BCPS 2013: Vaccines

Vaccines:  the memorization of when and what and when not to if the patient has certain conditions.  Imagine questions that are simple but complicated.  For example, perhaps an age is given and you need to know what vaccinations were due by that age or if the child had never had vaccines what could be given as catch-up?  It is really not complicated and again if you are a parent this may be an easier topic if you are of the pro-vax crowd (as I am). Below see the schedule from the CDC that is also approved by the American Pediatric Association along with the recommended schedule for catching up on vaccines if missed.

Special Population Considerations

1. Preterm infants

• Immunize on the basis of chronologic age.
• Do not reduce vaccine doses.
• If birth weight is less than 2 kg, delay HepB vaccine because of reduced immune response until the patient is 30 days old or at hospital discharge if it occurs before 30 days of age (unless the mother is positive for HepB surface antigen).

2. Children who are immunocompromised

• No live vaccines
• Inactivated vaccines and immune globulins are appropriate
• Household contacts should not receive oral polio vaccine
• MMR, influenza, varicella, and rotavirus vaccines are recommended

3. Patients receiving corticosteroids

a. Live vaccines may be administered to patients receiving the following:

• Topical corticosteroids
• Physiologic maintenance doses
• Low or moderate doses (less than 2 mg/kg/day of prednisone equivalent)

b. Live vaccines may be given immediately after discontinuation of high doses (2 mg/kg/day or more      of prednisone equivalent) of systemic steroids given for less than 14 days.

c. Live vaccines should be delayed at least 1 month after discontinuing high doses (2 mg/kg/day or more      of prednisone equivalent) of systemic steroids given for more than 14 days.

4.  HIV Positive Patients

a. MMR should be administered unless patient is severely immunocompromised. b. Varicella should be considered for asymptomatic or mildly symptomatic patients. c. Inactivated vaccines should be administered routinely.

US News 100 Best Jobs of 2013 | Pharmacist is #3

I am a little baffled at Pharmacist being listed as #3 on this year's US News 100 Best Jobs because it seems to me that many of the pharmacists I read about on the internet are not very happy.  Personally pharmacy has been good to me.  I definitely would rather be a pharmacist than a dentist or an RN. #1 - Dentist Overall Score: 8.4 | Median Salary $142,740 Ever heard the phrase "Your face is your fortune"? For dentists, our smile is their fortune. They earn their living diagnosing and treating teeth and gums, performing oral surgery, and counseling and educating us on maintaining proper oral health. The profession should grow 21.1 percent by 2020.

#2 - Registered Nurse Overall Score: 8.2 | Median Salary $65,690 The nursing profession will almost always have great hiring opportunity because of its expanse (from pediatric care to geriatric care, and everything in between). And as a substantial chunk of our population ages, the necessity for qualified RNs intensifies.

#3 - Pharmacist Overall Score: 8.2 | Median Salary $113,390 With excellent job prospects and a solid average salary, the pharmacist profession nabs the No. 3 spot on our list. Possessors of a Pharm.D can anticipate nearly 70,000 available jobs this decade—the brunt in physician offices, outpatient care centers, and nursing homes.

#4 - Computer Systems Analyst Overall Score: 8.2 | Median Salary $78,770 Think of a computer systems analyst as a tech project manager. He or she is often a liaison between the IT department and a client, and has influence over both the budgetary and technical considerations of a project.

#5 - Physician Overall Score: 8.2 | Median Salary $183,170 At the top of the medical food chain, physicians diagnose and treat patients, plus they instruct on proper diet, hygiene, and disease prevention. And like other jobs in the healthcare industry, physicians will see abundant job growth to 2020.

And because I love this link mostly because I am included on the page, I will repost.  You will notice though who #1 is:

The Angry Pharmacist: For opinionated posts about drugs, patients, and pharmacy in general, read through this blog and see how this blogger earned his name.

He's angry.  I bet he wouldn't say his procession should be listed #3.

Read more about the top pharmacy blogs out there.

