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GPhA 2011 Convention June 18-22, 2011 Register Now!
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Celebrating 30 years of service to the Pharmacists of Georgia!
Let us be Your Insurance Resource Join us in celebrating 30 years of serving the members of the Georgia Pharmacy Association. To learn more visit www.gpha.org. Call TODAY to schedule a time to discuss your health insurance needs.
404.237.8435
Georgia Pharmacy Association Members Take Advantage of Premium Discounts Up to 30% on Individual Disability Insurance Have you protected your most valuable asset? Many people realize the need to insure personal belongings like cars and homes, but often they neglect to insure what provides their lifestyle and financial well-being - their income! The risk of disability exists and the financial impact of a long-term disability (90 days or more) can have a devastating impact on individuals, families and businesses. During the course of your career, you are 3½ times more likely to be injured and need disability coverage than you are to die. (Health Insurance Association of America, 2000) As a member of the Georgia Pharmacy Association, you can help protect your most valuable asset and receive premium discounts up to 30% on high-quality Individual Disability Income Insurance from Principal Life Insurance Company.
For more information visit www.gpha.org. * Association Program subject to state approval. Policy forms HH 750, HH 702, HH 703. This is a general summary only. Additional guidelines apply. Disability insurance has limitations and exclusions. For costs and details of coverage, contact your Principal Life financial representative.
The Georgia Pharmacy Journal
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May 2011
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Departments
GPhA 2011 Convention Register NOW! FEATURE ARTICLES
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Pharm PAC 2010-2011 APhA Programs Information GPhA New Members Alumni Dinner Registration 12th Annual Georgia Pharmacy Foundation Golf Tournament 31 GPhA Board of Directors
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GPhA Moves to Online Voting Legislative Wrap-up 2011 Convention CPE Line-up Toye Moye Appointed to Georgia Board of Pharmacy
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The Insurance Trust Principal Financial Group Logix, Inc. Melvin Goldstein, P.C. Pharmacists Mutual Companies GPhA Workers Compensation AIP Bill McLeer for GPhA 2nd VP PQC University of Florida The Insurance Trust
Mr. Burcher Goes to Washington Continuing Education for Pharmacists: Understanding Asthma in Children and Adults: A Primer for Pharmacists
COLUMNS
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For an up-to-date calendar of events, log onto
President’s Message
www.gpha.org.
Editorial
The Georgia Pharmacy Journal
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May 2011
PRESIDENT’S MESSAGE Dale M. Coker, R.Ph., FIACP GPhA President
Disruptive Innovation/Seattle Stoned recent trip to Seattle, Washington, for the APhA annual convention will be long remembered on several counts, especially for one insightful presentation and a very memorable personal experience. The keynote speaker, Dr. Clayton Christensen, gave a brilliant presentation based on a book he had written entitled “The Innovator’s Prescription.” Dr. Christensen is a Harvard business professor who wrote the book in an effort to provide a solution to the seemingly unmanageable health care web that has been weaved in our country. He spoke about the need for disruptive innovation in our health care system. This is the type of innovation that can change an entire industry, or that can change the way an entire nation, or even the world, does business.
Christensen, is to decentralize, just as the personal computer had caused in relation to the main frame computer. He suggested breaking health care into specialty units, so that instead of trying to be everything to everybody, the emphasis is on being the best in the chosen area of specialty. Although he didn’t mention pharmacy in particular in this example, the implications are clear. Specialties in MTM, diabetes education, consultative services, and compounding are all examples of areas in which innovative pharmacists are already reaping professional as well as financial success in Georgia as well as across the country.
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Christensen used the example of the personal computer to explain what he means by disruptive innovation. Once personal computing made its way into businesses and homes, there became very limited use in the market for main frame computers. Those companies manufacturing main frame computers who did not recognize the changing market and refused, or waited too late to adjust to the market, soon found themselves out of business. I’m going to date myself, but I remember those first days of computers in pharmacies. In my first two years of practicing pharmacy, we were still using typewriters to produce prescription labels. Then in 1980, I worked for an independent pharmacy in Hiram, Georgia. The owner purchased a computer for around $20,000. I still remember that 200 pound monstrosity sitting in the corner of the pharmacy, purring like an air conditioning compressor. Then, as we all know, the affordable personal computers came along the next couple of years and made their way into every pharmacy in the country.
As I was listening to the speaker, I couldn’t help but think of the past two recipients of the GPhA Innovative Pharmacist awards, David Pope from Barney’s Pharmacy in Augusta, and the team of Jonathan and Pamala Marquess, who own several independent pharmacies in the North Atlanta area. David’s innovative approach to diabetes education and management has earned him national recognition. The education component of the Marquess’ practice makes them stand out in the crowd. Additionally, being sworn in as the first APhA Trustee from Georgia also speaks to Jonathan’s national recognition. In addition to learning about disruptive innovation while in Seattle, I experienced quite a different kind of disruption, which is what I referred to in the title of this article- Seattle Stoned, kidney stoned, that is. Thank goodness for pharmacist friends on the same flight who happened to have enough meclizine to knock me out so I could survive the flight back to Atlanta. As they say, all is well that ends well, as the boulder sized 9mm stone was passed a few agonizing days later. My urologist has prescribed a beer a night to solve my kidney stone problems. So this one’s for pharmacy innovation and no more stones!
The innovation brought about by the personal computer changed the landscape forever for information technology. But how, you might ask, does this relate to health care? He explained by making an analogy between the main frame computer and the centralization of health care. In his particular example, he explained how the hospital system in this country attempts to be everything to everybody, an attempt, he says, that can never be possible. The solution to the health care crisis, according to
The Georgia Pharmacy Journal
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May 2011
GPHA NEWS
GPhA Changes its Election Process: Important Date Changes for 2011 Election post-marked no later than midnight June 10, 2011, in order to allow for pick up, ballot security and counting.
February 15, 2011 The Georgia Pharmacy Association Nominating Committee made up of the twelve Region Presidents and the GPhA President will meet to consider nominations from the membership. March 20, 2011 The Georgia Pharmacy Association Nominating Committee will submit their selections for candidates for GPhA First Vice President and Second Vice President to the GPhA membership. Any GPhA member who would like to be a candidate for First or Second Vice President and is not among those presented by the GPhA Nominating Committee may petition to have their name included on the ballot or these offices. The petition requires the signature of at least twenty active members of the Georgia Pharmacy Association for the candidate to be certified by the GPhA Executive Vice President as a candidate via petition, and will allow candidates time to reach out to the membership during the Spring Region Meetings.
June 21, 2011 At noon on this date the electronic ballot via the internet will be closed and no other votes accepted. This will allow the candidates several days at the annual meeting to reach out to members who will be allowed to vote via the internet at the convention. An electronic tally will be provided to the Teller’s Committee at 3:00 p.m. on this day, and the results announced to the GPhA Board of Directors. The newly elected officers of GPhA will installed at the President’s Inaugural Banquet. We will be sending ballots via the email address we have on file at the GPhA office. If you do not wish to receive a digital ballot please call Tei Muhammad at 404-419-8115, and provide her with the mailing address at which you wish to receive your paper ballot. For those without email addresses on file with GPhA you will receive a paper ballot.
April 19, 2011 Noon on this date is the last time in which a candidate not presented by the GPhA Nominating Committee, can petition GPhA to be on the ballot as a candidate for office. Any member of GPhA not wishing to vote via the internet may request from GPhA via phone, mail or email a paper ballot for voting by April 19, 2011.
