoodRx, NeedyMeds, and Blink Health) for the prices of 30- and 90-day supplies of select guideline-directed medical therapy heart failure regimens for 6 Tennessee ZIP codes. Prices were compared with Amazon and Redbook prices., Results: Monthly costs among discount card services varied from $10.58 to $30.86 for a generic 3-drug regimen consisting of beta blockers, angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers, and mineralocorticoid receptor antagonists. With the addition of a sodium-glucose cotransporter-2 inhibitor, prices increased to $540.32 to $593.74. The ideal 4-drug regimen (beta blocker, angiotensin receptor neprilysin inhibitor, mineralocorticoid receptor antagonist, and sodium-glucose cotransporter-2 inhibitor) ranged from $1188.31 to $1464.54. When compared with Amazon cash prices, the cards offered an average discount of 65% on a generic 3-drug regimen; when brand-name medications were added, discounts were modest (<12%). There were no significant variations in pricing based on ZIP codes in differing economic and geographic regions., Conclusions: Although prescription discount cards offered significant savings on generic medications, brand-name drug discounts were small and overall costs remained high. These findings highlight the potential for unequal access to life-saving therapies for heart failure with reduced ejection fraction., Competing Interests: Disclosures Dr Hauptman serves on the Clinical Events Committee for the ANTHEM HFrEF study (https://www.clinicaltrials.gov; Unique identifier: NCT03425422) sponsored by LivaNova, the Steering Committee for REALM-DCM (https://www.clinicaltrials.gov; Unique identifier: NCT03439514), a rare diseases study sponsored by Array Biopharma/Pfizer, and a working group evaluating best practices concerning digoxin toxicity sponsored by BTG Inc. The other authors report no conflicts.

Objective: To assess pharmacy student responses to medication problems with and without clinical decision support (CDS) alerts during simulated order verification., Methods: Three classes of students completed an order verification simulation. The simulation randomized students to a different series of 10 orders with varying CDS alert frequency. Two of the orders contained medication-related problems. The appropriateness of the students' interventions and responses to the CDS alerts were evaluated. In the following semester for 2 classes, 2 similar simulations were completed. All 3 simulations contained 1 problem with and 1 without an alert., Results: During the first simulation, 384 students reviewed an order with a problem and an alert. Students exposed to prior inappropriate alerts within the simulation had less appropriate responses (66% vs 75%). Of 321 students who viewed a second order with a problem, those reviewing an order lacking an alert recommended an appropriate change less often (45% vs 87%). Among 351 students completing the second simulation, those who participated in the first simulation appropriately responded to the alert for a problem more often than those who only received a didactic debrief (95% vs 87%). Among those completing all 3 simulations, appropriate responses increased between simulations for problems with (n = 238, 72-95-93%) and without alerts (n = 49, 53-71-90%)., Conclusions: Some pharmacy students displayed baseline alert fatigue and overreliance on CDS alerts for medication problem detection during order verification simulations. Exposure to the simulations improved CDS alert response appropriateness and detection of problems., (Copyright © 2023 American Association of Colleges of Pharmacy. Published by Elsevier Inc. All rights reserved.)

Objective. To survey pharmacists, including those who make or contribute to hiring decisions, regarding certificate training programs and specifically about a primary care certificate for pharmacists. Methods. We conducted a cross-sectional survey of pharmacist registrants of the Office of Continuing Professional Development at the University of Tennessee Health Science Center College of Pharmacy's listserve, including both hiring and non-hiring pharmacists. The 40-question survey probed perceptions of various types of postgraduate training and the design of a primary care certificate training program for pharmacists. Data were collected between November and December 2020. Results. A total of 230 pharmacists participated in this study (14% response rate), and most reported practicing in the community (n=126, 57%). Nearly half of the respondents reported making or contributing to hiring decisions of other pharmacists (n=94, 41%), and, of those, most reported that completion of a primary care certificate program by a candidate would increase their likelihood of hiring that candidate (n=50, 78%). Both groups (hiring and non-hiring pharmacists) most commonly reported that a primary care certificate training program should be 30 hours total and 12 weeks in length, ranked communication as the most important topic to be included, and indicated the didactic and simulation/experiential components should be similarly weighted. Conclusions. Pharmacists, including those who make or contribute to hiring decisions, reported valuing certificate training programs. Developing a certificate training program that is at least 30 hours in length over 12 weeks may serve as an opportunity to address gaps in primary care in the United States., (© 2023 American Association of Colleges of Pharmacy.)

Background: Ensuring opportunities exist to dispose of unused or unwanted drugs that are appropriate, accessible, and affordable is critical to avoid misuse and lasting harm to the environment., Objective: The objectives of this study were to identify state statutes promulgated in all 50 states and the District of Columbia (DC) facilitating disposal of unused or unwanted drugs in the community setting and assess their characteristics., Methods: A retrospective review of state statutes in all 50 U.S. states and DC between October 2020 and May 2022 was conducted. Statutes using terms "drug and disposal or collection" and that were intended to facilitate disposal of unused or unwanted drugs were included. Drug donation programs or repositories, drug returns to the pharmacy, charitable clinics, and others not intended to dispose or unused or unwanted drugs were excluded. Publicly available resources and Westlaw, a legal resource, were used to identify state statutes. Descriptive statistics were used to describe the findings., Results: Of the 50 U.S. states and DC, we found that most states enacted a statute pertaining to drug disposal (63%; n = 32) as of May 2022. Of states with a drug disposal statute, few had funding mechanisms or required pharmacy participation. Most statutes specified the type of product that may be accepted for disposal, what site may accept them, and who may dispose of the product. Few states specified which health care provider or other individual may accept the product(s) for disposal., Conclusion: Most states have enacted statutes facilitating drug disposal, but their characteristics varied widely. Opportunities may exist at the state level to further incentivize proper drug disposal, and further research is needed to measure possible effects of these state statutes., (Copyright © 2022 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.)

