Justyna Sudyka, PharmD Candidate

During the summer after my second year of pharmacy school, I had the unique opportunity to create a veterinary pharmacy continuing education (CE) activity. Before this, my only veterinary pharmacy exposure was a short class lecture about niche pharmacist roles.

When I saw an email from my professor about writing a CE piece about cats and dogs, I was thrilled and knew I had to do it. Learning about people and pharmaceutical care is important, but when a chance to do something different fell at my feet, I just took a leap of faith.

I worked alongside 3 other motivated student pharmacists from the University of Connecticut School of Pharmacy: Heather Honor, Raquel Mateus, and Mia Sgamboti. I'm a cat person (who likes dogs too) and decided to focus my search on feline pharmacy safety. My partner and I made the "purrr-fect" duo and dove into our work, and our canine pals divided and conquered the world of man's best friend.

Our love for animals made the individual work a breeze, but the group effort was a bit more challenging. Our writing styles varied, but our goal was to write a piece that sounded like it was written by 1 person. Ultimately, we learned that writing with "1 voice" means writing with "1 approach."

1. Set Ground Rules and Make a Checklist. 

Before starting anything, we had to know who would work on which animal. Once topics were determined, we made a checklist, adding to it as needed. Given our busy and sometimes unpredictable summer schedules, we chose to pick subsections as we went and emailed the group about our selections.

Sometimes a group may find it easier to have everything preassigned. The choice is up to you.

Using active voice means having the subject perform an action. When a writer uses passive voice, the subject is not always clear, which may cause the reader to make inaccurate assumptions.

Authors can use passive voice when they believe the person or thing acted on is more important than the subject. In our case, we determined using active voice was best.

After finishing a section, we would send our drafts to each other. This allowed us to learn about personal findings, prevent redundancy, and familiarize ourselves with each other's writing styles.

The CE piece's audience included pharmacists and pharmacy technicians. As we wrote about our discoveries, 1 question helped guide what information to include or exclude: What should our audience know or woudl they want to know?

Have you ever read what you've written and misread it? It's probably because you read it the way you think you've written it. A fresh pair of eyes will help find your mistakes, and sometimes it even takes more than 1 pair. Throughout the project, our supervising professor, Jeannette Wick, was also our editor. She gave us feedback on content, grammar, and wordiness.

Everyone working in the science field wants the facts, including pharmacists. A repetitive article that contains unimportant filler information dulls the reader's mind to what's important. When you write, think to yourself, "What would I want to read?" Be concise.

We finished the CE piece after many hours of research, writing, and editing. We gained and spread knowledge on how to keep cats and dogs safer, learned from each other's mistakes, excelled as a team, and grew as individual writers.

My advice is this: Don't be afraid to take a chance and try something new. And remember the words of Nelson Mandela: "It always seems impossible until it's done."

 is a PharmD candidate at the University of Connecticut in Storrs.

Articles

Remember the words of Nelson Mandela: "It always seems impossible until it's done."

Paths Less Traveled: Writing a Successful Pharmacy CE Activity

Pharyngitis, an inflammation of the back of the throat, can be bacterial or viral.

Streptococcal pharyngitis, commonly referred to as strep throat, is caused by Streptococcus pyogenes, group A β-hemolytic Streptococci (GAS).

 GAS is responsible for fewer pharyngitis cases than viruses are (adults: 5%-15%, children: 20%-30%).

 Strep throat spreads through direct contact with respiratory fluids and has an incubation period of 2 to 5 days.

 Its prevalence increases during the winter and early spring, accounting for 1% to 2% of all ambulatory care visits in the United States.

Differentiating between a bacterial and viral etiology is difficult, especially in pediatric patients, which often results in antibiotic overprescribing. Of note, patients who present with clear viral signs and symptoms (Table 1

) do not require testing and should not receive antibiotics.

 Conversely, symptoms of GAS pharyngitis are nonspecific.

Treatment: Antibiotics and Supportive Care

The Infectious Disease Society of America’s guidelines highly recommend antibiotic treatment in children who tested positive for strep throat. Treatment prevents nonsuppurative (eg, acute rheumatic fever [ARF], acute glomerulonephritis) and suppurative (eg, cervical lymphadenitis, mastoiditis, and peritonsillar abscess) complications.

 Adult patients often do not need antibiotics because the relief they provide is minimal. Symptoms are self-limiting and usually last less than a week.

 summarizes antibiotic therapy options. Guidelines consider amoxicillin/penicillin as first-line therapy, followed by cephalosporins and macrolides/azalides in the presence of allergy to first-line agents. Avoid fluoroquinolones, sulfonamides, and tetracyclines because of high resistance rates, ineffectiveness, and/or unnecessary broad-spectrum coverage.

 Study results show that children experience more adverse events, notably gastrointestinal upset, when prescribed azalides/macrolides compared with β-lactam antibiotics. Rashes are more common with β-lactams.

Guidelines do not recommend antibiotic use in asymptomatic individuals positive for GAS pharyngitis, as they are likely chronic carriers at no/minimal risk of complications and not contagious.