If you have any questions about the election process please contact Maggie Patterson at mpatterson@gpha.org or 404-4198120.
May 4, 2011 On this day voting via the internet will open. All paper ballots must be returned to the special GPhA post office box and be
GPhA Needs You and Your Pharmacy Knowledge We are looking for a few good writers to write CPE Articles for the GPhA Journal. If you are interested in building your resume and helping GPhA create the premier CPE program in the state of Georgia please contact us at 404-231-5074. The Georgia Pharmacy Journal
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May 2011
FEATURE ARTICLE
Legislative Wrap-up 2011 by Andy Freeman Director of Government Affairs
ust a few weeks ago, the 2011 Session of the Georgia General Assembly ended. In the 40 day session, over 2500 bills and resolutions were introduced, of which around 80 contained some language in either the code section of Georgia law for controlled substances or the code section for pharmacies and pharmacists.
GPhA for six years. Pseudoephedrine is the main ingredient used to manufacture methamphetamine and by making it only available in pharmacies behind the counter, it should reduce the amount of meth that is manufactured in Georgia.
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On the last day of the session, we introduced SB 288 to allow pharmacists to give any immunization that is recognized by the CDC to patients while working within a protocol agreement with a physician, much like pharmacies can do with influenza vaccines now. Legislative hearings are already in the planning stages around this legislation for this summer and fall.
With help from members like you, GPhA was successful in passing our legislative agenda and defeating legislation that would be harmful to you, including beating back several attempts to add sales taxes to prescription drug purchases and repeated attempts by HCA hospital chains trying to attach language to different bills to allow automated pill dispensers without any involvement of a pharmacist in a hospital.
The success GPhA had this session is directly proportionate to the work our members are doing by their involvement in PharmPac and their direct contact with their individual legislators. Next year is going to be another great year because of this continued involvement of members like you.
One of our legislative victories was the passage of SB 36, the Prescription Drug Monitoring Bill. For four long legislative sessions, GPhA led the legislative fight to pass this legislation and the final version is something that we can be proud of. Despite attempts by some to severely limit what drugs would be monitored, SB 36 covers Schedules II through Schedule V narcotics. Georgia was the last state in the Southeast to pass this legislation, which led to us being a haven for prescription drug abusers. Even with the pill mills that have been popping up all over the state, it was still a battle to pass SB 36 because of some legislators’ concerns over privacy issues. The compromise we reached allows pharmacists and doctors to access the database but law enforcement will require a subpoena to view its information. GPhA also passed SB 93, the Annual Drug Update Bill, which included designating pseudoephedrine as a Schedule V Exempt Narcotic. This had been a legislative priority for
The Georgia Pharmacy Journal
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July 2010
EXECUTIVE VICE PRESIDENT’S EDITORIAL Jim Bracewell Executive Vice President / CEO
Unity: the Power of Pharm PAC
hat is the power and clout of Pharm PAC?
leadership of our state.
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Over fifty legislators also arrived between 7 a.m. and 8:30 a.m. to meet with pharmacy constituents from across the state.
It is our unity of purpose in the support of legislative office holders and candidates. “You have more clout and influence than you think you do,” said PAC Chairman, former state Senator Eddie Madden. When you reflect on the turn out for our February 23, 2011, VIP Day at the state capitol, you have to be amazed at the results of our unified effort.
Unity of purpose is the backbone of Pharm PAC. All the contributions that were given last fall to legislators and candidates who support pharmacy could have been given by all the individual pharmacists who support Pharm PAC but the power and clout of the unified contributions from pharmacy would have been lost among the countless individual ones that an office holder must solicit. A check from Pharm PAC was larger and clearly said this support is on behalf of the profession of pharmacy and represents a unity of purpose.
Mike Smith, the head football coach of the Atlanta Falcons, was on the coaching staff of the Baltimore Ravens when they won the Super Bowl in 2001, and he has coached with several other teams. I believe Coach Mike Smith has a unique perspective on what makes a football team a great football team. A great team is one that wins the Super Bowl while an average team doesn’t. Coach Smith has a simple one word answer and that word is–Unity.
Advocacy is a team sport. One person, one pharmacist alone does not have the power or the clout of a team of pharmacists united in purpose, speaking with one clear voice. The list of Pharm PAC contributors now runs onto two pages of this journal. Is your name there? Are you on the team that passed significant legislation to improve the practice of pharmacy this legislative session? Are you on the team that will expand the scope of the practice of pharmacy in the delivery of immunizations next year? If not, it is time you stepped up and joined the Pharm PAC team and celebrate with us at the Pharm PAC event at the GPhA Convention at Amelia Island.
Unity is the key. Whether you are talking about a sports team, work team, school team, or a health care team, it is essential that we get everyone on the bus and moving in the right direction with a shared vision, focus, purpose, and direction. When a team comes together, they are able to succeed together and succeed we did on VIP Day according to Madden. The speakers on the podium were Governor Nathan Deal, Insurance Commissioner Ralph Hudgins, Attorney General Sam Olens, Speaker of the House David Ralston, and Commissioner of the Department of Health and Human Services David Cook. No other organization in the state has had that level of participation from the The Georgia Pharmacy Journal
UNITY – the power of Pharm PAC.
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Pharm PAC Enrollment Pledge Year 2010-2011
Titanium Level ($2400 minimum pledge) Michael E. Farmer, R.Ph. David Graves, R.Ph. Jeffrey L. Lurey, R.Ph. Robert A. Ledbetter, R.Ph. Marvin O. McCord, III, R.Ph. Judson L. Mullican, R.Ph. W.A. (Bill) Murray, R.Ph. Mark L. Parris, Pharm.D. Fred F. Sharpe, R.Ph. Jeff Sikes, R.Ph.
Platinum Level ($1200 minimum pledge) Robert Bowles, Jr., R.Ph., CDM, Cfts Jim Bracewell T.M. Bridges, R.Ph. Bruce L. Broadrick, Sr., R.Ph. Thomas E. Bryan, Jr., B.S. William G. Cagle, Jr., R.Ph. Keith Chapman, R.Ph. Hugh M. Chancy, R.Ph. Dale M. Coker, R.Ph., FIACP J. Ashley Dukes, R.Ph. Jack Dunn, R.Ph. Stewart Flanagin, Jr., R.Ph. Andy Freeman Ann Hansford, R.Ph. Robert M. Hatton, Pharm.D. Alan M. Jones, R.Ph. Ira Katz, R.Ph. Harold M. Kemp, Pharm.D. J.Thomas Lindsey, R.Ph. Brandall S. Lovvorn, Pharm.D. Eddie M. Madden, R.Ph. Jonathan Marquess, Pharm.D., CDE, CPT Pam S. Marquess, Pharm.D. Kenneth A McCarthy, R.Ph.
Scott Meeks, R.Ph. Drew Miller, R.Ph., CDM Laird Miller, R.Ph. Jay Mosley, R.Ph. Allen Partridge, Jr., R.Rh. Tim Short, R.Ph. Dean Stone, R.Ph., CDM Chris Thurmond, Pharm.D.
