Community Practice Experience Research Articles

Community Practice Experiences with a Variety of Immunomodulatory Agents Co-Administered with Pegloticase for the Treatment of Uncontrolled Gout.

ObjectivePatients with uncontrolled/refractory gout have heavy disease burden, but few treatment options. Pegloticase lowers serum urate (SU), but anti-drug antibodies can limit treatment efficacy. Evidence supports immunomodulator-pegloticase co-administration to increase sustained urate-lowering rates, but published cases are limited. This study investigated experience with pegloticase-immunomodulation co-therapy at two community rheumatology practices.MethodsPatients initiating pegloticase with immunomodulation in 2017 or later were included. Patient/treatment characteristics and proportion of responders (≥ 12 pegloticase infusions, SU < 6 mg/dl at infusion-12) were examined. Patients on therapy at data collection with < 12 infusions were excluded from response analyses. eGFR before and after therapy was examined.ResultsThirty-four patients (79% male, 62.4 ± 16.3 years) with uncontrolled gout (SU = 9.1 ± 2.0 mg/dl, 91% tophaceous) were included. Most-reported comorbidities were hypertension (76%), obesity (71%), osteoarthritis (68%), and CKD (47%). Pre-therapy eGFR was 65.4 ± 25.2 ml/min/1.73 m2 (41% eGFR < 60 ml/min/1.73 m2). All patients initiated immunomodulation before (5.3 ± 3.0 weeks, n = 32) or at (n = 2) first pegloticase infusion. Subcutaneous methotrexate (15.4 ± 4.9 mg/week, n = 20), oral methotrexate (15.3 ± 3.6 mg/week, n = 9), mycophenolate mofetil (1000 mg/day, n = 3), and azathioprine (100 mg/day, n = 2) were administered. Patients received 14.6 ± 7.1 infusions over 28.5 ± 14.9 weeks. Overall response rate was 89%, ranging among immunomodulators (subcutaneous methotrexate: 93%, oral methotrexate: 89%, mycophenolate mofetil: 100%, azathioprine: 50%). On average, eGFR increased during therapy (+ 10.3 ± 16.9 ml/min/1.73 m2), with CKD stability/improvement in 85%. Nineteen patients (56%) experienced gout flares. No infusion reactions or infections were noted. No new safety concerns were identified.ConclusionsThese real-world findings provide further support for increased pegloticase response rates when co-treatment with immunomodulating therapy is used.

Integration of a Virtual Dispensing Simulator "MyDispense" in an Experiential Education Program to Prepare Students for Community Introductory Pharmacy Practice Experience.

Background: Technology is increasingly used to enhance pharmacy education. We sought to evaluate student learning and preparedness for community introductory pharmacy practice experiences (IPPEs) after implementation of “MyDispense” into experiential education. Methods: Both first-year pharmacy students and assigned community IPPE preceptors were eligible. Students were stratified based on previous community pharmacy experience (< or ≥ 50 h), then randomized to complete MyDispense exercises before IPPE (group A) or after 24–32 h of IPPE (group B). We evaluated preceptors’ assessment of student readiness using a 6-item Likert scale survey and students’ readiness and opinion of MyDispense using an anonymous 9-item survey. Descriptive statistics were used to characterize data. The Mann–Whitney U test was used to compare groups and a p-value < 0.05 was considered statistically significant. Results: Of 177 eligible students, 155 were randomized and 56 completed study. Group A included 32 students; 56.3% had prior community practice experience. Group B included 24 students; 50% had prior community practice experience. Forty-eight preceptors were enrolled. Students who completed exercises before rotation received higher preceptor scores for patient counseling of self-care and of medications (p < 0.05 for both). Students self-assessed their counseling skills lower than all other skills; 30.4% and 42.9% of students felt mostly or always prepared to counsel for self-care and medications, respectively. Students found MyDispense straightforward, realistic, and appreciated the ability to practice in a safe, electronic, community pharmacy, patient-care environment. Conclusion: Simulation-based software, such as MyDispense, can enhance learner understanding of the prescription fill and counseling process in a community pharmacy practice setting.