Background: As the pharmacy profession transforms toward practice centered around direct patient care and clinical services, upskilling the existing workforce may be required for pharmacists to take on expanded roles, especially in an increasingly competitive job market., Objective: To explore pharmacist employer perceptions of a primary care certificate training program including its design, value, and relevance and to develop and implement a pharmacist primary care certificate training program based on study results., Methods: Focus groups were conducted to a point of saturation in December 2020 via video conference. Participants were identified via the study institution's continuing professional development registrant listserv and invited to participate via self-selection. Interviews were recorded, transcribed, and underwent inductive thematic analysis., Results: Four focus groups were conducted with 15 pharmacist employers. Employers perceived primary care certificate training as valuable, helping pharmacists sustain shifting roles and increasing opportunities in a competitive job market. A combination of clinical and practice management topics with emphasis on an experiential component was recommended to achieve expected competency levels and favorably influence hiring decisions. The primary care certificate was specifically recommended to pharmacists aiming to transition into primary care or for pharmacists who did not complete residency training., Conclusions: This study's findings informed development of a pharmacist primary care certificate program containing didactic and experiential training on a variety of key topics. As pharmacists' roles evolve, this program may prepare pharmacists to engage in direct patient care and develop skills and expertise necessary to succeed in outpatient primary care., Competing Interests: None., (© 2022 The Authors.)

Abstract: The objective of this article is to assess the incidence of late bleeding following cleft palate repair (palatoplasty) in children. This is a retrospective review of a prospectively maintained database of patients treated for Cleft Lip and Palate in a tertiary academic pediatric hospital setting over 2 hospitals (Middlemore and Starship Hospitals) under the same multidisciplinary team of the Auckland Regional Cleft and Craniofacial Service, New Zealand. All patients with a diagnosis of Cleft Lip and/or Palate undergoing primary cleft palate repair over an 11 year period until March 2020 were included in the study. Our results found there were 482 patients with a new diagnosis of Cleft Lip and/or Palate from Jan 2009 through to March 2020. Three hundred sixty-six of those patients underwent primary palatoplasty at an average age of 10.5 months (range 8-18 months). The sub-types of cleft palate diagnoses were one-third Veau I, one-third Veau II, and the remaining one-third were Veau III, IV, and submucous cleft palate. One-third were syndromic. A total of 6 patients were re-admitted to hospital after discharge from their primary admission with bleeding from the cleft palate surgical site. Of the 6 patients re-admitted, 5 needed blood transfusions and 4 required an urgent return to the operating room. The authors found the rate of late bleeding following primary cleft palate repair in our unit is 1:61 operations or 1.6%. Late bleeding following cleft palate surgery is not well reported in the literature., Competing Interests: The authors report no conflicts of interest., (Copyright © 2021 by Mutaz B. Habal, MD.)

Schools and colleges of pharmacy are optimally positioned to train the entire pharmacy team, including pharmacists and pharmacy support personnel, because they can provide comprehensive workforce development, utilize established faculty expertise, harness existing infrastructure, afford opportunities for intraprofessional education, and support institutional growth and reputability. As the emphasis of training shifts towards team-based approaches and expanded responsibilities, ensuring the existing and future pharmacy workforce is equipped to serve their communities becomes increasingly important. Thus, schools and colleges of pharmacy should consider offering a pharmacy technician training program to meet the needs of their community and the profession., (© 2022 American Association of Colleges of Pharmacy.)

Background: Opioid use disorder affects millions of Americans, but only a fraction receive treatment. This may be due in part to inaccurate information available about buprenorphine waivered practitioners (waivered practitioners) and Opioid Treatment Programs (OTPs) on public, federally-sponsored locator databases. We aimed to assess the accuracy of publicly-listed locator information for waivered practitioners and OTPs across the US. Methods: Using a cross-sectional study design, we randomly sampled waivered practitioners ( n  = 253; 0.5%) and licensed OTPs ( n  = 165; 10%) that were publicly-listed on a federally-sponsored database. We used a three-pronged approach to assess the accuracy of the information available by concurrently administering a phone survey (making up to 3 attempts to contact), conducting online searches, and reviewing provider information on state board websites (practitioners only) between August and November 2020. We used descriptive analyses and inferential statitistics to analyze the data. Results: Among n  = 418 waivered practitioners and OTPs sampled, many were located in the South and in an urban area. For the phone survey, researchers were able to reach OTPs nearly twice as often as waivered practitioners. Of those reached, n  = 19 waivered practitioners and n  = 40 OTPs agreed to participate, and we found most had up-to-date contact information. OTPs yielded significantly more online search results and matching contact information than waivered practitioners ( p  < 0.001). Most waivered practitioners were located on state licensing board websites, but few had contact information listed, and only one listed the practitioner's waiver status. Conclusions: Waivered practitioners and OTPs were difficult to reach via phone but easier to find online and on state licensing board websites; when they were reached via phone, their contact information was very accurate. Whether challenges locating a waivered practitioner or OTP is associated with lower treatment utilization should be evaluated.

Background and Purpose: Competence in drug information (DI) skills fosters the application of evidence-based medicine (EBM) principles. However, concern exists about whether there is adequate DI preparation in curricula. This report describes the development, implementation, and evaluation of a team project utilizing the critically appraised topic (CAT) approach in a DI course., Educational Activity and Setting: To assess abilities and skills in DI and EBM principles, student teams (N = 26) were assigned DI requests. A grading rubric based on the validated EBM Critical Presentation Evaluation Tool was used to evaluate each team's project. As a secondary measure, students completed pre-and post-class self-efficacy assessments describing their confidence in DI processes., Findings: Twenty-six team posters were submitted with a mean project rubric score of 43 out of 50 points (86%). One hundred one of 172 students (59% response rate) completed the pre- and post-self-efficacy surveys, and results revealed gains in confidence for MEDLINE searching skills, properly citing sources, and knowing where to go next if the answer could not be found in a tertiary resource (all P < .001). The majority of respondents noted their teams collaborated to achieve project goals, actively participated, were open and accepting of others' ideas, and were satisfied with group interactions., Summary: Student team creation of DI responses via CATs are an innovative way to introduce, measure, and enhance DI skills in a didactic classroom setting. Fostering DI skills prepares pharmacy students for evidenced-based pharmacy practice., Competing Interests: Declaration of Competing Interest None., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: With the evolving roles of pharmacy technicians in the United States, the profession has attempted to define a national standard. Community pharmacy employers to-date have preferred on-the-job training to formal, accredited training programs or credentialing, however, limited evidence exists on the perceived needs of pharmacy technicians in the United States compared to those of community pharmacy employers., Objectives: The aims of this study were to explore: 1) community pharmacy employer perceptions of associated benefits and perceived value of pharmacy technician certification and 2) needs of employers related to pharmacy technician attitudes and knowledge, skills and abilities (KSAs)., Methods: Using a semi-structured interview guide, researchers interviewed 7 community pharmacy employers within top management teams in a variety of community pharmacy settings. The data were analyzed for themes using the human capital vs. signal theory., Results: Employers and managers generally saw both attitude and KSAs as vital to success. However, given a choice between experience and attitude, attitude was preferred. There was general agreement that certified technicians offered more value to their organization, however gaps in certified technician KSAs were noted (i.e., lack of day-to-day practical skills, vaccination screening, motivating patients to change behaviors, patient communication and workflow management)., Conclusions: New emerging directions for certification now exist due to the rapidly shifting pharmacy landscape, which is revolves around new and expanded clinical patient care services. This shifting landscape has exposed gaps, reinforced strengths, and uncovered potential new opportunities and needs related to technician certification., (Copyright © 2019 Elsevier Inc. All rights reserved.)