Gold Level ($600 minimum pledge) Larry Batten, R.Ph. James Bartling, Pharm.D., ADA, CAC II Liza G. Chapman, Pharm.D. Patrick M. Cook, Pharm.D. Mahlon Davidson, R.Ph., CDM Jim Elrod, R.Ph. H. Neal Florence, R.Ph. Kevein Florence, R.Ph. Ted Hunt, R.Ph. Robert B. Moody, III, R.Ph. Sherri S. Moody, Pharm.D. Sharon M. Sherrer, Pharm.D. Michael T. Tarrant Jeffrey Richardson, R.Ph. Houston L. Rogers, Jr., Pharm.D., CDM Robert Anderson Rogers, R.Ph. Daniel C. Royal, R.Ph. Dean Stone, R.Ph., CDM Thomas H. Whitworth, R.Ph., CDM
Silver Level ($300 minimum pledge) Renee D. Adamson, Pharm.D. John L. Colvard, J. R.Ph. Chandler Conner, R.Ph. F. Al Dixon, R.Ph. Marshall L. Frost, Pharm.D.
James Jordan, R.Ph. Michael O. Iteogu, Pharm.D. John Kalvelage Willie O. Latch, R.Ph. W. Lon Lewis, R.Ph. Michael McGee, R.Ph. William J. McLeer, Sr., R.Ph. Albert Nichols, R.Ph. Kalen Beauchamp Porter, Pharm.D. Bill Prather, R.Ph. Sara Mandy Reece, Pharm.D. Edward Franklin Reynolds, R.Ph. David Jack Simpson, R.Ph. James Thomas, R.Ph. Alex S. Tucker, R.Ph. Brandon Ullrich Alan M. Voges, Sr., R.Ph. Flynn W. Warren, M.S., R.Ph. Oliver C. Whipple, R.Ph. Walter Alan White, R.Ph.
Bronze Level ($150 minimum pledge) Monica M. Ali-Warren, R.Ph. John Bowen, R.Ph. James R. Brown, R.Ph. Mark C. Cooper, R.Ph. Michael A. Crooks, Pharm.D. Charles Alan Earnest, R.Ph. Amanda R. Gaddy, R.Ph. Amy S. Galloway, R.Ph. Johnathan Hamrick, R.Ph. EdKalvelage Steven Kalvelage Marsha Kapiloff, R.Ph. William E. Lee, R.Ph. Earl Marbut, R.Ph. Leslie Ponder, R.Ph. Richard Brian Smith, R.Ph.
If you made a gift or pledge to Pharm PAC and your name does not appear above please, contact Kelly J. McLendon at kmclendon@gpha.org or 404-419-8116. Donations made Pharm PAC are not considered charitable donations and are not tax deductible. The Georgia Pharmacy Journal
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May 2011
Pharm PAC Contributors’ List Continued Marion Wainright, R.Ph. Steven Wilson, R.Ph. Sharon B. Zerillo, R.Ph. Jackie White John Kalvelage Carey B. Jones, R.Ph. Fred W. Barber, R.Ph. Jeffrey Richardson, Jr., R.Ph.
Members (no minimum pledge) Jill Augustine Claude W. Bates, B.S. Chad J. Brown, R.Ph. Max C. Brown, R.Ph. Lucinda F. Burroughs, R.Ph. Shobhna D. Butler Pharm.D. Waymon M. Cannon, R.Ph. Walter A. Clark, Jr., R.Ph. Jean N. Courson, R.Ph. Carleton C. Crabill, R.Ph. Charles Gass, R.Ph. Alton D. Greenway, R.Ph. J. Clarence Jackson, Jr., R.Ph. Gina R. Johnson, Pharm.D., BCPS, CDE Joshua Kinsey, Pharm.D. Ashley S. London Charles Lott, R.Ph. Tracie D. Lunde, Pharm.D. Randall Marett, R.Ph. Ralph K. Marett, M.S. Roy McClendon, R.Ph. Steve Perry, R.Ph. Whitney B. Pickett, Pharm.D. Donald Piela, R.Ph. Rose Ann Pinkstaff, R.Ph. Michael Reagan, R.Ph. Leonard Franklin Reynolds, III, R.Ph. James Riggs, R.Ph. Victor Serafy, R.Ph. Harry A. Shurley, Jr., R.Ph. James Strickland, R.Ph. Leonard Templeton, R.Ph. Heatwole Thomas, R.Ph. James. E. Stowe, Jr., R.Ph. Erica Veasley, R.Ph. William D. Whitaker, R.Ph. Jonathon A. Williams, Pharm.D. Michael R. Williams, R.Ph.
The Georgia Pharmacy Journal
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APhA Certification Course in Pharmaceutical Care for Patients With Diabetes Friday, June 17, 2011 (12:30 - 6:30 PM) For more details and to register online today visit www.gpha.org or call 404-231-5074. If you plan to attend the GPhA Convention you must register for that event separately. Cost: Member: $350 Potential Member: $450 Student: $175 The American Pharmacists Association and the Georgia Pharmacy Association are accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. If you have any questions about these events please call 404-231-5074.
Basic Life Support for Health Care Providers Course Monday, June 20, 2011 (1:00 PM - 5:00 PM) Amelia Island Plantation 6800 First Coast Highway Amelia Island, FL 32034 For more details and to register online today visit www.gpha.org or call 404-231-5074. Cost: Member: $75 Potential Member: $100 Cancelation Policy: No refunds will be issued; however, timely notification of cancelation may allow another pharmacist to participate in this program. The Georgia Pharmacy Association is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.
The Georgia Pharmacy Journal
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May 2011
GPHA MEMBER NEWS
Welcome to GPhA! The following is a list of new members who have joined Georgia’s premier professional pharmacy association! Pharmacy School Student Members New Graduate Pharmacist Members Emilee Ann McDonald, Athens Todd Thomas, Athens Zachary Germann, Suwanee John Dow Hyerm, Rincon Fei Wang, Atlanta Dorris Ottens, Athens Bonnie Angel Rhodes, Buford Travis Ray Harrison, Jesup Judith I. Onwubiko, Lithonia Amanda Yassin, Savannah Thuy-Linh Thi Vo, Silver Spring, MD Afeez Salako, Lawrenceville Mebanga Ojong, Lawrenceville Priyank Devta, Snellville Melissa S. Denno, Atlanta
Cecilia J. Inhulsen, Pharm.D., Montezuma Jason Montegna, Pharm.D., Scottdale Thomas Henry Teasley, Pharm.D., Elberton
Individual Pharmacist Members Karen Michele Long, R.Ph., Tunnel Hill Mindy Kim, Pharm.D., Marietta Michael J. Deming, Ph.D., Suwanee Mitra Salehi, Pharm.D., Suwanee April L. Scott, R.Ph., Abbeville, SC Uko Ukoh, R.Ph., Dallas Kareema D. Abdul-barr, R.Ph., McDonough Hannah Couch, R.Ph., Watkinsville Betsy B Muia, Pharm.D., Atlanta Richard Kyle Lott, Pharm.D., West Green Wendy Dawson, Pharm.D. Brunswick Sara J. Lamb, R.Ph., Valdosta Jessica Taylor, Pharm.D., Woodstock Cimone Carter Forbes, Pharm.D., Grovetown Charles Nolan Dooley, R.Ph., Jefferson Travis Stream, R.Ph., Waycross Ginger Mendoza, R.Ph., Columbus Audrey M. Eckles, Pharm.D., McDonough Behzad Khazami, R.Ph., Atlanta Brandon Robert Selph, Pharm.D., Statesboro James “Jim” W. White, R.Ph., Kennesaw Robert M. Woodall, R.Ph., Villa Rica Lorri S. Cartin, R.Ph., Powder Springs Marian E. VanAmore’, R.Ph., Woodstock Nnenna K. Makanjuola, Pharm.D., Mabelton Adeyemi O. Takon, R.Ph., Suwanee Jonathan W. Taylor, Pharm.D., Stockbridge Alicia Todd Valdez, Pharm.D., Atlanta Ketan Patel, Pharm.D., Alpharetta Anna Marie Faulk, R.Ph., Jeffersonville
Pharmacist Technician Members Brandy Nicole Medlin, Villa Rica Kay Goodman, Tifton Josh A. Clark, C.Ph.T., Alamo Audrey Pietersen, C.Ph.T., Acworth Carol Coston, C.Ph.T., Kennesaw Cindy Cargill, C.Ph.T., Dallas Pat VanLinden, Acworth Robbie LaShawn Howard, Lithonia Stephen Andrew Farr, C.Ph.T., Martinez Lydia J. Daniel, Dallas Aurie L. Harden, East Dublin
Associate Members David W. Newman, Blue Ridge
The Georgia Pharmacy Journal
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May 2011