Integrating comprehensive genomic profiling into the clinical management of prostate cancer patients: A single institution community practice experience.

281 Background: Prostate cancer is a leading cause of cancer-related mortality with a 5-year survival rate of 69%. In this study, we examine the role of integrating CGP, including tissue and liquid biopsy testing, into the clinical management of prostate cancer patients. Methods: We analyzed 140 cases of advanced prostate carcinoma with tissue and ctDNA based Comprehensive Genomic Profiling (CGP). CGP analysis revealed genomic alterations (GAs), TMB and MSI status. Germline testing, using multiple commercially assays was also obtained. Results: The median age of patients tested by tissue-based and liquid-based CGP was 65 years (46 to 85 yrs) and 69 years (51 to &gt; 89 years), respectively. CGP analysis of tissue samples revealed the most commonly altered genes to be TP53 (34.6%), TMPRSS2- ERG (25.9%), PTEN (23.5%), NBN (14.8%), MYC (13.6%), BRCA2 (14.3%) and CDKN2A (13.3%). TMB analysis determined in 77 tissue samples showed a median (mean) value of 2.61 (5.00) mutations/Mb. 3.9% cases (3/77) were found to be hypermutated. MSI status was determined in 74 cases of which 2.7% (2/74) were found to be MSI-High. Of the tissue-based samples tested, 30.9% (25/81) were derived from metastatic sites. Analysis of commonly altered genes between primary vs metastatic tissue samples revealed TP53 mutations were significantly enriched in metastatic tumors. CGP analysis of the 59 liquid biopsy samples revealed the most commonly altered genes to be TP53 (37.3%), NF1 (10.2%), ATM (10.2%), CHEK2 (8.5%) and GNAS (8.5%). Germline testing was performed as described above on a clinically indicated subset of patients, which revealed alterations in BRCA, ATM, CHEK2, BRIP1 and TP53, among others. We are evaluating additional patient samples as part of the data set, which will be added to the final abstract presentation with a cutoff date of 12-31-2019. Conclusions: Genomic testing for high risk and advanced prostate cancer patients per the NCCN recommendations, with somatic testing, using tissue and liquid biopsy testing, as well as germline testing in selected cases, identifies DNA alterations which have potential clinical utility for clinical trial enrollment.

Knowledge, Awareness, and Perception of Community Pharmacists to Zika Virus Infection in Klang Valley, Malaysia.

Background:Zika fever is a mosquito-borne disease with global health concern. It has been underreported or misdiagnosed due to its unspecific clinical manifestations, including mild-influenza like and subclinical symptoms. However, its associated serious complications which include fetal microcephaly and Guillain-Barré syndrome remained a challenge to the public health sectors. This research aimed to evaluate the knowledge, awareness, and perception toward Zika virus infection among community pharmacists in the Klang Valley of Malaysia and to determine the association between the knowledge of Zika virus infectious disease and years of community practice experience among community pharmacists in this region.Methods:This survey research was conducted from August to December 2018 through a pre-tested, self-administration, and cross-sectional random convenient sampling at various districts in the Klang Valley. A total of 275 registered community pharmacists were involved in this study by completing a pilot-tested questionnaire. Descriptive analysis, Mann-Whitney U test, and Kruskal-Wallis H test were used to analyze the data.Results:The knowledge toward Zika virus infection of respondents was classified into “poor” (5.1%), “basic” (70.9%), and “broad” (24.0%). Most of the participants (n = 195, 70.9%) presented with basic knowledge toward Zika virus infection. A total of 268 (97.5%) participants presented with high awareness toward Zika virus infection. The mean score of respondents’ knowledge and awareness was 15.88 ± 3.61 (maximum score = 28) and 13.96 ± 1.60 (maximum score = 16), respectively. There was a statistically significant difference between the years of practice of community pharmacists and the level of knowledge toward Zika virus infection.Conclusions:In conclusion, our respondents demonstrated a basic level of knowledge and high awareness toward Zika virus infection. Also, we highlighted some possible pitfalls in the knowledge of Zika virus infection, including the virus transmission, symptoms, diagnosis, treatment, prevention, and complications of the disease.