BCPS 2013: Pediatrics Otitis Media

Such a fun topic!  Who loves it when the kid says his/her ear hurts?  I cringe just thinking about this one: Otitis Media:  The Bane of all Daycare and all School-aged Youngsters

Common Pathogens

• Viral
• S. pneumoniae
• Nontypeable H. influenzae
• Moraxella catarrhalis

Treatment

• Watch and wait if > 2 yo and pain/fever less than 48-72 hours
• Bulging tympanic membrane/perforation = antibiotics
• Always antibiotics if < 6 months old 4. Middle ear fluid does not indicate repeated treatment unless persists > 3 months
• Corticosteroids, antihistamines, and decongestants are not recommended

Antibiotic regimens a. Amoxicillin (high dose: 80–90 mg/kg/day): Recommended by AAP as the first-line therapy for acute otitis media b. Amoxicillin/clavulanate c. Cefuroxime d. Other antibiotic options (e.g., cefdinir, cefpodoxime) may be effective. e. Duration i. The most appropriate duration is unclear. ii. In general, 7–10 days, but a shorter course (5 days) has been used in children older than 2 years iii. For confirmed cases of acute otitis media not responding to the initial antimicrobial regimen within 48–72 hours, a change in antibiotic regimen is warranted. Failure of the the above warrants ceftriaxone IM for 3 days or tubes i. Intramuscular ceftriaxone may also be considered if adherence is a concern. ii. Tympanostomy with tube placement may be most beneficial for children with persistent otitis media with effusions and significant hearing loss (e.g., greater than 25-dB hearing loss in both ears for more than 12 weeks).

Prophylaxis 1. Reserved for patients with recurrent acute otitis media 2. Reduces occurrence by about one episode per year 3. The risk of promoting bacterial resistance may outweigh the slight benefit

BCPS 2013: Pediatrics

I feel I have a bit of insight into the test and can attest to what is needed to know in each section.  Keep in mind the guidelines could change between 2012 and 2013 along with the test questions, but for the most part I found the test to be incredibly fair though stressing areas more than others that I would have not expected. I want you to pass!  First attempt!

So what do you need to do to pass?  Start now.  I especially am talking to those with families and/or children and very little time to spare for sitting down and studying the traditional way.  Again, I did fail this past year, so I will disclose that immediately, but I do believe I have insight into the test and very much plan to pass it this fall.  It's a goal at this point for my own personal development.

So, ahead I will have some material presented that does come from the ACCP study material though reworded and simplified in more study form and perhaps some hints as to what was important on the test in each particular section.  I am hoping to not get in any sort of trouble by doing this as far as with the BPS, so if this is not appropriate, would someone from there contact me?  I do not plan on giving test questions per se' and I couldn't if I tried as there were far too many to memorize.

After two children I am convinced parts of my brain were delivered with the children as it is.

First up!  PEDIATRICS!

This was always the topic that would terrify me prior to having children, but at this point besides missing one of the most common concepts of children and the very small amount of data on the test regarding pediatrics (at least in my opinion), pediatrics just doesn't seem so daunting.

Know the common pathogens of children in sepsis and meningitis.

0–1 month  

• Group B streptococcus
• Escherichia coli
• Listeria monocytogenes
• Viral (e.g., herpes simplex virus)
• Coagulase-negative staphylococcus—nosocomial
• Gram (−) bacteria (e.g., Pseudomonas spp., Enterobacter spp.)
• nosocomial

1–3 months

• Neonatal pathogens (see above)
• Haemophilus influenzae type B
• Neisseria meningitidis
• Streptococcus pneumoniae

3 months–12 years

• H. influenzae type Ba
• N. meningitidis
• S. pneumoniae

> 12 years

• N. meningitidis
• S. pneumonia

Not to hard to figure out correct?  Keep in mind that H. flu is less and less due to immunizations.  I suppose if you live in an area where vaccination is the devil, you may find more of this organism.

Potential Antibiotic Regimens

Age                                                                         Regimen

0–1 month                                                            Ampicillin + gentamicin OR ampicillin + cefotaxime

1–3 months                                                          Ampicillin + cefotaxime/ceftriaxone

3 months–12 years                                             Ceftriaxone ± vancomycina

> 12 years                                                             Ceftriaxone ± vancomycina

**Addition of vancomycin should be based on the regional incidence of resistant S. pneumoniae.

Regimens for Chemoprophylaxis  (I will have to reformat this later)

Drug                      Neisseria meningitidis                                                                       Haemophilus influenzae

Rifampin            < 1 month old: 5 mg/kg/dose PO every 12 hours × 2 days                       20 mg/kg/dose (maximum 600 mg)

> 1 month old: 10 mg/kg/dose PO every 12 hours × 2 days                   daily x 4 days

Adults: 600 mg PO every 12 hours × 2 days

Ceftriaxone             < 15 years old: 125 mg IM × 1 dose                                                               Not indicated

> 15 years old: 250 mg IM × 1 dose

**Ciprofloxacin and azithromycin are possible alternatives although not routinely recommended.

RSV - Identify the drugs available for preventing and treating respiratory syncytial virus.