June 18-22, 2011: GPhA Convention, Amelia Island Plantation, Amelia Island, Florida Join us on the beaches of Amelia Island to learn about new trends in our ever-changing world of pharmacy. Lock in the lowest rates when you register today! The Plantation highlights include: • 249 luxurious oceanfront rooms with patios & balconies overlooking the Atlantic ocean • Indoor and outdoor pools and fully equipped fitness center • Luxurious full-service spa and salon on site • Golf & tennis shops on site and numerous activities available • Several fine and casual dining options • More than 49,000 square feet of state-of-the-art meeting space
Registration Form: GPhA Registration Types (Circle the rate below that applies): GPhA Member GPhA Potential Member GPhA Student Member
5/2 - 6/1 $320 $495 $150
6/1 - 6/17 $345 $520 $175
On site $400 $570 $175
Registration Options (Circle all below that apply): Spouse and Guest Registration (Does not include CPE) $265 Name of Guest or Spouse: ___________________ Student Sponsorship $100 Tennis Tournament Registration $25 Convention T-shirt $20 Name: ____________________________________________________ License Number: ___________ Billing Address for Credit Card: ___________________________________________________________ City: ________________________________ State: _____________ Zip Code: ___________________ Email Address:______________________________________________________________________ Credit Card Number: __________________________________ CID#: __________________________ Expiration Date: ___________ Total to be billed from above: _________ Fax thiscompleted form to Kelly McLendon at 404-237-8435. How to reserve a hotel room: For information regarding hotel reservations visit www.gpha.org or call 904-261-6161. Cancelation Policy: All registration cancelations must be in writing and emailed to kmclendon@gpha.org. Cancelations received before June 1, 2011, will be refunded less a $50 cancelation fee. After June 1, 2011, all registration fees will be non-refundable. The Georgia Pharmacy Association is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.
The Georgia Pharmacy Journal
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Mercer University College of Pharmacy and Health Sciences Alumni Dinner Monday, June 20, 2011, at 7:30 p.m. Sandy Bottoms Beach Bar & Grill, 2910 Atlantic Ave., Main Beach, Fernandina Beach, FL Please make ______ reservations at $35.00 per person. _______ I would like to sponsor ______ student(s) for the alumni dinner at $35.00 each. Name (on Credit Card): _______________________________________________________________ Name of spouse and/or guest(s): _________________________________________________________ Billing Address: _____________________________________________________________________ City: _______________________________ ST: ___________ Zip Code: ______________________ Cell: ____________________________ Work: ___________________________________________ E-mail: ___________________________________________________________________________ Circle One: Check Visa Master Card Amex Card Number: __________________________________ CVS#: __________ Exp.Date: ____________ Mail registration form to Sharon Lim Harle, Mercer University, 3001 Mercer University Drive, Atlanta, GA 30341. Make check payable to Mercer University. For more information call (678) 547-6420 or e-mail to lim_s@mercer.edu.
University of Georgia College of Pharmacy Alumni Dinner Monday, June 20, 2011, at Slider’s Seaside Grill 1998 S. Fletcher Ave., Fernandina Beach, FL 7:30 p.m. I will attend the Alumni Dinner for alumni spouses and friends of University of Georgia College of Pharmacy. Please make ______ reservations at $35.00 per person. _______ Yes, I would like to sponsor ______ student(s) for the alumni dinner at $35.00 each. Name: ______________________________________________ Name of spouse and/or guest(s): Address: City:
Class/Year:
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______________________________________________________________________
_____________________ State: ___________
Zip code:
_____________________
Work Phone: _________________________ Home Phone: __________________________ Mail registration form with check, payable to UGA Foundation, by June 17, 2011, to Sheila Roberson, College of Pharmacy Alumni Director, University of Georgia, College of Pharmacy, Athens, GA 30602. For more information please call 706.542.5303. The Georgia Pharmacy Journal
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May 2011
GPhA 2011 Convention CPE Line-up: Schedule is Tentative Audit Preparation and Reduction Tips Marlana Smith 6/21, 8:00 - 9:00 am CPE Hours: 1
General Session - Current Legislative / Healthcare Reform? Andy Freeman, Bob Greenwood CPE Hours: 2.5
Novel Routes of Drug Administration Kevin Henning 6/19, 8:00 - 9:00 am CPE Hours: 1
Addiction in pharmacy - treating patients OR pharmacists addictions Jim Bartling 6/18, 9:00 - 10:00 am CPE Hours: 1
General Session - State of the Profession? Tom Mennighan, APhA CPE Hours: 1
A Pharmacist's Role in Obesity Treatment Terry Forshee 6/21, 1:00 - 2:00 pm CPE Hours: 1
HIV / AIDS: The Community Pharmacist's Perspective Keith Herist 6/21, 1:00 - 3:00 pm CPE Hours: 2 Brown Bag Sharon Zerillo - coordinator 6/18, 1:30 - 2:30 pm CPE Hours: 1 Diabetes 1 - Guidelines and Treatment Mandy Reece 6/18, 9:00 - 10:00 am CPE Hours: 1 Diabetes 2 - Blood Glucose Monitoring: An Overlooked Treatment for Diabetes Jonathan Marquess 6/18, 10:30 - noon CPE Hours: 1.5 Diabetes 3 - Insulin 101: A Case-Based Approach to Understanding Insulin Adjustment Gina Ryan Johnson 6/19, 8:00 - 9:00 am CPE Hours: 1 Emergency Preparedness: Working Under Protocol Catherine White 6/21, 1:00 - 2:00 pm CPE Hours: 1
The Georgia Pharmacy Journal
Geriatric Pharmacy Armon Neel 6/20, 8:00 - 9:00 am CPE Hours: 1 Immunization Update 2011 Liza Chapman 6/19, 8:00 - 9:30 am CPE Hours: 1.5 Pharmacy Law Review Flynn Warren 6/18, 1:30 - 3:30 pm CPE Hours: 2 Current Concepts In Lipid Therapy Management Charles McDuffie, Lindsey Welch 6/20, 8:00 - 9:00 am CPE Hours: 1 Men's Health: Hypogonadism and Commercially available Testosterone Replacement Therapy Dee Fanning 6/18, 11:00 - noon CPE Hours: 1
OSHA Update Liza Chapman 6/21, 8:00 - 9:00 am CPE Hours: 1 Pharmacogenomics for the Pharmacist Thomas C. Kupiec (Contact - Amy Dean) 6/20, 8:00 - 9:00 am CPE Hours: 1 Pharmacists Pheud Josh Kinsey - coordinator, Dee Dee McEwen 6/19, 1:15 - 4:00 pm (general session) CPE Hours: 1.5 Poster Presentation 6/18, 11:00 - noon CPE Hours: 1 Self-care / OTC Update Sukh Sarao 6/20, 1:00 - 2:00 pm CPE Hours: 1
MTM - Geriatric Pharmacy Armon Neel 6/20, 1:00 - 2:00 pm CPE Hours: 1
2011 Women's Health Update Heather DeBellis, Lauren Garton 6/21, 8:00 - 9:00 am CPE Hours: 1
New Drug Update: A Formulary Approach Rusty May 6/18, 9:00 - 10:00 am CPE Hours: 1
Revitalize Your Store from the Outside In Gabe Trahan 6/19, 10:00 - 11:30 am CPE Hours: 1.5
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Do you want to work for an Independent Pharmacy?