Pharmaceutical care practices among registered community pharmacists in a state in southeast Nigeria: a frontier dynamics assessment

Anambra State with over 5million people has prevalence of chronic diseases and drug related problems in a report from a survey by the Department of Epidemiology and Disease Control, of the State Ministry of Health in 1015. It underscored the pharmaceutical care practices assessment among community pharmacists since they are usually first point of call by patients. This study assessed pharmaceutical care practices among community pharmacists in a State in southeast Nigeria. We assessed pharmaceutical care practice among registered community pharmacists. The study was a cross sectional survey of pharmaceutical care activities of community pharmacists resident and practicing in the state. Data were analyzed for descriptive and inferential statistics. A P-value of &lt;0.05 was considered statistically significant. The study determined the documentation practices of community pharmacist and know if they carryout referral, consultation, counseling and instrumental services. It identified the conditions or cases commonly encountered and managed their knowledge of pharmaceutical care, the influence of gender, age on the respondents’, additional qualifications and the influence of years of experience on the respondents’ score on the domains. Of the 87 community pharmacists who participated in the study 53.0(60.9%) were females. The mean years of community practice experience was10.71±6.9years. Only 45.89±20.57 community pharmacists’ document patient care and pharmacy practice activities, 45.82 document patients’ medication, and history taking, while 46.03±20.90 document pharmaceutical care process. The diseases commonly encountered were malaria 459.9±366.4, typhoid fever 437.0±75.20, hypertension 300.37±281, and diabetes mellitus 298.21additional qualification had significant impact on respondents awareness of pharmaceutical care, p=0.05. Respondents’ age has no significant impact on the scores on pharmaceutical care domains. The result suggests that majority of the community pharmacists do not document their pharmaceutical care activities, which is essential in audit trail and a core component of pharmaceutical care. Malaria, typhoid fever, hypertension, and diabetes mellitus accounted for the highest disease burden in the area. They are aware of pharmaceutical care but lacked good knowledge of the technical aspects of the concept. The practices were not affected by respondents’ gender, age, number of years of experience and additional qualifications.

Evaluating knowledge, skills, and practice change after an accredited evidence-based medicine course for community pharmacy preceptors

IntroductionIncorporating evidence-based medicine skills into practice is vital for pharmacists to promote rational medication use while making optimal patient care decisions. The objective of this study was to evaluate the impact of an evidence-based medicine course on the knowledge and precepting skills of community pharmacy preceptors. MethodsThis was a longitudinal, multiphase, interventional study, which involved the development of an evidence-based medicine course based on results of an educational assessment. The course was delivered over five sessions and included didactic and active learning strategies. The impact was measured by the preceptor's ability to apply knowledge gained from the course while providing student feedback during a community practice experience using a journal club context. ResultsTen preceptors completed the course with 50% and 70% passing the drug information and critical appraisal assessments, respectively. When measuring course impact, 44% of preceptors were able to provide feedback at a proficient level while 56% needed further development. Preceptors' confidence improved across pre-course, post-course, and after the observation phase in interpreting study results (p = 0.016), teaching the student evidence-based medicine skills (p = 0.008), and providing feedback to the student regarding journal clubs (p = 0.010). Students rated high improvement in the preceptor's ability to provide feedback related to critical appraisal skills. ConclusionA course-based approach to increase preceptor's knowledge of critical appraisal and drug information skills may be effective.

P88 - Community Practice Experience with Subsequent Vertebral Compression Fractures during the Year after Vertebral Augmentation Using an Expandable Implant

P88 - Community Practice Experience with Subsequent Vertebral Compression Fractures during the Year after Vertebral Augmentation Using an Expandable Implant

Influence of simulated and actual community vaccination clinics on student empowerment and self-efficacy for public health nursing competencies.

