Keeping Tabs

KEEPING TABS

UF COP Jacksonville APhA-ASP Volume 3, Issue 1

TABLE OF CONTENTS Region 3 MRM Recap

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Immunization Refusal: What it Means for Society and Why it Happens

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It's Over-the-Counter, It Must Be Safe Right?

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The Gut Microbiome and the Gut-Brain Axis

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Three Chairs, Two Events, One Goal

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American Pharmacists Month Career Spotlight

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Patient Care Over Politics

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Why We Became Pharmacists

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Semester Recap

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Thank You!

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REGION 3 MRM RECAP By: Kelli Herrin

During my first semester of pharmacy school, I had the privilege of attending the 2018 APhA-ASP Region 3 Midyear Regional Meeting in Memphis, Tennessee. MRM was easily one of the greatest highlights from the last few busy months. The theme of the conference was “Connect. Grow. Go.”, and I can attest to the relevance of this slogan.

Connect: I had an excellent time getting to know other students from across the three UF campuses. From the airports to the barbecue restaurants, Memphis sites and trolley rides, we all made memories and shared laughs that I won’t soon forget. During conference sessions, I was able to talk with students from Tennessee, Mississippi, Alabama, North Carolina, Puerto Rico, and some from USF in Tampa. It made me aware of similarities and differences in pharmacy school programs and our experiences as students.

Grow: I realized how great the potential for growth as a pharmacy student can be. The students running the conference displayed impressive professionalism, leadership, and accomplishments. It opened my eyes to how students really are the future of pharmacy, and each one of us can make an impact. I also learned a lot during the policy proposal sessions. The issues ranged from those facing students, to those facing various areas of pharmacy, and to legislation across states. As the UF chapter discussed each proposal, I listened to explanations, opinions, and debates. I asked questions and took my own stance on what I think the future should look like. It is exciting to be at the forefront of action on interesting, relevant, and sometimes controversial topics relevant to our profession.

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Go: One of my main take-aways from MRM is how great it is to be a Florida Gator. We are a powerful, accomplished chapter in our region. There is a lot of talent spread across each of our three campuses, and I hope to help to embrace the potential for networking here within our own school. We watch the same lectures and experience the same Active Learning Sessions, but we don’t often have the chance to meet one another. I would love to help improve unity across campuses, perhaps through organizing UF APhA-ASP tri-campus social events.

As I go on in my pharmacy school experience, I hope to become more involved in our APhA-ASP chapter, and to help with the policy process. I can’t wait to attend future conferences, where I will continue to “Connect, Grow, and Go” more and more each time.

If any students have questions about what to expect from an MRM conference, please feel free to ask me! MRM next year will be held in Atlanta, Georgia, which is a much closer trip. I am excited that many more UF students will likely be able to attend. The conference itself, plus traveling, staying in a hotel, and exploring the city together is an amazing experience. I highly encourage you to go, as you will make fun memories, form strong friendships, and learn more about both yourself and the pharmacy profession.

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CONNECT

GROW

GO!

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Immunization Refusal: What it Means for Society and Why it Happens Operation Immunization: Mariah Bigaud, Christophe Valdes, Larissa Marchetti

History has shown the need to keep our population protected from various diseases as well as how effective vaccines are at protecting people from them.

Unfortunately, in recent years, there has been a growing concern with the reappearance of previously eradicated diseases due to people not keeping up to date with immunizations. For example, from 2014 to 2015, a measles outbreak that was believed to have originated at the Disneyland Resort in Anaheim, California led to 125 people contracting the disease. When looking at the exposed population in this case, it was noted that MMR vaccination rates among this population was between 50% and 86%. In order to maintain herd immunity against measles, a vaccination rate of 96% to 99% is needed.

The United Kingdom and other western European nations have also seen decreases in immunization rates which have led to breakouts as well. [1]

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Considering stories such as this one, why do people choose to refuse vaccinations? There are various social stigmas associated with vaccination.