Do you want to own your own pharmacy? Call Jeff Lurey, R.Ph. AIP Director 404Ǧ419Ǧ8103 jlurey@gpha.org
FEATURE ARTICLE
GPhA Member Appointed to the Georgia Board of Pharmacy by Rebecca Brewer
s Governor Perdue’s last appointee to the Georgia State Board of Pharmacy, Tony Moye is excited to serve the pharmacists and citizens of the state. “It has been one of my dreams to be able to serve on this board,” Tony said. “I thank Governor Perdue for believing in me and trusting that I will be an asset to this great board. Many wonderful men and women have served well and brought us forward in Georgia. I hope and pray that my appointment will do the same.”
award, and Mercer University awarded him its Young Alumni award. An Eagle Scout himself, Tony has also been very involved in the Boy Scouts of America and received the Golden Eagle award from the Flint River Council BSA as well as the God and Country award.
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In a recent interview, we asked Tony about the biggest influence in his life that led him to success. “My parents taught me that I could be and do anything if I set out to achieve that goal,” Tony said. “I followed their advice and tried to live up to their expectations, as well as those of Dr. Vince Lopez, who taught me and gave me great support and advice during school.”
Tony has been serving his community as a pharmacist for almost forty years. A graduate of the University of West Georgia in 1970, Tony went on to complete his education at Mercer University, earning a B.S. in pharmacy in 1973. He has been a member of the Georgia Pharmacy Association since his graduation from pharmacy school.
Asked about the changes in pharmacy since he began working, Tony said, “Change is a part of our life, which is very evident in the pharmacy world. When I graduated, the average pharmacist filled 75 prescriptions a day. Most of the drugs that we studied in pharmacy school are not even in use anymore.
For the first few years after graduation, Tony worked in a couple of different locations, learning the ropes of owning and running a pharmacy business until he felt he was ready to strike out on his own. The first Moye’s Pharmacy was established in McDonough in 1977, and has grown to six locations, including Moye’s Long Term Care and Mobility Warehouse. In 2007, the hard work and dedication of Moye’s Pharmacy was recognized by McKesson as a national pharmacy of the year.
In the beginning of my practice, we had much more time to spend with the patients. Now managed care controls much of our life and there are more rules and regulations and fewer new drugs coming out of the pipeline. But I also believe there are many more areas of opportunity for pharmacists to excel and expand their profession.”
Tony and his wife, Nancy, live in McDonough and enjoy spending time with their son Michael and his family – wife, Lisa, and daughters, Abby and Lilly. The Moyes have always been involved in their community and Tony has been recognized and awarded by various community organizations for his service. In 2008, he was named Henry County Citizen of the Year, and he is also a previous recipient of the Herman Talmadge Visionary award in Henry County. The University of West Georgia awarded Tony its Alumni Achievement
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We asked Tony what he would like to see in the future for the pharmacy profession, a wish list of sorts: “My wish list for pharmacy is to enjoy the profession, look forward every day to a new adventure and have a more level playing field in managed care. And smile a lot and enjoy your family.” GPhA is proud of Tony and looks forward to working with him in his appointed position.
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Tony Moye’s Biography Community Involvement: Former trustee of University of West Georgia Foundation Two terms as trustee of Mercer University Past chair of Henry County Chamber of Commerce Past president of Kiwanis Club, McDonough Director of United Community Bank, Henry County Georgia Sports Hall of Fame Authority member Adjunct professor, Mercer School of Pharmacy and Health Sciences Past chair of McKesson’s national advisory board Served as member of Independent Pharmacy Co-op board of directors Past member of board of governors of Eagles Landing County Club Past president of Alumni Association for Mercer’s Pharmacy School
GPhA member since 1973 Education: B.A. Biology, 1970, University of West Georgia B.S. Pharmacy, 1973, Mercer University Southern School of Pharmacy Employment: Standard Rexall, McDonough Oglethorpe Pharmacy, Atlanta Opened Moye’s Pharmacy in McDonough, 1977 Awards: Henry County Citizen of Year, 2008 Herman Talmadge Visionary award, Henry County Golden Eagle award winner, Flint River Council BSA Eagle Scout and God and Country award with the Boy Scouts University of West Georgia Alumni Achievement award Young Alumni award, Mercer University
Personal: Married to Nancy One son, Michael, and his wife, Lisa Two wonderful granddaughters, Abby and Lilly
This is a paid advertiment, and should not be construed as an endorsement.
Elect
B BILL MCLEER
F o r 2 ND Vice President of GPHA The Right Prescription for the Georgia Pharmacy Association
TRUSTED •INVOLVED • COMMITTED To serve Georgia Pharmacists in all Practice Settings
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•BILL BACKS PHARM PAC •2008 Recipent of the GPHA ‘s Mal T. Anderson Outstanding Region President Award • Region President 4 years • AEP Chairman 2 years • AEP Board of Directors 6 years • GPHA Board of Directors 6 years • A longͲstanding member of GPHA • Member of APhA • Previous Independent Pharmacy owner 6 years • Currently employed Fred’s Pharmacy, Zebulon
Bill is ready to continue giving back to the profession which has afforded him 38 years of pharmacy practice. As a candidate for 2nd Vice President, Bill is ready to serve GPHA by continuing to promote and enhance the pharmacy profession as it serves Georgians.
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FEATURE ARTICLE
Mr. Burcher Goes to Washington by Kyle Burcher
just returned from the RxImpact “U” Academy in Washington, D.C., organized by the National Association of Chain Drug Stores (NACDS). The academy is designed to develop and hone advocacy skills for student pharmacists. Not only did the Academy prepare me for a lifetime of advocacy and leadership, I was able to immediately put my new found skills to good use as I met with many Georgia legislators the following day as part of NACDS RxImpact Day on Capitol Hill. I was among my peers at the meeting as nearly 100 student pharmacists attended the academy from 32 schools or colleges of pharmacy.
I was further instilled with passion for advocacy by a presentation by Dr. John Michael O’Brien, policy coordinator for the Center for Medicare and Medicaid Services. O’Brien painted a clear portrait of student pharmacist’s potential to influence the policy process and drive change. As large an endeavor as that may seem, after attending the Academy I realized that it was very possible. Through these presentations the students learned how to become effective promoters for the profession.
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Walking into congressional offices the next day to speak with legislators may have intimidated me before, but after the Academy I was strengthened and confident in my propharmacy message. My fellow Georgia students and I spoke with three congressman and many legislative aides regarding H.R. 891: Medication Therapy Management Benefits Act of 2011 and how it would benefit both patients and pharmacists alike.