To examine students' structural empowerment during simulated learning and actual nursing practice, and assess students' self-efficacy for public health nursing competencies (PHNC) after involvement in a mass influenza vaccination clinic as a community practice experience. A nonexperimental survey design was used with a sample of year three baccalaureate nursing students. Students completed a demographic form after the simulated clinic experience, they were assessed for perceptions of empowerment after being involved in the simulated and actual clinic settings, and self-efficacy was assessed after the actual clinic experience. Students perceived themselves as structurally empowered after completing the simulated and actual community vaccination clinics. Students reported a high level of self-efficacy for PHNC after their actual community vaccination clinic involvement. There was a significant correlation between empowerment and self-efficacy, which suggests that when students have access to empowering structures, they feel more confident to enact PHNC that align with practice in the clinics. This study suggests that nursing students acquired the necessary knowledge and skills for safe vaccination administration through the combination of simulated practice and participating in an actual public health vaccination clinic.

Pharmacy Students' Application of Knowledge From the Classroom to Introductory Pharmacy Practice Experiences

To determine whether and how pharmacy students used knowledge learned in the classroom during their introductory pharmacy practice experiences (IPPEs) in community and hospital settings. To reinforce course concepts and make connections between coursework and practice, students documented examples of how knowledge from first-year courses was used in IPPEs. Data submitted were categorized by classroom-based pharmacy course, including the frequency with which each course was cited. For community practice experiences, most student examples of knowledge application related to the self-care therapeutics course, pharmacy practice laboratory course, and dose form/compounding laboratory courses. Hospital IPPE examples were most frequently based on the pharmaceutical calculations course, physiology/pathophysiology course, medicinal chemistry course, and pharmacy practice laboratory course. All prior classroom-based pharmacy courses were cited by students as being useful during IPPEs, although some were more frequently cited than others. This activity provided useful programmatic assessment data.

Preceptors’ Self-Assessment of Their Ability to Perform the Learning Objectives of an Experiential Program

To evaluate preceptors' perception of their ability to perform the Structured Practical Experiences in Pharmacy (SPEP) learning objectives through a self-assessment activity. A self-assessment instrument consisting of 28 learning objectives associated with clinic, community, and hospital pharmacy practice experiences were developed. Preceptors rated their performance ability for each of the learning objectives using a 3-point Likert scale. Of the 116 preceptors, 89 (77%) completed the self-assessment survey instrument. The overall preceptor responses to the items on performance of the 28 SPEP learning objectives ranged from good to excellent. Years of experience, practice experience setting, and involvement as a SPEP or SPEP and PharmD preceptor had no influence on their self-reported capabilities. Most preceptors rated their ability to perform the learning objectives for the structured practical experiences in pharmacy as high. Competency areas requiring further preceptor development were identified.

The Development of a Patient Care Center in a Supermarket Chain Pharmacy

Purpose: The objective of this manuscript is to describe the development and implementation of a patient care center in a grocery store supermarket chain pharmacy. Methods: A clinical pharmacist and shared faculty member between Wayne State University and Kroger Pharmacy developed a patient care center and rotation site for P4 PharmD advanced pharmacy practice experiences (APPEs). The site was developed to provide advanced pharmacy services to patients and as a practice site for students to learn how to deliver care. Preliminary outcomes observed include the number and types of patients that utilized the patient care center and the educational experiences provided for student pharmacists practicing in this setting. Results: Since implementation, 160 patients visited the patient care center. The pharmacists involved in the clinic performed 30 biometric screenings and 47 comprehensive medication reviews. Conclusions: Establishing a patient care center in a supermarket pharmacy provides important care for patients and valuable learning experiences for student pharmacists. The collaborative efforts of both Wayne State University and Kroger Pharmacy demonstrate commitment to providing clinical care to patients and strong clinical community practice experiences for students. Future goals include creating more clinical services in the community and practice experiences for students.

Dose Intensity in Early-Stage Breast Cancer: A Community Practice Experience

Although nodal status, grade, size, and receptor status play roles in determining breast cancer prognosis, there is increasing evidence that maintaining dose intensity of adjuvant chemotherapy increases disease-free survival rate.

Neighborhood geographical factors and the presence of advanced community pharmacy practice sites in Greater Chicago.