Certain vaccines, such as the MMR vaccine, contain gelatin, which may not be favorable for people of certain faiths due to pork content. [1] Another explanation may be the recent a rise in anti-vaccination beliefs that they can cause issues such as autism in children or that they can cause the diseases they were meant to prevent. This in combination with the power of social media has led to a magnification of anti-vaccine sentiments which can lead people down a dangerous path when it comes to their health. [2] Part of Operation Immunization’s vision for the year has been to reach out to the public and provide education about available vaccines and how useful they are in preventing a wide range of diseases. However, based on various social media posts found online, there are a wide variety of concerns those with anti-vaccine sentiments may have in addition to those previously discussed. They may worry about what ingredients are in these vaccines and if those ingredients are toxic in the long run. It may not be enough to just discuss the benefits of immunization, and we look forward to being more involved in open discussions with the public in addition to providing education to hopefully ease people’s concerns regarding vaccines.

References: 1. Hussain A, Ali S, Ahmed M, Hussain S. The Anti-vaccination Movement: A Regression in Modern Medicine. Cureus. 2018 Jul;10(7).

2. Stein A. The Golden Age of Anti-Vaccine Conspiracies. European HIV/AIDS Academy. Germs: Enabling the Future. 2017 Dec;7(4);168-170.

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It’s Over-the-Counter, It Must Be Safe Right?

Operation OTC Medicine Safety: Danielle Morgan, Jordyn Veres, Nicole Maranchick

“Multiple Over the Counter Medications have the potential for abuse, with commonly abused medications being antihistamines, sleep aids, caffeine, ephedrine, pseudoephedrine, antitussives and expectorants, dextromethorphan, and laxatives”. An article from the Integrated Pharmacy Research and Practice journal notes that these medications are likely due to increased access to these medications, and abuse of these medications is also likely unintentional due to using the wrong medication for a particular indication, using the wrong dosage, or having a lack of knowledge of particular interactions with other medications.

Polypharmacy is an issue that contributes to unsafe use of OTC medicines as well. Many patients have multiple medications for chronic conditions, and often fill these medications at different pharmacies. Patients may not consider telling their pharmacist about all of their medications which may lead to an inappropriate OTC recommendations and health consequences.

For example, NSAIDs such as ibuprofen may cause GI bleeding and increases in blood pressure, which can have serious health consequences.

Polypharmacy is especially prevalent in the older population, so both patients and healthcare professionals need to be cognizant and careful with their OTC selections. Patients should be encouraged to provide their pharmacist/doctor with all their current medications and seek their guidance when selecting an OTC medicine. Another patient-friendly resource such as knowyourotcs.org provides easy-to-understand information about active ingredients in OTC medicines.

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Tips when selecting OTC medicines 1. Always make sure to read the label. Every time you buy or use an OTC medication pay attention to the ingredients, indications, directions of use, and warnings.

2. Take only the recommended dose of the medication stated on the label.

Talk to your doctor or pharmacist before taking an OTC medication in combination with a prescription medication or with more than one OTC medicine at the same time.

3. Keep a record of all the OTC medications you are taking so that you can share it with you healthcare provider.

4. Don’t split up or crush tablets unless directed by a healthcare professional.

This could change the effectiveness of the drug.

5. Take cough syrups and other liquid medications with the measuring device that comes with the drug. This ensures that you are taking the proper amount of medication.

References: 1. Tips to Use Over The Counter Medications. (2017, March 17). Retrieved November 21, 2018, from http://www.wiserxcard.com/tips-to-use-over-the-counter-medications/.

2. NCPIE BeMedWise. (n.d.). Retrieved November 21, 2018, from http://www.bemedwise.org.

3. Sangsiry, S. et al. (2016). Abuse of Over-the-Counter Medicines: A Pharmacist’s Perspective. Integrated Pharmacy Research and Practice. 19(6), 1-6. doi: 10.2147/IPRP.S103494.