Prophylaxis

1. Nonpharmacologic: Avoid crowds during RSV season and conscientiously use good hand-washing practice.
2. RSV IVIG (RespiGam): No longer marketed in the United States (didn't see on the test ;))
3. Palivizumab (Synagis)

• a. Dosing: 15 mg/kg/dose intramuscularly; given monthly during RSV season
• b. Effects on outcomes

i. A 55% reduction in hospitalizations for RSV

ii. Safe in patients with cyanotic congenital heart disease

iii. No reduction in overall mortality

iv. Does not interfere with the response to vaccines

v. Not recommended for the prevention of nosocomial transmission of RSV

Know this:  Supportive care.  Treatment is supportive care only.

American Academy of Pediatrics Palivizumab approval:  (you WILL see this)

i. Premature infants born before 32 weeks’ gestation (i.e., 31 weeks, 6 days or earlier) who are 6 months old or younger at the beginning of RSV season

(a) Infants born at less than 28 weeks’ gestation may benefit up to 12 months of age.

(b) Eligible for a maximum of five doses of palivizumab during RSV season

ii. Infants with chronic lung disease who are 2 years or younger and who required medical management of their chronic lung disease in the previous 6 months – Eligible for a maximum of five doses of palivizumab during RSV season

iii. 32 and 35 weeks’ gestation (i.e., 32 weeks, 0 days through 34 weeks, 6 days) who are 3 months or younger at the beginning of RSV season

(a) With at least one of the following risk factors may benefit: infant attends childcare or sibling younger than 5 yo in same household

(b) Eligible for a maximum of three doses of palivizumab during RSV season

iv. Infants 24 months and younger with hemodynamically significant congenital heart disease

(a) Eligible for a maximum of five doses of palivizumab during RSV season

(b) There is a 58% decrease in palivizumab serum concentration after cardiopulmonary bypass; therefore, a postoperative dose of palivizumab is recommended as soon as the patient is medically stable.

v. Infants 12 months and younger with congenital abnormalities of the airway or neuromuscular disease that compromises the handling of respiratory tract secretions – Eligible for a maximum of five doses of palivizumab during RSV

Tomorrow will continue with otitis media...

When People Fail

I am personally struggling with two pieces of information today.  The first is that Lance Armstrong has come clean with Oprah about his doping scandal.  I had hoped that it was all fabricated by those who were jealous, but alas he is guilty.  I cannot even understand why the leagues (baseball, biking etc...) don't realize that the cost of winning is at ALL costs.  Why not just make these substances all legal and do away with that aspect of what we are capable of doing on our own.  This is 2013.  I would say at this point most sports has seen their very best without enhancement.  What is left?  Enhancement. I know that seems bizarre for a pharmacist to say publicly that doping for sports should be made legal, but that is what I am saying.  As long as it stays illegal, the coaches and trainers and others involved in making the best of the best will go at all lengths to find substances that are not yet known or tested and continue to dope.  It is inevitable.

The other piece of information that I am struggling with today is that a former classmate in pharmacy school (who I will call Ed for his own privacy) has made a deal in pleading guilty in a case that I have had a hard time understanding.

You see, Ed was the type of student in our class who was a man of character.  He was one of the good guys.  I believe he was already married and was in the pharmacy fraternity that was more studious and less partying.  You can imagine that I was in the partying one and you would imagine right.  Ed has a large family now; he has small children and a wife that need him.

Ed has had some legal trouble in which there was some sort of federal charge brought against him for distributing controlled substance (Oxycontin) from his pharmacy.  I don't know how this whole thing began, but apparently it began fairly innocent enough with perhaps one bad decision or perhaps another part of the story that I do not know.  Maybe it was driven by needing money.  Perhaps it was driven by a bad decision further snowballing into extortion by some drug addicted criminals.

Either way, Ed is going to likely go to prison for around five years or so, and my heart breaks for him.

I know that it is easy for many to condemn a man like Lance Armstrong for doping but the bigger offense being the lies he told over the years and nastiness that ensued.  He threatened, sued and was a bully for the most part.  He "beat" cancer of the brain metastasized from testicular cancer, and he founded Livestrong.  There was good to the fame and notoriety even if he came by it by cheating.  Does the means justify the end?  Sometimes?

Fifteen years ago I would have looked at both men making bad decisions and would have spewed my opinion, and it would have been quite judgmental.  I tend to not do that as much because the situation is much more complicated the older I get.  You see, people fail.  People are human - even the most trusted professional, the pharmacist.  The moment that I believe that I am infallible of filling will be the moment where I am the most vulnerable.  We must always strive to do our best.  Do not compromise even for a moment the integrity and good name you have.  It is all you have in the way of public opinion, and in the case of Ed, I was a little saddened to read that he has struck a deal with the government about pleading guilty to one count and going to prison.  He will be sentenced right before this summer, and I dread it for him and his sweet wife and children.