The United States healthcare system faces immense challenges related to cost, quality, and access. As the pharmacy profession addresses these challenges by shifting toward a practice model centered around direct patient care clinical services, a competent and capable technician workforce is needed to support the roles of pharmacists. Until recently, little focus has been paid to pharmacy technicians or their role as they relate to practice model change. With ongoing pharmacist practice transformation, an approach that ensures uniform technician education, training, registration, and certification is vital to support a practice model designed to transform medication management across the continuum of care. The purpose of this commentary is three-fold: to review the history of pharmacy technician training and practice, discuss current and future technician practice models, and examine workforce development implications., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objectives: (1) To develop an adaptation framework for MTM delivery for pharmacists (the MTM Adaptability Framework), (2) to examine the impact of an educational intervention informed by the MTM Adaptability Framework on MTM completion rates over a 2-year period, and (3) to explore pharmacists' perceptions regarding knowledge and beliefs about MTM and MTM implementation self-efficacy pre- and post-intervention., Methods: This study is a prospective, mixed-methods research study including a quasi-experimental, one-group pretest-posttest quantitative study with a sequential explanatory qualitative study arm featuring semi-structured key informant interviews. US supermarket pharmacy chain setting included 93 community pharmacy sites located in Tennessee, Kentucky, and Alabama. MTM completion rates are reported as percentage of completed comprehensive medication reviews (CMRs) and targeted medication reviews (TMRs) and pharmacist perceptions., Results: An 11.4% absolute increase in MTM completion rates was seen after the educational intervention targeting adaptation of MTM in the community pharmacy setting. This was found to be significant (46.92% vs. 58.3%; p < 0.001). Responses to the semi-structured interviews were mapped against CFIR and included themes: "knowledge and beliefs about MTM (pre-intervention)," "self-efficacy for MTM implementation (pre-intervention)," "knowledge and beliefs about MTM (post-intervention)," and "self-efficacy for MTM implementation (post-intervention)." Data convergence was found across these methodologies and suggested that targeting adaptability of MTM delivery increases MTM completion rates (quantitative data) and positively changes perceptions of MTM feasibility and self-efficacy (interviews)., Conclusion: The use of an educational intervention about adaptation of MTM to influence adaptation of MTM to a chain community pharmacy setting part of an implementation strategy improved MTM completion rates significantly. Future research should investigate combined implementation strategies and their impact on MTM implementation success.

Objectives: To compare viewpoints of nationally certified and noncertified technicians and explore the perceived value of technician certification in the job performance domains of medication safety, skills and abilities, experience, engagement and satisfaction, and productivity., Methods: A cross-sectional survey of pharmacy technicians, from 6 states representing 4 regions of the United States, was conducted. Technician mailing lists were purchased from Boards of Pharmacy, and randomly selected technicians were sent survey invitations. Surveys were completed via Qualtrics and analyzed with the use of SAS., Results: Six hundred seventy-six technicians (547 certified, 103 noncertified, and 26 previously certified) responded to the survey (9.4% response rate). Certified technicians reported significantly higher confidence rating for desire to take on new responsibilities (P < 0.01; Cohen d 0.45) and plans to remain in the pharmacy field (P = 0.01, Cohen d 0.35), lower rating for leaving the job in the next 12 months (P < 0.01; Cohen d 0.35), and perceived lower rate of medication errors (P < 0.01; Cohen d 0.35) compared with other technicians in the work setting. The majority of respondents stated confidence in performing the "final check" on another technician's preparation of a new or refill medication if allowed. Both certified and noncertified technicians noted dissatisfaction with pay. The majority of respondents reported that they spent none of or less than 10% of their workday assisting pharmacists with medication therapy management (MTM) sessions, immunizations, or point-of-care tests; however, 71 respondents specifically described how they assist pharmacists with MTM., Conclusion: Results from our survey sample indicate that certified technicians have a stronger organizational and career commitment and desire to take on new roles. A majority of respondents noted dissatisfaction with pay but feel a sense of pride in their work. Both groups were confident in their abilities needed for tech-check-tech product verification., (Copyright © 2019 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.)

Background: Given the significant public health burden of pulmonary diseases and the vital role pharmacists play in management across the continuum of care (and within transitions in care), an elective course for pharmacy students focused on pulmonary diseases was developed., Educational Activity: A month-long elective course for third-year pharmacy students consisting of 12 class sessions delivered in two-hour periods three times per week, was implemented. The course was delivered using the team-based learning (TBL) format in addition to hands-on skills and simulation sessions. Knowledge and skills assessments were administered before and after completion of the course. Student perceptions of self-confidence and ability regarding management of pulmonary diseases pre- and post-course and their perceptions of the course and TBL as a teaching strategy for this course were evaluated upon course completion., Critical Analysis: Nine students completed the course. Mean scores on knowledge and skills assessment significantly improved after completion of the course (54.5% pre-course vs. 79.3% post-course; p < 0.05% and 60.3% pre-course vs. 93.2% post-course; p < 0.05, respectively). Student perceptions of their ability to care for patients with pulmonary diseases significantly increased, compared to pre-assessments, in all areas taught in the course (p< 0.05). Additionally, students' confidence in managing specific disease states significantly improved in all areas (p < 0.05) except for spirometry (p = 0.06). Students' knowledge, skills, and confidence regarding management of common pulmonary disease states improved following this month-long elective course delivered using a combination of TBL activities and hands-on skills sessions., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Limited information exists regarding medication errors and trainees (students or residents). Yet during the experiential education component of their training, learners are expected to assume significant responsibilities in the medication use process. This commentary addresses both trainees and organization leaders on medication safety practices and the incorporation of learners into the organization's medication safety culture.