THE GUT MICROBIOME AND THE GUT-BRAIN AXIS

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By: Lia Argevani

In recent decades, medicine has been exploring the role of bacteria as commensal organisms in our bodies. Administration of probiotics has been studied as a possible adjunctive treatment for disease states ranging from Clostridium difficile to infectious diarrheas. However, the role of our gut microflora extends past just the immediate effects on the GI tract to distant organs such as the brain, in what has been recently coined as the “gut-brain axis�. Recent literature has only begun to uncover the complex interactions that microbiota have with neurological and endocrine mediators that lead to unexpected changes in areas ranging from higher level cognition to mood and emotion.

Although the exact mechanism for communication between gut microbiota and the CNS remains unclear, evidence suggests that it occurs primarily through the vagus nerve. Through this nerve, bacteria are able to communicate information about the environment in the gut lumen to the brain. In studies involving mice who had their vagus nerve removed, neurological and endocrine effects normally attributed to microbiota were largely absent, confirming the nerve as the primary mode of communication. Gut flora also play a large role in influencing intestinal permeability through restoration of the tight junctions.

When the intestinal barrier is compromised, there is enhanced permeation of foreign substances, triggering the stress and immune response which can lead to various pathologies including inflammatory disease states.

Microbiota have been implicated in affecting anxiety and attenuating the hypothalamic-pituitary-adrenal system through their influence on brain neurochemistry. Recent studies involving mice have found that administration of Lactobacillus rhamnosus led to alteration of GABA mRNA in the brain and reduced stress-induced release of cortisol as well as anxiety and depressive behavior. An association between alterations in gut microflora and central nervous disorders has been demonstrated in humans on a few different accounts.

In patients presenting with autism, various alterations in gut flora have been noted that appear to be correlated with the level of severity of autism. Further studies are being conducted to see if this association is causative. Moreover, intestinal bacteria are involved in modulating immune response through their complex interactions with cytokines and immune cells. For example, a species of Bacteroides was found to mediate inflammation by increasing the export of PPAR-γ from the nucleus of immune cells. Other mechanisms for immune involvement may include proteases that are upregulated in intestines with abnormal flora, contributing to increases in mucosal immune response. In the case of irritable bowel syndrome, this ultimately leads to increased intestinal epithelial permeability and hypersensitization of sensory pathways that results in pain and enteric nervous system dysregulation.

Furthermore, signals generated in the brain have the potential to alter intestinal microbiota through signaling molecules carried by neurons and immune cells. Many bacteria contain binding sites for neurotransmitters, which provides the basis for the interaction between the two. It is postulated that exposure to stressors results in changes in gut flora mediated through the release of norepinephrine, which can stimulate the proliferation of virulent bacteria such as E. coli. Exposure to stressors also influences gastric motility, affecting delivery of prebiotics and nutrients to microbiota.

Uncovering these mechanisms of interaction offers a new understanding of disease states and the various etiologies behind them, providing insight to potential factors involved in disease initiation and progression. Exploring the complexities of the gut-brain axis opens the door for new treatments that exploit the full potential and therapeutic benefit this complex system holds.

References 1. Carabotti, M., Annunziata, S., Maselli, M., Severi, C. “The gut brain axis: interactions between enteric microbiota, central and enteric nervous systems.” Annals of

Gastroenterology. Apr-Jun 2015. 28(2): 203-209.

2. Wu, H. “The role of gut microbiota in immune homeostasis and autoimmunity.” Gut Microbes. Jan 2012. 3(1):1-14.

3. Liang, S., Wu, X., Hu, X., Wang, T., Jin, F. “Recognizing depression for the microbiota gut-brain axis.” International Journal of Molecular Sciences. Jun 2018. 19(6):1592.

4. Salem, I., Ramser, A., Isham, N., Ghannoum, M. “The gut microbiome as a major regulator of the gut-skin axis.” Frontiers in Microbiology. 2018. 9:1459

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Three Chairs, Two Events, One Goal By: Corinne Singer and Haley Lewis

Operation Diabetes takes pride in offering blood glucose screenings and Type 2 Diabetes Risk Assessments to various people around Jacksonville and surrounding areas. What happens when two amazing events are scheduled for the same day and Operation Diabetes would like to be involved in both events?