 Similarly, recent exposure does not warrant testing if asymptomatic.

 The exceptions are patients with family or personal histories of ARF and post-streptococcal glomerulonephritis. Asymptomatic and symptomatic GAS infections can prompt ARF recurrence. Experts also recommend secondary prophylaxis in patients with a history of ARF.

Avoid acidic or spicy foods, cleaning product fumes, and smoking.

Cover face when coughing or sneezing to prevent spread and use other hand hygiene.

Drink cold and hot fluids; eat cold, easy-to-swallow foods, such as popsicles; and get rest.

Keep in mind that symptom improvement may take 1 to 3 days after starting treatment.

Stay home until feeling better, and wait at least 12 hours after starting antibiotics before return- ing to school or work.

(see Online Table 3 for more supportive care options).

Patients with clear viral symptoms do not require testing or antibiotics.

 Children younger than 3 years of age do not require testing unless symptomatic with a known exposure.

Patients with pharyngitis often seek medical guidance. Assessing and counseling them on common adverse effects, hygiene, and supportive care prevent complications and transmission of infections. Pharmacists can help ensure the selection of appropriate antibiotic therapy. 

is a PharmD candidate at the University of Connecticut School of Pharmacy in Storrs.

Ebell MH. Diagnosis of streptococcal pharyngitis. 

Shulman ST, Bisno AL, Clegg HW, et al. Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America. 

. 2012;55(10):1279-1282. doi:10.1093/cid/cis8473. 

Committee on Infectious Diseases, American Academy of Pediatrics, Kimberlin DW, Brady MT, Jackson MA, Long SS. Group A Streptococcal Infections. In: Red Book. 31st ed. American Academy of Pediatrics; 2018:748-762. Accessed March 3, 2021.

https://redbook.solutions.aap.org/chapter.aspx?sectionid=189640187&bookid=22054

Harris AM, Hicks LA, Qaseem A; High Value Care Task Force of the American College of Physicians and for the Centers for Disease Control and Prevention. Appropriate antibiotic use for acute respiratory tract infection in adults: advice for high-value care from the American College of Physicians and the Centers for Disease Control and Prevention. 

. 2016;164(6):425-434. doi:10.7326/M15-18405. 

Shaikh N, Swaminathan N, Hooper EG. Accuracy and precision of the signs and symptoms of streptococcal pharyngitis in children: a systematic review. 

 2012;160(3):487-493.e3. doi:10.1016/j.jpeds.2011.09.0116. 

Randel A; Infectious Disease Society of America. IDSA updates guideline for managing group A streptococcal pharyngitis.Am Fam Physician. 2013;88(5):338-340.7. Nationwide Children’s. Strep throat (bacterial). Updated October 2017. Accessed March 4, 2021.

https://www.nationwidechildrens.org/conditions/strep-throat

Mayo Clinic. Strep throat: diagnosis and treatment. Accessed March 4, 2021. 

https://www.mayoclinic.org/diseases-conditions/strep-throat/diagnosis-treatment/drc-20350344

van Driel ML, De Sutter AI, Habraken H, Thorning S, Christiaens T. Different antibiotic treatments for group A streptococcal pharyngitis. 

. 2016;9(9):CD004406. doi:10.1002/14651858.CD004406.pub410. 

Gerber MA, Baltimore RS, Eaton CB, et al. Prevention of rheumatic fever and diagnosis and treatment of acute streptococcal pharyngitis: a scientific statement from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee of the Council on Cardiovascular Disease in the Young, the Interdisciplinary Council on Functional Genomics and Translational Biology, and the Interdisciplinary Council on Quality of Care and Outcomes Research: endorsed by the American Academy of Pediatrics. 

. 2009;119(11):1541-1551. doi:10.1161/CIRCULATIONAHA.109.191959

Pharmacists and other clinicians share responsibility for relieving symptoms, preventing transmission, and avoiding complications.

Streptococcal Pharyngitis Is a Seasonal Concern

Breast cancer accounts for 16% of all female cancers. Malnutrition may increase mortality and morbidity risk, and lengthens the cancer recovery process. Patients with cancer who undergo chemotherapy often experience adverse effects, such as early satiety, food aversions, loss of smell, loss of taste, and nausea, that prevent adequate food intake.

Previous studies have found that dietary intake of certain vitamins decreased in women undergoing chemotherapy treatment. One study observed that vitamins A, B3, and B6 intake were below the recommended value. Another study detected an inadequate dietary intake of vitamins B1,B2, B3, B6, and C.

International Journal of Environmental Research and Public Health

 recently published a survey that assessed the impact of breast cancer treatment on dietary intake. Researchers surveyed women with noninvasive cancer undergoing chemotherapy for 3 consecutive days—before, during, and after treatment.

A computer program evaluated the nutritional value of food with regard to 13 vitamins: A, B1, B2, B3, B5, B6, B8, B9, B12, C, D, E, and K.

An analysis determined that intake of vitamins B2, B3, B5, and B8 decreased during and after chemotherapy compared to pre-treatment.

A separate analysis showed that during and after treatment, a deficit risk was possible with vitamins B5, B8, and B12.