To determine the availability of experiential learning opportunities in culturally diverse areas and to identify opportunities and barriers to attract and sustain sites for the University of Illinois at Chicago College of Pharmacy. Utilizing variables of census tract income, racial/ethnicity composition and crime index, data analyses included descriptive statistics and multivariate logistic regression. Faculty members involved in experiential education were interviewed to identify other factors influencing site placement and selection for community-based advanced pharmacy practice experiences (APPEs). Median family income and Asian population were significantly higher and black population was significantly lower in census tracts with community APPE sites than in census tracts without APPE sites (p < 0.05). No significant differences were found in the population variables of white and Latino populations and crime index. The Asian population variable was the only significant predictor of an APPE site (p = 0.0148) when controlling for other variables. Distance from the College, pharmacy staffing issues, goodwill, influence of district and corporate managers, and strategic initiatives were critical considerations in site establishment and overall sustainability. Advanced community pharmacy practice sites were fairly well distributed across metropolitan Chicago, indicating that exposure to diverse populations during the advanced community practice experiences parallels with strategic College objectives of expanding and diversifying experiential sites to enhance pharmacy students' abilities to meet emerging patient care challenges and opportunities.

Enhancing an advanced community pharmacy practice experience through use of a student pharmacist manual

ObjectiveTo present a model to preceptors in a community setting for a structured and quality advanced community pharmacy practice experience (ACPPE). DesignExperiential report. SettingChain pharmacy. ParticipantsNot applicable. InterventionDevelopment and use of a student pharmacist manual in a structured, organized ACPPE. Main outcome measuresNot applicable. ResultsThe manual, in addition to introductory materials and competencies for the ACCPE, contains five modules that focus on dispensing, management and law, nonprescription medications, consultation, and patient care. The student pharmacist is also provided with a schedule and calendar showing how goals and objectives for the rotation are distributed throughout the modules and activities of the ACCPE. Activities and assignments during the ACCPE include topic discussions, physical assessment skills review, “living with diabetes for the weekend,” developing patient handouts, implementing a new pharmacy patient care service, patient consultations, and presentations. Evaluations conducted during the ACCPE help student pharmacists monitor their progress and identify strengths and weaknesses. ConclusionEfforts to enhance a community practice experience can be rewarding and beneficial to both the student pharmacists and the pharmacy. A structured ACPPE gives student pharmacists an opportunity to develop skills to improve patient care in the community.

Community experience with bortezomib in patients with multiple myeloma

Community practice experience allows a nonselective care of patient using information derived from a more controlled clinical trial environment. We present our community experience with multiple myeloma patients with advanced age, long disease duration since diagnosis, advanced stage, multiple prior therapies including stem cell transplantation, co-morbidities, and other poor prognostic features, such as low albumin, high B-2 microglobulin, renal failure, and the presence of poor risk chromosomal abnormalities. Our response rates are comparable to those from clinical trials. Bortezomib is well tolerated in this population of multiple myeloma patients with the exception of infection adverse events that are generally mild grade 1-2.

Community practice experience with gefitinib (ZD1839) as treatment for patients with advanced non-small-cell lung cancer (NSCLC) within an expanded access clinical program

7367 Background: Preclinical and clinical studies including IDEAL 1 and 2 showed that oral gefitinib (Iressa, ZD1839) is an effective treatment for advanced NSCLC. Because reported studies reflect referral oncology experience, we reviewed toxicity and outcome data on 100 patients entered into an expanded access clinical program within a community oncology program. Methods: Patients with histologically confirmed advanced NSCLC (Stages IIIB and IV) were maintained on 250 mg of gefitinib daily until they developed worsening performance status (PS), gefitinib related intolerance/ toxicity, disease progression or death. PS and drug toxicity were monitored at 4 weeks and then at 12-week intervals. Informed consent was obtained from all patients. Results: During September 2000 to April 2003, 100 patients were enrolled. Pretreatment characteristics included a higher percentage of males (54M, 46F) and older median age (68) than IDEAL 2. The PS of the patient population (ECOG 0/1/2: 8/44/48) was worse compared with IDEAL 2 (19/68/13). The disease control rate was lower (28%> 4 months) compared with IDEAL 2 (42%). Better PS was associated with longer average time to progression (155 days/110/69). Patients with adenocarcinoma had a significantly longer time to progression (156 days) when compared with other histologies (Squam: 94 days, Large-cell 92 days, Bronchoalv: 86 days). Those who developed a rash while on treatment also had a significantly longer time to progression (162 days) than those without (100 days). Within the group of patients with a rash, those with adenocarcinoma had a longer time to progression (196 days) when compared to the other histologies (Squam: 105 days, Bronchoalv: 96 days). Conclusions: Gefitinib use in the community was less efficacious than in the IDEAL 2 trial. Clinical predictors of response to gefitinib included better PS, adenocarcinoma histology, and development of rash while on treatment. No significant financial relationships to disclose.