I do hope for a silver lining for Lance Armstrong somehow.  I hope that he is able to look back at his life and see his own shortcomings and how they shaped him into something even better.  Yes, he made a mistake and turned that mistake into a snowball of lies and more denials that took years for him to admit, but there are good things that he has done.

My friend made a mistake and is going to pay the consequence for it by missing five years of his children's lives.  Both of them still are men I can admire for good things in the past and I hope even better things in the future.  Somehow.

The Power of Quizlet and Studying for the BCPS 2013

Quizlet is an amazing online flashcard storage site where there are many many sets of different types of collections of cards or "sets" to study.  I do not remember exactly how I found Quizlet, but suffice it to say that it is a great resource.  I am "lofgrenb" on there if you are looking for me.  I have tons of sets that are mostly set to private, but would be glad to share.  Just message me. Basically you create a profile either by hand or like everything else out there on the interwebs, just link it to your Facebook, because you KNOW you want everyone to know your business.  (wink wink)

In the "search Quizlet" box, you will type in BCPS.  Right now it's 2012 and 2011 cards that pop up, but as more and more BCPS pharmacists-to-be (including me) start creating new sets, you will be able to see them.  There is a "copy" button where you can copy the entire set that the user spent hours on and make it your own.  I know, slick right?  I have done a bit of both:  making my own and copying others and then editing to my liking.  Since there isn't a lot of ACCP material on regulations and stats, I highly recommend taking a look at some sets I like at the moment.

This is a regulatory one.

See this user:  rx_jenn:  All of her sets are fabulous.

If anyone knows her, tell her Blonde Pharmacist thanks her.  I should have spent a little more time studying to pass rather than barely failing, but I'm ready to tackle the beast again.

Anyone want to join in on flashcard creating?

Anyone up for meeting in Reno, NV at the ACCP 2013 Update in Therapeutics?  I will be there!

Coca-Cola Commits to Obesity Reduction

[embedplusvideo height="298" width="480" standard="http://www.youtube.com/v/zybnaPqzJ6s?fs=1" vars="ytid=zybnaPqzJ6s&width=480&height=298&start=&stop=&rs=w&hd=0&autoplay=0&react=1&chapters=&notes=" id="ep6358" /] All the while trying to fight the ban in NYC on giant servings.

Read more:  Obesity Epidemic in America

Guest Post: Pain Management - A Way Out of Addiction To Pain-Killers and Opiates

Pain is a natural process we all have to go through in life, physical pain being the most common type. Whether it be from the prick of a needle or the debilitating pain of rheumatism, such circumstances require appropriate management, otherwise it can critically affect one's lifestyle. The use of painkillers and opiates are typical in the medical field. Ranging from Hydrocodone to Morphine, these valuable tools are used to treat many different diseases and injuries, including ankle sprains, headaches, animal bites, etc. Though they are safe to use in controlled frequencies and amounts within the care and observation of medical institutions, things can go out of hand when measures proper care isn't taken. If this sound all too familiar to you, here's what you should know.

What is Addiction? To work your way out of painkiller and opiate addiction, you must first understand when you're in that actual state. There are many symptoms of addiction that anyone can recognize. They are somewhat of a gray matter, however, mainly because pain is a subjective experience. Since different patients have different thresholds for pain, it becomes complicated to know whether the drugs have failed to manage the patient's pain or whether the patient is lying in order to be administered more painkillers. Common signs of addiction include running out of a prescription early, telling your physician the prescription is lost, using multiple doctors to get pain medication, and borrowing pain medication from friends.

The Best Solution Withdrawing from painkillers and opiates may just be as difficult and consequential as withdrawing from stronger illegal drugs. For this reason, it is recommended that one enter an inpatient facility in order to take on this challenging process right. An inpatient detox facility can help you through the initial pains of detox. The first few days are usually the hardest and most demanding, as it causes chills, fever, muscle pain, nausea and vomiting, due to spontaneous withdrawal. The staff in this facility also will also help one to understand why they began using in the first place and how to avoid making the same mistakes again.

Other Options? If inpatient care is not an option, the next best way to withdraw safely and effectively from painkillers and opiates is to slowly but surely stop taking the substance. For many, stopping spontaneously only makes the process of withdrawal more complicated and escalates the chances of a relapse before one even has the opportunity to orient themselves.

Natural Pre-Emption One of the best ways to avoid addiction to dangerous substances is to head off the reasons for taking them in the first place. For instance, headaches are currently the most common form of pain in today's fast-paced lifestyle. Many factors lead to headaches, and they can commonly be dealt with by tuning in to what your body naturally requires (rest, reduction of stress, etc), instead of simply reaching for drugs.