We divide and conquer!

On October 20, Operation Diabetes wanted to offer blood glucose screenings and diabetes education at two separate events that were happening at the same time. The first event was the American Pharmacists Month Health Fair that was being held at the Main Library in Downtown Jacksonville. The second event was held at the St. Augustine Outlet Mall and was open to the public through Lifestyle Events under the name of Healthy Lifestyle Expo.

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Both events lasted from 10 AM until 2 PM and, because every Operation Diabetes event requires at least one chairperson to be present, we had to split our team and supplies.

Operation Diabetes uses many disposable supplies which can be quite costly; however, the benefit to those people that we screen and counsel is greater than the monetary costs. In order to offer the blood glucose screenings at both events, we had to obtain a sufficient number of glucometers, testing strips, lancets, cotton balls, alcohol wipes, Band-Aids, and gloves. We also had to have Sharps containers available at both locations, as well as, an ample number of printed risk assessment worksheets so patients could obtain a greater understanding of their potential risk for Type 2 Diabetes and what their blood glucose reading means.

Although our Operation requires that we “poke“ people with a little needle and draw blood, most of the patrons are appreciative of the brief pain in order to understand their current blood sugar readings. It is not uncommon to find adults with blood sugar readings that are higher than average, but who have not yet developed diabetes. We have a unique opportunity in these patients because we are able to counsel them about measures they can take to help them prevent the onset of diabetes and keep their blood sugar within normal limits. These suggestions include changing their diet and adding exercise. Once someone develops diabetes, it is a permanent disease. If it is caught while someone is on the border of developing diabetes, it can be prevented with lifestyle changes. It is a goal of Operation Diabetes to target these borderline patients and help them understand how to make lasting, positive changes in their lives.

By splitting our team and supplies, we were able to screen 94 people between the two events on October 20. Thankfully, Operation Diabetes has chairpeople who are involved in events and able to take a leadership role when necessary.

MICHELLE CARRASQUILLO

American Pharmacists Month Career Spotlight Dr. Carrasquillo graduated from the University of Florida College of Pharmacy Jacksonville in 2016. She is currently serving as the Clinical Pharmacy Manager at St. Joseph’s Hospital North. Continue reading to learn more about her position and how her involvement in APhA-ASP impacted her career!

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AN INTERVIEW WITH DR. MICHELLE CARRASQUILLO, PharmD, MS Please describe your current position and the

Please describe your student involvement with APhA-

responsibilities that this position entails.

ASP. How has being involved in APhA-ASP impacted

I am currently the Pharmacy Manager at St. Joseph’s

your career path?

Hospital North, which is a part of BayCare Health System.

My involvement in APhA-ASP began early on during my first

We are currently a 108 bed hospital, but we will be expanding

year of pharmacy school. I was President of the UF

to 216 beds this year. I oversee a wonderful team of 24

Jacksonville Campus for 2 years and then subsequently served

pharmacists and technicians. I am responsible for

as APhA-ASP Executive Liaison for our UF Chapter for 1 year.

developing and implementing pharmacy operations such as

My involvement in the organization and my 4PD rotation at

policies and procedures. My daily responsibilities range from

APhA Headquarters shaped my desire to pursue a combined

the management and coordination of clinical services and

PGY1/PGY2/MS Health-System Pharmacy Administration

both inpatient and outpatient operations to the oversight of

residency at the University of North Carolina Medical Center

human resources, revenue integrity, productivity, Joint

in Chapel Hill, NC. My passion for our advancing pharmacist

Commission readiness, medication safety, and the pharmacy

and technician roles grew out of advocating for our profession

budgets. I am also involved at the Health-System level in

alongside other student pharmacists both at the state and

assisting with development and implementation of system-

national level. Attending both MRM and the Annual Meeting

level pharmacy goals. This is my first role post-residency

on a consistent basis throughout pharmacy school kept me

completion and I am very excited to continue to work with

energized and also expanded my professional network in a

my team in delivering excellent patient care here at St.

way that I could have never foreseen. I will be forever grateful

Joseph’s Hospital North.

for my opportunities within APhA-ASP and for the countless

What is the most rewarding aspect of your position?