Community practice experience with gefitinib (ZD1839) as treatment for patients with advanced non-small-cell lung cancer (NSCLC) within an expanded access clinical program

7367 Background: Preclinical and clinical studies including IDEAL 1 and 2 showed that oral gefitinib (Iressa, ZD1839) is an effective treatment for advanced NSCLC. Because reported studies reflect referral oncology experience, we reviewed toxicity and outcome data on 100 patients entered into an expanded access clinical program within a community oncology program. Methods: Patients with histologically confirmed advanced NSCLC (Stages IIIB and IV) were maintained on 250 mg of gefitinib daily until they developed worsening performance status (PS), gefitinib related intolerance/ toxicity, disease progression or death. PS and drug toxicity were monitored at 4 weeks and then at 12-week intervals. Informed consent was obtained from all patients. Results: During September 2000 to April 2003, 100 patients were enrolled. Pretreatment characteristics included a higher percentage of males (54M, 46F) and older median age (68) than IDEAL 2. The PS of the patient population (ECOG 0/1/2: 8/44/48) was worse compared with IDEAL 2 (19/68/13). The disease control rate was lower (28%> 4 months) compared with IDEAL 2 (42%). Better PS was associated with longer average time to progression (155 days/110/69). Patients with adenocarcinoma had a significantly longer time to progression (156 days) when compared with other histologies (Squam: 94 days, Large-cell 92 days, Bronchoalv: 86 days). Those who developed a rash while on treatment also had a significantly longer time to progression (162 days) than those without (100 days). Within the group of patients with a rash, those with adenocarcinoma had a longer time to progression (196 days) when compared to the other histologies (Squam: 105 days, Bronchoalv: 96 days). Conclusions: Gefitinib use in the community was less efficacious than in the IDEAL 2 trial. Clinical predictors of response to gefitinib included better PS, adenocarcinoma histology, and development of rash while on treatment. No significant financial relationships to disclose.

Treatment of Crohn's disease with infliximab—An initial community practice experience

Treatment of Crohn's disease with infliximab—An initial community practice experience

CLINICAL EXERCISE TESTING: A Review of Personal and Community Practice Experience

Protocols for clinical exercise stress testing aid functional evaluation of cardiac impairment of ambulatory persons. Normal standards, criteria for functional impairment and exercise-enhanced prediction of risk of future cardiac events provide guidelines for clinical management. This review highlights development and evolution of relevant personal and community practice studies over decades that contributed to understanding and application of exercise testing for functional evaluation and enhanced risk prediction.

How Best to Train Physician-Managers

To the Editor.— In the April 3, 1987, issue, Dr Henry 1 makes an interesting point concerning the MD-MBA dual degree. I would like to add to his discussion my belief that physicians who become physician-executives should be required to have a minimum of five years of community practice experience. My reason for this belief is that we currently have many physicians in administrative and regulatory capacities who lack such experience. Some of these physicians have gone directly out of medical school or residency into an administrative or regulatory post. A few of these physicians have had some academic experience before assuming their administrative or regulatory role. The problem with these physicians is that they do not have an intimate understanding of the problems faced in community practice. Since community practice far outweighs academic practice in terms of the total number of patients served and since community practice presents many