Alex Adams, the event coordinator and Director of Pharmacy Programs for NACDS, explained that “The overarching goal (of the advocacy academy) was to create a program that helps train and develop the next generation of advocates for the profession, and to encourage students to think broadly about the relationship between public policy and pharmacy.”
I encourage all members of the profession to get involved. Whether you’re a working pharmacist, or a student pharmacist it’s never too late to get started with advocacy. We all have the ability to impact the political process. Through NACDS RxImpact it is simple to find out what legislation is affecting pharmacy at the national level. Just access: capwiz.com/nacds. To see what is affecting our profession here in Georgia, please visit the Georgia Pharmacy Association website for more information at gpha.org. I’m already looking forward to attending next year’s RxImpact. I hope to see you there.
The speakers and leaders at the event had a variety of backgrounds, ranging from academia to government. Although, each speaker brought their own unique insights to the advocacy process, they were all united in their message. The leaders impressed upon us the need for students to teach members of the Senate and House of Representatives about the integral role that pharmacy plays in the healthcare team. We learned that one of the biggest ideas we could communicate to our legislators was the benefit that pharmacists can provide by directly improving patient care.
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May 2011
“We implemented PQC in our pharmacy four months ago – it was easy. I have noticed an enhanced effort from the staff to work together to avoid and eliminate quality-related events.” Pharmacy Quality Commitment® (PQC) is what you need! PQC is a continuous quality improvement (CQI) program that supports you in responding to issues with provider network contracts, Medicare Part D requirements under federal law, and mandates for CQI programs under state law. When PQC is implemented in your pharmacy, you will immediately improve your ability to assure quality and increase patient safety. Do you have a CQI program in place?
Call toll free (866) 365-7472 or go to www.pqc.net for more information. PQC is brought to you by your state pharmacy association.
Online Master of Science in Pharmaceutical Outcomes & Policy Part Time • 30 Credits • Non Thesis Specialty Tracks: (WWSPLK 7OHYTHJVLJVUVTPJZ 7OHYTHJ` 9LN\SH[PVU 7VSPJ` *SPUPJHS 9LZLHYJO 9LN\SH[PVU ,[OPJZ 7H[PLU[ :HML[` 9PZR 4HUHNLTLU[ +Y\N 9LN\SH[VY` (MMHPYZ UF MS / Stetson University MBA option
http://pharmreg.dce.ufl.edu The Georgia Pharmacy Journal
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continuing education for pharmacists Volume XXIX, No. 1
Understanding Asthma in Children and Adults: A Primer for Pharmacists Thomas A. Gossel, R.Ph., Ph.D., Professor Emeritus, Ohio Northern University, Ada, Ohio and J. Richard Wuest, R.Ph., PharmD, Professor Emeritus, University of Cincinnati, Cincinnati, Ohio that a great number of patients overestimate their personal level of asthma control. Moreover, studies FRQÀUP WKDW PDQ\ SK\VLFLDQV DOVR tend to overestimate a patient’s level of education on asthma and its control.
Dr. Thomas A. Gossel and Dr. J. Richard :XHVW KDYH QR UHOHYDQW ÀQDQFLDO UHODWLRQships to disclose.
Goal. The goal of this lesson is to review the characteristics of asthma with emphasis on its causes and triggers for inciting symptoms, epidemiology, prevalence, pathogenesis and clinical impressions, and differentiate between pediatric and adult forms of the disease. Objectives. At the conclusion of this lesson, successful participants should be able to: 1. demonstrate knowledge of asthma including its causes and triggers, epidemiology and prevalence, pathogenesis, and clinical impressions; 2. differentiate between asthma pathology in children and adults; 3. identify criteria that differentiate adult-onset from pediatric asthma; and 4. exhibit knowledge of information relative to asthma to convey to patients and their caregivers.
Background
Asthma is one of the most common FKURQLF LQÁDPPDWRU\ GLVHDVHV RI the airways, affecting almost 300 million people worldwide. Approximately 15.7 million adults and 6.7 million children in the United States have it. The burden of asthma affects patients, their families and society in terms of lost school
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days and work, decreased quality of life, and unavoidable emergency department visits, hospitalizations and deaths. Asthma accounts for about one out of every 250 deaths worldwide; in 2007, approximately 3,780 patients in the United States died from asthma and its complications. Direct and indirect costs associated with asthma in this country now total about $16 billion annually, with most expenses attributed to prescription drugs, emergency department care and hospitalizations. Asthma is the most common cause of hospitalization among children, and its mortality rate in older adults continues to rise. Despite current guidelines for its control and effective treatments, asthma remains less than optimally controlled in many patients. At the same time, approximately 60 percent of people with moderately persistent asthma and 30 percent of people with severely persistent asthma consider their illness to be well controlled or completely controlled. This has led many medical researchers to postulate
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Epidemiology and Prevalence
Asthma occurs at all ages, with symptoms appearing most often in infancy. Its prevalence spikes in FKLOGUHQ EHWZHHQ DJHV ÀYH DQG years. It increases during adulthood in females (50 percent higher than in males), and in African Americans (28 percent higher than in Caucasians). Childhood asthma affects minority populations disproportionately with differences in prevalence and severity, emergency department- and outpatient visits, and hospitalizations. Inequities involving socioeconomic status, housing quality, population density, stresses related to living in an urban area, lack of family and community support, environmental tobacco smoke exposure, and rodent- and cockroach-infested living areas are contributing factors. There are also disparities in minority populations regarding their level of personal knowledge about asthma, access to medical care and use of healthcare services, accurate asthma diagnosis, inadequate medication prescriptions from clinicians, and patient and parental adherence to prescribed treatment protocols.