Objectives: Postgraduate training, dual degrees, and board certifications are credentials viewed by academic pharmacy communities and professional organizations as positive assets for those seeking pharmacist jobs; however, a key question merits further investigation: do these views match employer expectations? The primary objective of this study was to identify the most common qualifications employers require as stated in job advertisements., Methods: Pharmacist job postings from the aggregate jobs website Indeed.com were evaluated for the 20 largest metropolitan areas in the United States. Search criteria included: pharmacist, full-time, and within a 50-mile radius of the metropolitan area. Positions were excluded if they were not pharmacist specific, did not require a pharmacy degree, were part-time, or were temporary. Required and preferred qualifications were collected in the following categories: practice type, experience needed, training, certification, and desired skills., Results: Six hundred and eleven of 1356 postings met inclusion criteria. Positions were classified as community (113), health-system (264), industry (149), academia (9), or other (76). Four hundred and six (66.4%) required a minimum of a Bachelor's of Pharmacy degree, while 174 (28.4%) required a Doctor of Pharmacy degree. Experience was required for 467 positions (range of 6 months to 14 years). Postgraduate training was required for 73 positions (66 residency/7 fellowship). One job required a Master's degree, type unspecified. BPS certifications were required for 7 positions (1.1%) and preferred for 22 positions (3.6%). Certifications and skills most required by employers were verbal and written skills (248), Microsoft Office proficiency (93), immunization certifications (51), and Basic Life Support/Cardiopulmonary Resuscitation certifications (37)., Conclusion: Postgraduate training, dual degrees, and board certification were not significant factors in the qualification criteria for the positions identified. The qualifications most often required by employers were experience and skills. Our findings indicated that employers wanted many soft skills that cannot be quantified., (Copyright © 2017 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.)

Objective: This study quantifies and describes student self-assessment approaches in colleges of pharmacy across the United States., Methods: Faculty members identified as assessment directors from college websites at U.S. colleges of pharmacy were electronically surveyed. Prior to distribution, feedback and question validation was sought from select assessment directors. Surveys were distributed and recorded, via Qualtrics ® survey software and analyzed in Microsoft Excel ® ., Results: Responses were received from 49 colleges of pharmacy (n = 49/134, 37% response rate). The most commonly used strategies were reflective essays (n = 44/49, 90%), portfolios (n = 40/49, 82%), student self-evaluations (n = 35/49, 71%) and questionnaires/surveys/checklists (n = 29/49, 59%). Out of 49 submitted surveys, 35 programs noted students received feedback on self-assessment. Feedback came most commonly from faculty (n = 31/35, 88%). Thirty-four programs responded regarding self-assessment integration including fifteen colleges (n = 15/34, 44%) that integrated self-assessment both into the curriculum and co-curricular activities, while 14 (n = 14/34, 41%) integrated self-assessment exclusively into the curriculum, and five (n = 5/34, 15%) used self-assessment exclusively in co-curricular activities., Discussion and Conclusions: Student self-assessment is a critical first step of the Continuing Professional Development (CPD) process. Colleges and schools of pharmacy use a wide variety of methods to develop this skill in preparing future practitioners., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Previous studies have shown that development of a unit-specific combination antibiogram improves optimal selection of empiric therapy for Gram-negative infections, yet no published data exist regarding the role of the combination antibiogram as an antimicrobial stewardship program tool for disease-specific prescribing., Objective: To evaluate the utility of a combination antibiogram to guide antibiotic prescribing for patients with health care-associated pneumonia (HCAP)., Methods: This was a retrospective preprovider and postprovider education intervention study aimed to evaluate fluoroquinolone (FQ) use in patients with HCAP. Data were collected retrospectively to evaluate antibiotic prescribing patterns and patient outcomes., Results: A total of 87 patients were eligible for study inclusion. The primary end point, FQ days of therapy (DOT) was decreased by 2.3 days (P < 0.001). The secondary end point included FQ DOT per 1000 patient-days in patients with discharge diagnosis-related group of pneumonia and was decreased by 83.5 days (P = 0.08); double coverage reduced by 13% postintervention (P = 0.22); mean days of double coverage decreased by 2.1 days (P < 0.001), and length of stay was shortened by 2.1 days (P = 0.22). Clinical success was achieved more often in the postintervention group (90% vs 98%, P = 0.18) when compared with the preintervention group. No difference was found in microbiological outcomes in the subset of microbiologically evaluable patients (P = 0.57)., Conclusion: Facility-specific combination antibiograms may be used to inform antibiotic prescribing in HCAP patients., (© The Author(s) 2016.)

Mono-hydroxylated polychlorinated biphenyls (OH-PCBs) are found in human biological samples and lack of data on their potential estrogenic activity has been a source of concern. We have extended our previous in silico 2D QSAR study through the application of advance techniques such as docking and 3D QSAR to gain insights into their estrogen receptor (ERα) binding. The results support our earlier findings that the hydroxyl group is the most important feature on the compounds; its position, orientation and surroundings in the structure are influential for the binding of OH-PCBs to ERα. This study has also revealed the following additional interactions that influence estrogenicity of these chemicals (a) the aromatic interactions of the biphenyl moieties with the receptor, (b) hydrogen bonding interactions of the p-hydroxyl group with key amino acids ARG394 and GLU353, (c) low or no electronegative substitution at para-positions of the p-hydroxyl group, (d) enhanced electrostatic interactions at the meta position on the B ring, and (e) co-planarity of the hydroxyl group on the A ring. In combination the 2D and 3D QSAR approaches have led us to the support conclusion that the hydroxyl group is the most important feature on the OH-PCB influencing the binding to estrogen receptors, and have enhanced our understanding of the mechanistic details of estrogenicity of this class of chemicals. Such in silico computational methods could serve as useful tools in risk assessment of chemicals., (Published by Elsevier Ltd.)