Women who did not meet the Estimated Average Requirement for vitamin intake prior to treatment experienced even further reduction in vitamin intake post-treatment.

Is this decrease in vitamin intake important? Do patients need dietary supplementation?

The authors noted that a low dietary intake does not necessarily mean vitamin levels in the body are inadequate. Vitamin absorption and bioavailability varies from one person to another; therefore, blood samples are a better marker of malnutrition.

Prior to health care providers advising patients to take over-the-counter vitamin supplements, patients need a thorough evaluation. Lack of a given macronutrient can be detrimental, but so is having too much.

Sometimes nutritional counseling regarding dietary adjustments may be enough.

 is a 2021 PharmD candidate at the University of Connecticut in Storrs.

Morales-Suárez-Varela M, Ruiz Simon A, Blanch Tormo S, et al. Effect of breast cancer treatment on dietary vitamin intake levels. 

Pharmacists may provide nutritional counseling regarding dietary adjustments or recommendations for over-the-counter supplements to assist patient with cancer.

Breast Cancer Treatment Associated with Lower Vitamin B Intake

Caucasian, postmenopausal women make up the highest percentage of patients who experience osteoporosis-related vertebral (74.4%) and nonvertebral (72.8%) fractures.

 Fractures, especially subsequent ones, positively correlate with an increased mortality risk.

Although many studies have shown bone mineral density increases more with teriparatide compared to bisphosphonates, only 1 study, the VERO trial (NCT01709110), directly compares fracture incidence.

A recent article, published in the journal 

, compares the efficacy of teriparatide and bisphosphonates in fracture prevention in postmenopausal women with osteoporosis.

The authors conducted a meta-analysis, pooling data from 9 different randomized controlled trials, including the VERO trial. Ouyang et al. assessed the incidence of new vertebral and non-vertebral (e.g., hip, arm) fractures in the 2 study arms.

Overall, the analysis results support that teriparatide was better than bisphosphonates in preventing both fracture types, vertebral and nonvertebral, in postmenopausal women with osteoporosis (fracture risk not specified). These results reflect data collected at both 12- and 18-month follow-up visits.

Women taking teriparatide did not experience more adverse events (eg, arthralgia, back pain, hyperuricemia) compared to bisphosphonates.

Two obvious limitations exist for teriparatide use

Cost: average wholesale price (AWP) is ~$3,000 (generic) for a 28-day supply

Administration: daily subcutaneous injection

Oral and intravenous bisphosphonates are less expensive (AWP: ~$150) and administered anywhere from once per week to once per year.

The 2020 American Association of Clinical Endocrinologists & American College of Endocrinology and 2020 Endocrine Society guidelines contain a treatment algorithm based on fracture risk and history. Currently, teriparatide is only first-line therapy in postmenopausal osteoporotic women with very high fracture risk and/or prior fracture history. Bisphosphonates are first-line in women with high risk and/or no prior fractures and are an alternative treatment to teriparatide.

Despite the positive study findings, the authors concluded a cost-benefit analysis and further studies are necessary to determine what place teriparatide truly has in treatment guidelines.

 is a 2021 PharmD Candidate at the University of Connecticut in Storrs.

Robinson WA, Carlson BC, Poppendeck H, et al. Osteoporosis-related vertebral fragility fractures: A review and analysis of the American Orthopaedic Association's Own the Bone database. 

. 2020;45(8):E430-E438. doi:10.1097/BRS.0000000000003324

Lee SB, Park Y, Kim DW, et al. Association between mortality risk and the number, location, and sequence of subsequent fractures in the elderly. 

. 2021;32(2):233-241. doi:10.1007/s00198-020-05602-x

Ouyang Y, Chen S, Wan T, Zheng G, Sun G. The effects of teriparatide and bisphosphonates on new fractures in postmenopausal women with osteoporosis: A protocol for systematic review and meta-analysis. 

. 2021;100(7): e24839. doi:10.1097/MD.0000000000024839

RED BOOK Online. IBM Micromedex [database online]. IBM Watson Health; 2021. Accessed March 22, 2021. https://www.micromedexsolutions.com

Camacho PM, Petak SM, Binkley N, et al. American Association of Clinical Endocrinologists/American College of Endocrinology clinical practice guidelines for the diagnosis and treatment of postmenopausal osteoporosis – 2020 update. 

. 2020;26(Suppl 1):1-46. doi:10.4158/GL-2020-0524SUPPL

Eastell R, Rosen CJ, Black DM, Cheung AM, Murad MH, Shoback D. Pharmacological management of osteoporosis in postmenopausal women: An Endocrine Society* clinical practice guideline. 

. 2019;104(5):1595-1622. doi:10.1210/jc.2019-00221

Shoback D, Rosen CJ, Black DM, Cheung AM, Murad MH, Eastell R. Pharmacological management of osteoporosis in postmenopausal women: An Endocrine Society guideline update. 

. 2020;105(3):dgaa048. doi:10.1210/clinem/dgaa048

Fractures, especially subsequent ones, positively correlate with an increased mortality risk.