Painkillers and opiates do have advantageous effects. However, make sure you practice only the pain management techniques prescribed by a doctor. Even if you think something's not working or not strong enough, never make an adjustment to your dosage without consulting a professional - and never, ever try any medication without a prescription. Not only is it illegal, it could have very dangerous side effects.

Mya Gilmore is a nurse who writes about health, nutrition and more at the Bow Creek & Bella Vista Recovery Centers.

The Obesity Epidemic in America

I am amazed daily when I am working at the hospital at the correlation between heavy weight or obesity and chronic illness.  Home medication rec sheets reach pages and pages with blood pressure medications, statins for high cholesterol, diuretics, and the list goes on. (Even sadder is the hospital cafeteria, but I have yet to dine in a hospital cafeteria and find healthy food which is odd to me)

Today, I was in Costco where I observed a couple of obese customers in electronic wheelchairs buying their food...  IN BULK.  We then went to Sonic (I know) and instead of ordering a Route 44 which can hold the contents of a person's daily urine output with normal renal function (seriously) I ordered a medium.

Guess what?  The medium was what x-large was years ago.

The stats:

• More than one-third of Americans are obese (> 30 BMI).  Another third are overweight.  Combined this means that almost 70% of the US are either obese are overweight.
• 16% of children and teens are obese
• Obesity-related conditions include heart disease, stroke, type 2 diabetes and certain types of cancer, some of the leading causes of preventable death
• Medical costs associated with obesity were $147 billion in 2008
• There was a dramatic increase in obesity in the United States from 1990 through 2010
• The average size of a bagel doubled in size from 1983 to today.  Three-inch diameter with 140 calories to 6-inch diameter at 350 calories.  Super-size me please.
• One in three children born today will be diagnosed with diabetes in their lifetimes

So why lose the weight this 2013 and make this the year of change?

• Obese workers are less likely to be promoted
• Obesity related healthcare costs will take more money out of your pocket
• Obesity mortality rates are surpassing smoking-related deaths

Guest Post: Depression And Addiction - How Are They Related?

Both addiction and depression are two serious health concerns that plague millions of people around the world. Dealing with addiction or depression on their own can be hard enough, but what happens when the two combine ? Studies have shown that there is a definite correlation between depression and addiction, and the two often go hand in hand. Here are some examples of how addiction and depression are related.

Depression Can Cause Addiction/Addiction Can Cause Depression

Depression can cause a person to turn to illegal drugs and alcohol to help mask the sadness and despair. Unfortunately, drugs and alcohol can cause an even deeper depression when a person realizes these substances only disguise problems for a short time. Because addiction and depression often occur simultaneously, they are closely related.

Psychological Problems

One way that depression and addiction are related is that they both stem from psychological problems. Chemical imbalances in an addicted or depressed person's brain cause him or her to suffer from these crippling mental illnesses.

Changes In Behavior

Both addiction and depression cause changes in a person's behavior. Both of these mental illnesses cause a person to become withdrawn, irritable and angry. These mental illnesses can also cause negative changes in the depressed or addicted person's relationships with others.

Medical Attention

In order to begin the long journey to recovery from depression or addiction, a person must seek medical attention. It is only with the help of ongoing therapy and/or medication that a depressed or addicted individual can have the tools needed to combat these horrible mental diseases.

Suicidal Thoughts

Depression and addiction can cause any person to have suicidal thoughts. In some cases, a person may even make suicide attempts. This is because both addiction and depression can completely diminish a person's will to live.. This hopelessness can cause suicidal thoughts and attempts.

Weight

A person who is suffering from addiction or depression usually experiences drastic weight gain or loss. This is because both of these mental illnesses cause disruptions with a person's appetite.

Appearances

When a person is depressed or addicted to illegal drugs or alcohol, he or she will eventually begin to acquire a disheveled appearance. Addiction and Depression often cause a person to give up caring about personal hygiene and cleanliness.

Depression and addiction to illegal drugs or alcohol are crippling conditions that can cause a variety of issues in a person's life. While depression and addiction are different mental health issues, they are related in many ways. In fact, in many cases addiction and depression occur at the same time. From a disheveled appearance to angry outbursts, addiction and depression can cause a variety of related problems. While they do have many similarities, both addiction and depression need to be treated individually by a medical professional. It is only through treating each issue individually that a person can begin to heal from addiction or depression.

Marcia Timm is a substance abuse counselor who who writes about health, nutrition and more. Her most recent work focuses on the Top 10 TED Talks on Psychology.