Modification of the dipeptide of phenylalanine, FF, with a boronic acid (BA) functionality imparts unique aqueous self-assembly behavior that responds to multiple stimuli. Changes in pH and ionic strength are used to trigger hydrogelation via the formation of nanoribbon networks. Furthermore, we show for the first time that the binding of polyols to the BA functionality can modulate a peptide between its assembled and disassembled states.

The secondary structure of peptides in the presence of interacting additives is an important topic of study, having implications in the application of peptide science to a broad range of modern technologies. Surfactants constitute a class of biologically relevant compounds that are known to influence both peptide conformation and aggregation or assembly. We have characterized the secondary structure of a linear nonapeptide composed of a hydrophobic alanine/phenylalanine core flanked by hydrophilic acid/amine units. We show that the anionic surfactant sodium dodecyl sulfate (SDS) induces the formation of β-sheets and macroscopic gelation in this otherwise unstructured peptide. Through comparison to related additives, we propose that SDS-induced secondary structure formation is the result of amphiphilicity created by electrostatic binding of SDS to the peptide. In addition, we demonstrate a novel utility of surfactants in manipulating and stabilizing peptide nanostructures. SDS is used to simultaneously induce secondary structure in a peptide and to inhibit the activity of a model enzyme, resulting in a peptide hydrogel that is impervious to enzymatic degradation. These results complement our understanding of the behavior of peptides in the presence of interacting secondary molecules and provide new potential pathways for programmable organization of peptides by the addition of such components.

Mimicking the remarkable dynamic and multifunctional utility of biological nanofibers, such as microtubules, is a challenging and technologically attractive objective in synthetic supramolecular chemistry. Understanding the complex molecular interactions that govern the assembly of synthetic materials, such as peptides, is key to meeting this challenge. Using molecular dynamics simulations to guide molecular design, we explore here the self-assembly of structurally and functionally asymmetric wedge-shaped peptides. Supramolecular assembly into nanofiber gels or multilayered lamellar structures was determined by cooperative influences of hydrogen bonding, amphiphilicity (hydrophilic asymmetry), and the distribution of electrostatic charges on the aqueous self-assembly of asymmetric peptides. Molecular amphiphilicity and β-sheet forming capacity were both identified as necessary, but not independently sufficient, to form supramolecular nanofibers. Imbalances in positive and negative charges prevented nanofiber assembly, while the asymmetric distribution of balanced charges within a peptide is believed to affect peptide conformation and subsequent self-assembly into either nanofibers or lamellar structures. Insights into cooperative molecular interactions and the effects of molecular asymmetry on assembly may aid the development of next-generation supramolecular nanomaterial assemblies.

Thiazolidinedione (TZD) insulin sensitizers have the potential to effectively treat a number of human diseases, however the currently available agents have dose-limiting side effects that are mediated via activation of the transcription factor PPARγ. We have recently shown PPARγ-independent actions of TZD insulin sensitizers, but the molecular target of these molecules remained to be identified. Here we use a photo-catalyzable drug analog probe and mass spectrometry-based proteomics to identify a previously uncharacterized mitochondrial complex that specifically recognizes TZDs. These studies identify two well-conserved proteins previously known as brain protein 44 (BRP44) and BRP44 Like (BRP44L), which recently have been renamed Mpc2 and Mpc1 to signify their function as a mitochondrial pyruvate carrier complex. Knockdown of Mpc1 or Mpc2 in Drosophila melanogaster or pre-incubation with UK5099, an inhibitor of pyruvate transport, blocks the crosslinking of mitochondrial membranes by the TZD probe. Knockdown of these proteins in Drosophila also led to increased hemolymph glucose and blocked drug action. In isolated brown adipose tissue (BAT) cells, MSDC-0602, a PPARγ-sparing TZD, altered the incorporation of (13)C-labeled carbon from glucose into acetyl CoA. These results identify Mpc1 and Mpc2 as components of the mitochondrial target of TZDs (mTOT) and suggest that understanding the modulation of this complex, which appears to regulate pyruvate entry into the mitochondria, may provide a viable target for insulin sensitizing pharmacology.

Alternative methods, including quantitative structure-activity relationships (QSAR), are being used increasingly when appropriate data for toxicity evaluation of chemicals are not available. Approximately 40 mono-hydroxylated polychlorinated biphenyls (OH-PCBs) have been identified in humans. They represent a health and environmental concern because some of them have been shown to have agonist or antagonist interactions with human hormone receptors. This could lead to modulation of steroid hormone receptor pathways and endocrine system disruption. We performed QSAR analyses using available estrogenic activity (human estrogen receptor ER alpha) data for 71 OH-PCBs. The modelling was performed using multiple molecular descriptors including electronic, molecular, constitutional, topological, and geometrical endpoints. Multiple linear regressions and recursive partitioning were used to best fit descriptors. The results show that the position of the hydroxyl substitution, polarizability, and meta adjacent un-substituted carbon pairs at the phenolic ring contribute towards greater estrogenic activity for these chemicals. These comparative QSAR models may be used for predictive toxicity, and identification of health consequences of PCB metabolites that lack empirical data. Such information will help prioritize such molecules for additional testing, guide future basic laboratory research studies, and help the health/risk assessment community understand the complex nature of chemical mixtures.

Sodium and potassium are essential for human health. They are important ions in the body and are associated with many physiologic and pathophysiologic processes. The chapter summarizes the basic physiologic actions of sodium and potassium on membranes of the neurologic and muscular systems. It provides information regarding the kinetics, i.e., absorption, distribution, and excretion of these ions and their movement between the intracellular and extracellular compartments. It also explains the physiologic systems that can influence proper homeostasis between sodium and potassium. Concentrations of sodium in the blood that exceed or do not reach the normal value range are called hypernatremia or hyponatremia, respectively. Similarly, the clinicians recognize hyperkalemia and hypokalemia. Pathologies associated with these states are described and examples of some of the diseases are presented here.