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Table 1 Inflammatory mediators of asthma Histamine Leukotrienes Prostaglandins Thromboxane Platelet-activating factor Bradykinin Tachykinins Reactive oxygen species Adenosine Anaphylatoxins Endothelins Nitric oxide Growth factors
Pathogenesis
Atopy (the genetic tendency to develop classic allergic disease) is the single largest risk factor for the development of asthma. Atopy involves a capacity to produce excessive amounts of immunoglobulin E (IgE) to environmental allergens such as grass or pollen. Allergic asthma is associated with a personal and/or familial history of allergic disease such as rhinitis, urticaria and eczema. Sufferers experience W\SLFDO ZKHDO DQG à DUH VNLQ UHDFtions to intradermal injection of extracts of airborne antigens with increased serum levels of IgE, and/or a positive response to provocation tests involving inhalation of VSHFLÀF DQWLJHQV At the same time, there is a VLJQLÀFDQW IUDFWLRQ RI SDWLHQWV ZLWK asthma who do not have a personal or family history of allergy. They have negative skin tests and normal serum levels of IgE; therefore, WKHLU GLVHDVH FDQQRW EH FODVVLÀHG on the basis of immunologic mechanisms. These patients have idiosyncratic (abnormal susceptibility to a substance that is peculiar to the individual) or nonatopic asthma. Other patients have asthma that GRHV QRW ÀW FOHDUO\ LQWR HLWKHU RI these categories, but rather falls within a mixed group with features of each. For the most part, asthma that appears in younger individuals tends to have a strong allergic component, compared with asthma that develops in patients later in
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life, which tends to be nonallergic or to have mixed etiology. $LUZD\ ,Qà DPPDWLRQ Asthma results from persistent VXEDFXWH LQà DPPDWLRQ RI WKH DLUways that results in their reduced diameter brought about by contraction of smooth muscle, vascular congestion, edema of the bronchial wall, and thick, tenacious secretions. The net result is that airway resistance is increased, forced H[SLUDWRU\ YROXPHV DQG à RZ UDWHV are decreased, the lungs and thoUD[ EHFRPH K\SHULQà DWHG EUHDWKing requires more energy, elastic recoil is changed, both ventilation DQG SXOPRQDU\ EORRG à RZ EHFRPH abnormal with mismatched ratios, and arterial blood gas concentrations are altered. Thus, although asthma is primarily a disease of the airways, virtually all aspects of pulmonary function are compromised during an acute attack. Furthermore, in very symptomatic patients there is often electrocardiographic evidence of right ventricular hypertrophy with pulmonary hypertension. At the time of therapy, the patient’s FEV1 or peak H[SLUDWRU\ à RZ UDWH LV W\SLFDOO\ percent of predicted. In keeping with the alterations in mechanics, the associated air trapping is substantial, frequently approaching 400 percent of normal, while functional residual capacity doubles. Most individuals with asthma KDYH K\SRFDSQLD GHÀFLHQF\ RI carbon dioxide in the blood) and respiratory alkalosis. Hypoxia R[\JHQ GHÀFLHQF\ LQ WKH EORRG LV D XQLYHUVDO ÀQGLQJ GXULQJ H[DFHUEDtions. The appearance of metabolic DFLGRVLV LQ DFXWH DVWKPD VLJQLÀHV severe obstruction. Cyanosis is a late sign. Interaction among the resident DQG LQÀOWUDWLQJ LQà DPPDWRU\ FHOOV in the airway surface epithelium, LQà DPPDWRU\ PHGLDWRUV DQG F\WR kines (endogenous proteins released by cells that have a speFLÀF HIIHFW RQ LQWHUDFWLRQV EHWZHHQ cells or on their behavior) bring about the physiologic and clinical features of the disease. Cells that contribute in great part to
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WKH LQà DPPDWRU\ UHVSRQVH LQFOXGH mast cells, eosinophils, lymphocytes, and airway epithelial cells. Each can contribute mediators and cytokines to initiate and amplify DFXWH LQà DPPDWLRQ DQG ORQJ WHUP pathologic changes. The airway epithelium, therefore, serves both as a target of, and a contributor WR WKH LQà DPPDWRU\ FDVFDGH 7KLV exacerbates bronchoconstriction and promotes vasodilation through UHOHDVH RI VXEVWDQFHV H[HPSOLÀHG by those listed in Table 1. Eosinophils play an important UROH LQ WKH LQÀOWUDWLYH FRPSRQHQW Interleukin (IL)-5 stimulates their release into the circulation, which extends their survival. When activated, these cells become a rich source of leukotrienes, and the granular proteins (major basic protein and eosinophilic cationic protein) released and oxygenderived free radicals are capable of destroying the airway epithelium that is then sloughed into the bronchial lumen. In addition to resulting in a loss of barrier and secretory function, such damage elicits production of chemotactic cytokines (chemokines; a group of low molecular weight secreted proteins that function in the activation and migration of leukocytes, although some of them also possess other functions) that lead to IXUWKHU LQà DPPDWLRQ ,Q WKHRU\ LW can also expose sensory nerve endings, thus initiating neutrogenic LQà DPPDWRU\ SDWKZD\V WKDW LQ turn, could convert a primary local event into a generalized reaction YLD D UHà H[ PHFKDQLVP :KLOH DQ LPSRUWDQW HOHPHQW LQ LQà DPPDtion, the role that eosinophils play in establishing and maintaining airway hyperresponsiveness – the basis for asthma – is undergoing reevaluation. T lymphocytes are also imporWDQW LQ WKH DVWKPDWLF LQà DPPDtory response. Activated TH2 cells are present in increased numbers in asthmatic airways and produce cytokines such as IL-4 that initiate humoral (the aspect of immunity that is mediated by secreted antibodies, as opposed to cell-mediated
May 2011
Table 2 Clinical signs and symptoms indicating a diagnosis other than asthma Sign or Symptom Neonatal symptoms/ventilation :KHH]H DVVRFLDWHG ZLWK IHHGLQJ Sudden onset of cough/choking 6WHDWRUUKHD Stridor )DLOXUH WR WKULYH 'LJLWDO FOXEELQJ Unilateral signs Cardiac murmur
immunity, which involves T lymphocytes) responses. They also elaborate IL-5 with their effect on eosinophils as stated above. Data are accumulating that asthma may be related to an imbalance between TH1 and TH2 immune responses, EXW ÀUP FRQFOXVLRQV FDQQRW EH drawn at this time.
Clinical Impressions
Asthma is an episodic disease that proceeds with acute exacerbations interspersed with symptom-free periods. Most attacks are short-lived, lasting minutes to hours. The patient appears to recover completely after an attack; however, there can be a phase in which the patient experiences some degree of airway obstruction daily. This phase can be mild, with or without superimposed severe episodes. Conversely, it may be much more serious, with severe obstruction persisting for days or weeks. This latter condition is known as status asthmaticus. In unusual circumstances, acute episodes can cause death. Symptoms. Asthma symptoms consist of recurrent episodes RI WKH WULDG RI G\VSQHD GLIÀFXOW breathing), coughing and wheezing. Recurrent symptomatic periods of wheezing, coughing and breathlessness in infants may be characteristic of the natural history of the disease, serving as early indicators of developing asthma. Wheezing is regarded as an absolute determinant in asthma, although all three symptoms usually coexist. Such wheezing in very young children is
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Probable Diagnosis Bronchopulmonary dysplasia $VSLUDWLRQ RU WUDFKHRHVRSKDJHDO ÀVWXOD Aspirated foreign body &\VWLF ÀEURVLV Vascular ring &\VWLF ÀEURVLV &\VWLF ÀEURVLV Foreign body Congenital heart disease
EHOLHYHG WR EH UHÁHFWLYH RI DLUZD\ LQÁDPPDWLRQ WKDW XQGHUSLQV WKH pathologic condition of asthma. At the same time, not all children who wheeze subsequently develop asthma. Moreover, in early childhood, asthma is often underdiagnosed because its symptoms can vary widely and are similar to other common childhood maladies including bronchitis, viral lower respiratory infection, and recurrent upper respiratory tract infections. Clinical signs and symptoms of episodic or chronic wheezing, coughing or breathlessness that may indicate a condition other than asthma are listed in Table 2. As an attack begins, patients note a sense of constriction in the chest, often with a nonproductive cough. Respiration becomes more GLIÀFXOW ZLWK ZKHH]LQJ QRWHG GXUing both inspiration and expiration. Expiration becomes prolonged and patients frequently experience tachypnea (extremely rapid respiration), tachycardia and mild systolic hypertension. The lungs TXLFNO\ EHFRPH RYHULQÁDWHG An episode is often marked with a cough along with production of thick, stringy mucus. In extreme situations, coughing may be ineffective to remove respiratory irritants and the patient may begin a gasping type of respiratory pattern. This implies extensive mucus plugging with impending suffocation. Ventilatory assistance by mechanical means may be required. Atelectasis (collapsed lung tissue) to inspissated (thickened, dried or
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OHVV ÁXLG VHFUHWLRQV RFFDVLRQDOO\ occurs during asthmatic attacks. Spontaneous pneumothorax (accumulation of air or gas in the pleural cavity) and/or pneumomediastinum (presence of air or gas in the mediastinum [tissue and organs that separate the two lungs that contains the heart and its vessels, the trachea, esophagus, thymus, lymph nodes and other structures]) are rare. Less often, asthmatic patients may complain of intermittent episodes of nonproductive cough or exertional dyspnea (shortness of breath during physical activity). Unlike more traditional asthma patients, when these individuals are examined during symptomatic periods, they usually have normal breath sounds but they wheeze following repeated forced exhalations and/or may exhibit shortness of breath when tested in the laboratory. A very common feature of asthma is awakening during the night with dyspnea and wheezing. In fact, the absence of this phenomenon questions the diagnosis. Diagnosis rests on history (Table 3) and characteristic pulmonary function testing, with the demonstration of reversible airway obstruction. Exacerbations. Exacerbations in children and young adults in northern climates peak in September with return to school. In a study of children during a peak period, 62 percent of cases versus 41 percent of controls showed evidence of viral infection, predominantly rhinovirus (84 percent), highlighting viral etiology as an important trigger. Although a number of exacerbations are associated with viral infections, there is increasing evidence that atypical bacterial infections such as Chlamydia pneumoniae may also be contributory. There is a relationship between C. pneumoniae IgA and exacerbation frequency, and in one study, 38 percent of adults presenting with an asthma exacerbation in an emergency department had an increase in C. pneumoniae antibody levels.