The most rewarding aspect of my job is having the opportunity to affect change within practice to continue to advance the role of pharmacy as a whole. This includes advancing the roles and responsibilities of my pharmacy technicians and pharmacists. In my role, I have the honor of mentoring my staff and creating opportunities for career advancement. I also have the pleasure of being able to affect change on a larger scale with changes in policies and procedure and pharmacy department infrastructure.

friendships that I have developed over the years because of my involvement. If you are not currently involved in a committee or leadership role, I would highly encourage you to do so! You never know where it will lead you.

PATIENT CARE OVER POLITICS

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BY: CATHERINE HUDSON

In the highly charged, complicated, and convoluted arena of politics, it is easy to feel unqualified or discouraged from getting involved. As we saw on the Florida ballot this year, sometimes seemingly unrelated issues, such as offshore drilling and indoor vaping, can influence each other in apparent or hidden ways. Whether you enjoy or detest politics, our governmental policies ultimately dictate our professional practice, our healthcare landscape, and our day to day lives. Pharmacy is regarded as one of the most regulated professions. It fosters an environment where every pharmacist, no matter their career path, is responsible for their own license. As pharmacy changes in the future, whether that be increased presence and collaboration on the patient care team or remote supervision of technicians via telemedicine, it is our duty to advocate for our patients.

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As technicians, interns, students, pharmacists, researchers, and even patients ourselves, we are the experts in our field. We are trained to critically evaluate problems and find evidence-based solutions. Many student pharmacists became interested in the field because they wanted to help others, and every pharmacist works to optimize the health and safety of their patients. Research has shown that utilizing pharmacists on the patient care team improves patient outcomes and ends up saving money in healthcare costs. We are also well aware of the overwhelming metrics many community pharmacies are striving to achieve while supervising pharmacists are tasked with more and more responsibilities. It is not only our job as pharmacists to find and correct errors in prescriptions before they reach the patient, but it is also our obligation to ensure working conditions and environments exist where we are able to perform our jobs to the best of our abilities.

Patient-centered care and outcomes-driven reimbursement is quickly changing the frontier of healthcare. As each facet of the patient care team can be better utilized to satisfy our overwhelming primary care shortage and medically underserved communities, it is the civic responsibility of pharmacists to stand up and represent our patients, our profession, and the improved outcomes we bring to the table. No matter your personal political views, whether passionately held or nonexistent, as patient advocates we must set aside our beliefs and party affiliations to come together and support legislation that best cares for our communities. Through collaboration as pharmacists, healthcare providers, and patient advocates, we can make our voices heard and work together to create a better future of healthcare; because, as Michael Jackson, Executive Vice President and CEO of the Florida Pharmacy Association often quotes, "If you're not at the table, you're on the menu".

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WHY WE BECAME PHARMACISTS By: Madison Clayton

The first time I truly found my passion for pharmacy was during my psychiatry rotation, when I crossed paths with a patient with neurosyphilis. Let me start from the beginning. A 49year-old male arrived to the emergency department with altered mental status, no past medical history of mental illness, and a clean drug screen. His friends who are with him say he’s been acting “out of it” for about a week, but that he was also recently demoted from his position as a chef because he started forgetting the recipes. After being admitted to the behavioral health unit and undergoing more blood work, our patient was confirmed to have neurosyphilis.