Many reactions in both chemistry and biology rely on the ability to precisely control and fix the solution concentrations of either protons or hydroxide ions. In this report, we describe the behavior of thermally programmable pH buffer systems based on the copolymerization of varying amounts of acrylic acid (AA) groups into N-isopropylacrylamide polymers. Because the copolymers undergo phase transitions upon heating and cooling, the local environment around the AA groups can be reversibly switched between hydrophobic and hydrophilic states affecting the ionization behavior of the acids. Results show that moderate temperature variations can be used to change the solution pH by two units. However, results also indicate that the nature of the transition and its impact on the pH values are highly dependent on the AA content and the degree of neutralization.

Background: Better methods are needed for recording urethral function for complex urologic problems involving the bladder, urethra, and pelvic floor., Objective: To evaluate a balloon catheter for recording urethral pressure and function using bench-top testing and evaluation in an animal model., Methods: Balloon pressure-recording methods included slightly inflating the balloon with water and placing the pressure transducer on the distal end of the catheter. For bench-top testing, manual procedures and a silastic tube with a restriction were used. In 3 anesthetized dogs, pressure recorded from the skeletal urethral sphincter was induced with electrical stimulation of the sphincter. Anal sphincter pressure was also recorded., Results: Bench-top testing showed good pressure recordings, including a confined peak at the tube restriction. Animal tests showed urethral pressure records with rapid responses when electrical stimulation was applied. Peak pressure at the urethral skeletal sphincter was 55.7 +/- 15 cmH2O, which was significantly higher than the peak pressure recorded 2 cm distally in the proximal urethra (3.3 +/- 2.3 cmH2O). Peak anal pressures were smaller and unchanged for the 2 stimulations., Conclusions: Balloon-pressure recordings showed rapid responses that were adequate for the tests conducted. In the animal model, high-pressure contractions specific to the skeletal urethral sphincter were shown. Balloon-tipped catheters warrant further investigation and may have applications for the evaluation of detrusor-sphincter dyssynergia after spinal cord injury or for stress urinary incontinence.

This feasibility study was conducted to evaluate design features of the novel intraurethral valved catheter, Surinate (Urovalve, Inc; Newark, New Jersey). The device extends from the bladder neck to just beyond the external sphincter and contains a valve that can be activated by an external magnet for bladder emptying. Five patients were recruited from the Edward Hines Jr Department of Veterans Affairs Hospital spinal cord injury population. We conducted cystometry and cystoscopy to evaluate the lower urinary tract. Then, the device was inserted for 24 hours with careful monitoring. The catheter was removed from the first patient because he developed autonomic dysreflexia during implantation. The next four patients used the catheter overnight and tolerated it well: one with independent use and two with increased abdominal pressure. Emptying time was 208 +/- 99 s, residual was 42 +/- 33 mL, and the first-stream flow rate was 1.8 +/- 0.7 mL/s. The safety tether was used in three patients because the extraction device did not work. Results showed effective implantation and stability of the device in the urethra. However, objectives for use and extraction were not met. This feasibility study provided important information that will help guide design improvements for the intraurethral valved catheter.

Urinary retention is a serious urological problem associated with spinal cord injuries (SCIs) and other pelvic disorders. Effective methods of pelvic nerve stimulation were investigated for this problem. Following anesthesia in five dogs, the bladder was surgically exposed. Bladder and anal sphincter pressures were recorded. Testing was first conducted with probe electrodes. Barb electrodes were then implanted with a needle near the pelvic plexus nerves and the bladder wall. We tested different electrode arrangements and stimulating parameters to induce bladder contractions without skeletal muscle stimulation. The pelvic plexus nerves near the bladder were identified, and the barb electrodes were effectively implanted. Stimulation with bipolar and bilateral electrodes induced pressures over 30 cmH(2)O without skeletal muscle activation. Common stimulation parameters were 40 pps, 400 microseconds pulse duration, and 15 to 25 mA stimulating current applied for 3 s. Effective electrode implantation methods were shown. Also identified were electrode arrangements and stimulating parameters that induced strong bladder contractions without skeletal muscle activation. However, voiding studies were not conducted. Further studies with barb electrodes are warranted, and these methods may have applications for bladder stimulation following SCI.

This study examined subjective continence status and use of subsequent alternative therapeutic procedures at long-term follow-up after collagen injection for stress incontinence (SI) in women. Seventy women who underwent collagen injection for SI were identified by retrospective chart review and surveyed by mail questionnaire for subjective continence status, daily pad usage pre- and post-treatment, and use of anticholinergics and alternative procedures. Questionnaire responders' versus non-responders' mean age, follow-up, and pad usage were compared. Thirty-three women (47%) responded on questionnaires. Of the 33, 50% were dry or subjectively improved at long-term follow-up and 91% had not chosen an alternative invasive treatment after collagen injection. Chart review showed responders were not significantly different from non-responders in mean age (65.9 vs. 69.2 years), pad usage (0.6 vs. 0.8 pads/day), or follow-up (4.5 vs. 4.3 years). Collagen injection, a minimally invasive treatment for SI, appears to benefit a significant number of women.

Severe urinary retention is not a common condition, but may occur following some pelvic surgeries or other medical conditions. Electrical stimulation of the bladder has been examined as a means of managing this difficult problem. We conducted preliminary investigations in cats to prove the hypothesis that pelvic-plexus (bladder-neck) stimulation would produce greater micturition response with reduced side effects, such as animal movement or discomfort, than bladder-wall stimulation with electrodes implanted higher on the bladder wall. We used model microstimulators that mimic the look and function of commercial microstimulators, but that we constructed. We instrumented four female cats during a survival surgery. Animals recovered well and studies were conducted over a 1-month period in the conscious animal and under anesthesia. We performed a variety of studies with different stimulation parameters and electrode locations to evaluate our hypothesis. In the active animal, we supplied only low currents, but two animals responded to stimulation with bladder contractions and voiding. Following anesthesia, higher stimulating currents resulted in greater bladder contractions during stimulation in two of the three animals. In two cases, pelvic-plexus (bladder-neck) stimulation induced greater micturition responses than direct bladder-wall stimulation. In conclusion, we learned from these preliminary observations that stimulation at the pelvic plexus (bladder neck) may induce a better micturition response than stimulation higher on the bladder-wall. Newly available commercial microstimulators should be further studied for the treatment of urinary retention.