Now, imagine this is your patient. You’ve done the research, you have a treatment plan ready. According to the guidelines, the recommended treatment for neurosyphilis is aqueous penicillin G 18-24 million units per day, administered as 3-4 million units intravenously (IV) every 4 hours, or by continuous infusion, for 10-14 days. Simple enough. Here’s the problem: The Internal Medicine physician doesn’t want to admit the patient to a medical floor, so you will have to administer IV medications on the behavioral health unit six times a day. But, that won’t work either, because of the unpredictability of the patient population. What if another patient were to pull out the needle or interfere with the machine or tubing? According to the guidelines, a recommended alternative is procaine penicillin G 2.4 million units intramuscularly (IM) once daily PLUS probenecid 500 mg orally (PO) four times a day, both for 10–14 days. Easy solution, except, it’s on backorder. There is another preparation of IM penicillin available, benzathine penicillin G, but you’ve done the research, so you know that it has not been shown to achieve detectable levels in the cerebrospinal fluid (the site of infection) even with the aid of probenecid. You have one last backup plan, ceftriaxone 2 g daily either IM or IV for 10–14 days, which is used in patients with a penicillin allergy.

Photo by: Lightspring

However, you know that penicillin is the drug of choice for all forms of syphilis. Is a physician’s stubbornness a good enough reason to divert from standard of care? The physician decides to use the benzathine penicillin G preparation IM with probenecid PO for 14 days. You know this is not going to work, so you present your case, you defend your points with the literature, and you’re posed the question, “What do you want to do for this patient?”

There are no multiple-choice questions in the real world. Sure, sometimes you have multiple choices, but none may clearly be the “most correct.” During my first three years of pharmacy school, I looked at the lecture slides and assignments and asked myself, “How can I use this information to get the best possible grade on the next exam?” Yes, your exam grades are a reflection of your ability to learn and use the material, and this is a great start. Now, I urge you to take it a step further. Next time you watch a lecture video, next time you read a chapter on a new topic, ask yourself, “How can I use this information to change the lives of my patients?”

You’ll notice I titled this article, “Why We Became Pharmacists,” using the past tense of the word. Until recently, I did not see myself as a pharmacist. I kept putting off that responsibility, saying, “but don’t take my word for it, I’m not an actual pharmacist yet.” If you find yourself saying this, stop. You need to take ownership of your role as a healthcare professional.

Soon, you may be the only one on the team who understands the difference between aqueous penicillin G and benzathine penicillin G. You need to be sure. You need to be ready to advocate for your patients. We are student pharmacists. Don’t wait for a case of neurosyphilis to realize the responsibility you have to your patients. The recommendations you make (or don’t make) while you are still a student, will affect your patients’ outcomes. Whether it’s a central nervous system infection, a mood disorder, or a simple case of high blood pressure, treat every case like it’s life or death, because it is.

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SEMESTER RECAP Operation Diabetes screened 145 patients for high blood glucose!

Operation Heart screened 85 patients for hypertension!

Generation Rx provided education to 25 people!

Operation Immunization provided shots to 70 patients, educated 42 patients, and reached 26,012 people through social media!

OTC Med Safety provided education to 129 patients!

Operation Mental Health reached 2,257 people through social media!

Infectious Diseases collected 100 miles for charity miles drive & reached 643 people through social media!

We increased membership and won a regional award!

We had 10 IPSF events including a successful blood drive and reached 4,520 people through social media!

We had 6 policy events including a voter registration drive and received a proclamation from the mayor!

Members of the Month!

- Jake Chulla - Kelli Herrin - Jessica Mosher Officers of the Month!

- Communications VP: Jennifer Parmar - International VP: Melissa Catalano - Membership VP: Jeremy Obordo - Member-at-large: Alexander Maki - Finance VP: Victoria LaVine Chairs of the Month!

- Operation Immunization: Mariah Bigaud, Christophe Valdes, Larissa Marchetti - Operation Diabetes Chair: Corinne Singer - Operation OTC Medicine Safety Chair: Danielle Morgan

THANK YOU! Editor and Designer Jennifer Parmar

Designers Larissa Marchetti Jourdan Boyle-Taylor

Writers Kelli Herrin Mariah Bigaud Christophe Valdes Larissa Marchetti Danielle Morgan Jordyn Veres Nicole Maranchick Lia Argevani Corinne Singer Haley Lewis Catherine Hudson Madison Clayton

From the Keeping Tabs team and your leaders of UF COP Jacksonville APhA-ASP, thank you for another amazing semester! We hope you have a great winter break and look forward to seeing you in the new year!