The Agency for Toxic Substances and Disease Registry (ATSDR) is currently evaluating the potential public health impacts associated with the processing of asbestos-contaminated vermiculite at various facilities around the country. Vermiculite ore contaminated with significant levels of asbestos was mined and milled in Libby, Montana, from the early 1920s until 1990. The majority of the Libby ore was then shipped to processing facilities for exfoliation. ATSDR initiated the National Asbestos Exposure Review (NAER) to identify and evaluate exposure pathways associated with these processing facilities. This manuscript details ATSDR's phased approach in addressing exposure potential around these sites. As this is an ongoing project, only the results from a selected set of completed site analyses are presented. Historical occupational exposures are the most significant exposure pathway for the site evaluations completed to date. Former workers also probably brought asbestos fibers home on their clothing, shoes, and hair, and their household contacts may have been exposed. Currently, most site-related worker and community exposure pathways have been eliminated. One community exposure pathway of indeterminate significance is the current exposure of individuals through direct contact with waste rock brought home for personal use as fill material, driveway surfacing, or soil amendment. Trace levels of asbestos are present in soil at many of the sites and buried waste rock has been discovered at a few sites; therefore, future worker and community exposure associated with disturbing on-site soil during construction or redevelopment at these sites is also a potential exposure pathway.

Background: Microstimulators are new devices that should be considered for management of lower urinary tract problems following spinal cord injury (SCI) such as urinary retention. These devices are small (less than 25 mm by 5 mm) with the electrodes located on the ends of the stimulator. However, it is not known whether the small electrodes on these devices would be effective in stimulating the plexus of nerves that innervate the bladder. The aim of the present study was to provide preliminary observations with model microstimulators (M-Micro) for inducing bladder contractions in an SCI animal model. Bladder wall and pelvic plexus stimulation sites were compared. Additional investigations evaluated parameters such as stimulation polarity, frequency, and period as well as bladder filling volume., Methods: In an initial survival surgery, bilateral M-Micros were implanted on the bladder wall and the pelvic plexus along the urethra in 3 female cats. A second survival surgery was conducted 3 to 5 weeks later to produce a T1 0 SCI. Studies are reported following the second survival surgery. These studies included the effects of stimulation and bladder filling., Results: The postmortem location of the implanted pelvic plexus M-Micro was previously described as near the bladder neck. Therefore, the pelvic plexus location is described in this report as "pelvic plexus (bladder neck)" stimulation. The observations showed effective stimulation with pelvic plexus (bladder neck) stimulation and voiding in some cases. Stimulation was limited by side effects of increased abdominal pressure and leg movement. Other factors also affected the response to stimulation, including the initial bladder volume and stimulating parameters. Fluoroscopy showed that when stimulation did not induce voiding the striated urethral sphincter was closed., Conclusions: This case series of 3 SCI animals showed that the small electrodes on the M-Micro could be used to stimulate the bladder with contractions and voiding in some cases. The pelvic plexus (bladder neck) location for the M-Micro may be a better location than higher on the bladder wall. Limiting side effects of stimulation included leg movement and increased abdominal pressure. Additional important factors included the stimulation parameters, initial bladder volume, and the function of the skeletal urethral sphincter.

Background: Microstimulators are a new type of neuroprosthetic device that should be considered for applications such as micturition control after spinal cord injury (SCI). These devices are small (less than 25 mm by 5 mm) and the electrodes are located on the ends of the stimulator. The aim of the current study was to develop methods for chronic implantation of model microstimulators (M-Micro) on the bladder wall and pelvic plexus of female cats. A postmortem evaluation of the effects of 3 months of implantation is reported., Methods: Techniques to produce the M-Micro are described. Four of these devices were implanted in 4 female cats and maintained after the initial instrumentation surgery and a second survival surgery for SCI (at T10). Using a single suture tied around the M-Micro, these devices were secured to the bladder wall or the fat pads adjacent to the pelvic plexus. Additional instrumentation was implanted, including 2 catheters in the bladder, 1 abdominal balloon, and electromyography electrodes in the urethral and anal sphincters. Postmortem observations of the location of the M-Micro on the bladder wall were conducted after fixation., Results: The animals' conditions were good. One animal was sacrificed early because of a skin infection. A single suture was sufficient to anchor the M-Micro. However, during the surgical implantation the pelvic plexus M-Micro ended up close to the bladder neck. Extensive fibrous connective tissue formed around the M-Micro and implanted catheters on the bladder wall. This appeared to result, in part, from multiple devices implanted on or near the bladder wall., Conclusions: These pilot studies showed that the M-Micro could be easily constructed and secured to the bladder wall or fat pads close to the pelvic plexus. There was a concern that the pelvic plexus location for the M-Micro ended near the bladder neck during the surgical implantation; however, these devices did not appear to migrate over this short, 3-month implantation period. The extensive connective tissue responses of the bladder wall to the tubes, wires, and M-Micro was a major concern. The M-Micro appears to be a good device to assess the potential of commercial microstimulators for use in micturition control.

Background: Surgery has previously been the mainstay of treatment for lymphatic malformations but has attendant problems of marked scarring, high chance of recurrence and potential nerve damage. Alternative management for these lesions involves the intralesional injection of OK-432. The present paper reviews OK-432 use in lymphatic malformations in children., Methods: A retrospective chart review was carried out of children undergoing intralesional OK-432 therapy from the Departments of Paediatric Surgery, Paediatric Otolaryngology and Plastic Surgery at Starship Children's Hospital, Auckland., Results: Over the past 4 years, seven children under the age of 5 years underwent OK-432 therapy as day-case procedures requiring between one and seven procedures each. Four children had lesions involving the axilla/chest wall, two involved extra-mylohyoid tissues in the neck and one child had lymphatic malformation involving tongue, floor of mouth and an extra-mylohyoid component. Spontaneous haemorrhage into a cystic space may be the cause of the observed partial resolution of the lymphangiomas in two. A predictor of a successful outcome was the ability to aspirate fluid prior to injection. Ultrasound guidance was useful to localize the lesions for aspiration and injection. Macrocystic lesions respond well to OK-432 therapy but the response of microcystic or cavernous lesions to OK-432 is disappointing and surgery remains the definitive treatment for these microcystic lesions., Conclusion: OK-432 appears to be a safe and effective treatment for the macrocystic component of lymphatic malformations.

Background/objectives: High urethral resistance or detrusor-sphincter dyssynergia (DSD) is characterized by obstructed voiding during bladder contractions. DSD is caused by an exaggerated pelvic floor reflex resulting from sensory input from elevated pressure in the bladder that produces reflex constriction of the urethral sphincter. The objective of this study was to determine whether sensory input from the bladder produced synergistic or dyssynergic pelvic floor reflexes following SCI in an animal model., Methods: A pelvic floor reflex that shares the same motor pathway with DSD is the bulbocavernosus (BC) reflex. The BC reflex was elicited with electrical stimulation in 4 male cats with T1 spinal injury, and recorded as an anal sphincter contraction. Recordings were obtained during control and elevated bladder pressures. Increased bladder pressure was induced with either manual pressure (Crede procedure) or spontaneous contractions resulting from bladder filling., Results: During the control period, the BC reflex indicated by the peak anal pressure response was 23 +/- 6 cmH2O. During elevated bladder pressure of 34 +/- 18 cmH2O, the BC response decreased to 10 +/- 3 cmH2O (not significant), showing a synergistic relationship. Anal sphincter tone between BC reflex tests showed a dyssynergic response. All 4 animals showed increased tone during elevated bladder pressures that averaged 9 +/- 5 cmH2O. Because abdominal pressure was not recorded, the significance is not clear. However, there was further support of a dyssynergic relationship based on increases in the anal and urethral electromyography recordings and some pelvic floor spasms during the elevated bladder pressure., Conclusions: Because 2 different pelvic floor activities were observed during increased bladder pressures, this animal model may be described best as a mixed model. This model shows both synergistic and dyssynergic relationships between the bladder and the BC contractions. Although observed changes were not significant, the unique observations of synergistic bladder-sphincter activity shown by the inhibited BC reflex is in marked contrast to the strictly dyssynergic bladder-sphincter relationship seen in SCI patients.

Background/purpose: There are few reports describing the surgical management and outcome of children suffering purpura fulminans secondary to meningococcal sepsis. New Zealand is in the grips of a meningococcal epidemic, and, with the attendant sequalae of the disease process, the authors sought to formally review the children who have required surgical involvement., Methods: A retrospective case review of children with the sequalae of meningococcal disease presenting to the Orthopedic and Plastic Surgical Units in a university teaching hospital was undertaken., Results: There were 117 procedures in 21 children performed over a 12-year period. Surgical management was separated into 2 phases-early and late. The mean delay from admission with acute sepsis to the first surgical procedure (ie, early intervention) was 15.9 days. Debridement and autologous skin grafting was the mainstay of managing the necrotic defects; however, allograft skin proved a useful adjunct as a physiologic dressing. Local flaps were used with deep defects down to bone, but in the extremities amputation to viable tissue was required once gangrene was demarcated. Amputations were carried out in 9 of 21 children. Late interventions were related to relief of contractures or fibula overgrowth causing stump ulceration. Clinical follow-up showed that all children interviewed over 5 years of age (9 children) attend ordinary regular school classes and were physically active within the context of their physical disabilities., Conclusions: The data would suggest that children requiring surgery for purpura fulminans achieve age-appropriate milestones and are primarily limited by their physical disability related to amputations, scarring, and abnormal bone growth., (Copyright 2003, Elsevier Science (USA). All rights reserved.)

Aims: Mathematical models are useful for developing predictive parameters for characterizing the biomechanics of voiding dysfunction. The goal of this project was to test a one-dimensional steady flow model used to predict the minimum cross-sectional urethral area from urodynamic data., Methods: Nine adult female subjects underwent video-urodynamic testing. By using Bernoulli's formula and the Torricelli theorem, the minimum urethral area was predicted from pressure and flow rate at the moment of maximum flow rate during voiding. This prediction was compared with the minimum cross-sectional area of the urethra, which was calculated from minimum urethral diameter as measured from fluoroscopy, assuming a circular cross-section., Results: The maximum flow rate during voiding was 14.4 +/- 3.0 mL/sec. Mean bladder, abdominal, and detrusor pressures simultaneous with maximum flow rate were 63 +/- 7, 29 +/- 6, and 33 +/- 6 cm H(2)O, respectively. Mean minimum cross-sectional area of the urethra from fluoroscopy was 8.0 +/- 2.0 mm(2). Mean minimum cross-sectional area of the urethra predicted by the mathematical model was 5.0 +/- 1.0 mm(2) using bladder pressure and 7.0 +/- 2.0 mm(2) using detrusor pressure. There were no significant differences between the three cross-sectional area measures. However, when area predictions were expressed as percentage of fluoroscopic measurements, the estimate from detrusor pressure (97 +/- 13%) was significantly larger than the estimate from bladder pressure (69 +/- 7%)., Conclusions: A steady flow model is accurate enough on average to describe urine flow in the urethra. However, it may not be sufficiently accurate to aid in diagnosis of individuals.

Aims: We previously have investigated a technique for serial bladder pressure measurements in patients with spinal cord injury (SCI) using intermittent catheterization. In the current study, we compared an FDA-approved digital gauge with the previously studied analog gauge and studied the effects of hydrostatic pressure differences., Methods: Either a digital or an analog pressure gauge was attached to each subject's catheter just before bladder catheterization. Both immediate and stable pressures were recorded. The bladder was then drained until nearly empty and pressure was again recorded (almost empty bladder pressure). Detrusor pressure was estimated as full minus almost empty bladder pressure. Bladder pressures greater than 40 cm H2O were presumed to represent bladder contractions. To investigate the effects of hydrostatic pressure, additional measurements, adjusting the level of the air-urine meniscus, were obtained in three subjects., Results: Recordings were made from nine SCI subjects using both gauges. Estimates of detrusor pressure, with and without bladder contractions, and associated bladder volumes, were not significantly different between digital and analog gauges. In the absence of bladder contractions, detrusor pressure with the meniscus at the end of the catheter (5 +/- 1 cm H2O) was significantly lower than that recorded with no adjustment of the urine meniscus (12 +/- 1 cm H2O)., Conclusions: Standardizing measurement techniques to equalize hydrostatic pressures should facilitate reliable estimates of detrusor pressure. Frequent monitoring of bladder pressure using this technique may assist with the urological care of SCI patients.