May 2011
Table 3 Key elements in a medical history that support a diagnosis of asthma* ‡ :KHH]LQJ ² KLJK SLWFKHG ZKLVWOLQJ VRXQGV GXULQJ H[SLUDWLRQ HVSHFLDOO\ LQ FKLOdren. A lack of wheezing and a normal chest examination do not exclude asthma. ‡ +LVWRU\ RI DQ\ RI WKH IROORZLQJ Cough (worse particularly at night) Recurrent wheeze 5HFXUUHQW GLIÀFXOW\ LQ EUHDWKLQJ Recurrent chest tightness ‡ 6\PSWRPV RFFXU RU ZRUVHQ LQ WKH SUHVHQFH RI Exercise Viral infection Inhalant allergens (e.g., animals with fur or hair, house dust mites, mold, pollen) Irritants (tobacco or wood smoke, airborne chemicals) Changes in weather Strong emotional expression (laughing or crying hard) Stress ‡ 6\PSWRPV RFFXU RU ZRUVHQ DW QLJKW DZDNHQLQJ WKH SDWLHQW *The presence of multiple key indicators increases the probability of asthma, but objective measures (i.e., spirometry) are needed to establish a diagnosis.
Triggers That Incite Asthma
Allergens. Allergic asthma has a genetic component, but the genetics involved remain complex. As stated above, allergic asthma is dependent on an IgE response controlled by T and B lymphocytes and activated by the interaction of antigen with mast cell-bound IgE molecules. IgE circulates in the blood, and binds with receptors on mast cells and basophils. Most allergens that provoke asthma are airborne. Once sensitization has occurred, minute amounts of the offending DOOHUJHQ FDQ SURYRNH VLJQLĂ€FDQW H[acerbations of the disease. Immune mechanisms are believed to be the cause of development of asthma in up to one-third of all cases and are contributory in another third. Allergic asthma is often seasonal and most often noted in children and young adults. A perennial (nonseasonal) form may result from allergy to animal dander, dust mites, feathers, mold and other environmental airborne allergens that are present year around. Exposure to antigens usually results in an immediate response that leads to airway obstruction within minutes and then resolves. A sec-
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ond wave of bronchoconstriction, the so-called late reaction, develops six to 10 hours later in 30 to 50 percent of patients. Pharmacologic Agents. Aspirin, beta-adrenergic antagonists, coloring agents such as tartrazine, and sulfating agents are agents commonly associated with the induction of acute episodes of asthma. Drug-induced bronchial narrowing is often associated with high morbidity. The typical aspirinsensitive respiratory syndrome affects adults primarily, although the condition may occur in childhood. This problem typically begins with perennial vasomotor rhinitis that is followed by a hyperplastic UKLQRVLQXVLWLV LQĂ DPPDWLRQ RI WKH mucous membranes of the nose and sinuses) with nasal polyps, with asthma then appearing. Affected individuals typically develop ocular and nasal congestion and acute, often severe episodes of airways obstruction with even small quantities of aspirin. There is a great amount of cross-reactivity between aspirin and other nonsteroidal DQWL LQĂ DPPDWRU\ GUXJV 16$,'V that inhibit cyclooxygenase type 1. Indomethacin, fenoprofen, naproxen, ibuprofen and mefenamic acid
26
DUH SDUWLFXODUO\ VLJQLĂ€FDQW LQ this regard. The mechanism by which aspirin and NSAIDs produce bronchospasm appears to be a chronic overexcretion of leukotrienes, which activate mast cells. Adverse reactions to aspirin can be inhibited with use of leukotriene synthesis blockers or receptor antagonists. Beta-adrenergic antagonists can obstruct the airways in asthmatic patients as well as in others with heightened airways reactivity and should be avoided by such individuals. The selective ǃ EORFNHUV DUH PRUH OLNHO\ WR FDXVH this, particularly at higher doses. In fact, the use of intraocular ǃ EORFNHU GURSV IRU WKH WUHDWPHQW RI glaucoma has been associated with worsening asthma. 6XOĂ€WLQJ DJHQWV VXFK DV SRWDVsium and sodium bisulfate, sodium VXOĂ€WH SRWDVVLXP PHWDELVXOĂ€WH and sulfur dioxide that are used in the food and pharmaceutical industries as sanitizing and preserving agents can produce acute airway obstruction in sensitive individuals. Exposure typically follows ingestion of food or beverages containing these compounds, e.g., VDODGV IUHVK IUXLW VKHOOĂ€VK DQG wine. Exacerbation of asthma has been reported following the use of VXOĂ€WH FRQWDLQLQJ WRSLFDO RSKWKDOmic solutions, intravenous corticosteroids and some inhalational bronchodilator solutions. Environmental Factors. Acute and chronic airway obstruction has been reported following exposure to selective substances used in a wide array of industrial processes. The agents can generally EH FODVVLĂ€HG LQWR KLJK PROHFXODU weight compounds, which are believed to induce asthma through immunologic mechanisms, and lowmolecular-weight agents, which serve as haptenes (the portion of an antigenic molecule that determines LWV LPPXQRORJLFDO VSHFLĂ€FDOO\ RU can release bronchoconstrictor substances. High-molecular-weight compounds of importance are wood and vegetable dusts (e.g., those RI RDN JUDLQ Ă RXU JXP DFDFLD
May 2011
and tragacanth), pharmaceutical agents (e.g., antibiotics, piperazine and cimetidine), animal and insect dusts, serums and secretions (e.g., laboratory animals, chickens, FUDEV SUDZQV R\VWHUV Ă LHV EHHV and moths), biologic enzymes (e.g., laundry detergents, pancreatic enzymes, and Bacillus subtilis). Problematic low-molecular-weight compounds include some metal salts (e.g., chromium, platinum, nickel and vanadium) and industrial chemicals and plastics (e.g., ethylenediamine, toluene diisocyanate, phthalic acid anhydride, persulfates, p-phenylenediamine, western red cedar and various dyes). Formaldehyde and urea formaldehyde are also included in this group, as is exposure to sensitizing chemicals, particularly those used in paints, solvents and plastics. Infections. The most common stimuli that evoke acute exacerbations of asthma are respiratory infections by pathogens other than bacteria. The most important infectious agents in young children are respiratory syncytial virus and rhinovirus. In older children and DGXOWV UKLQRYLUXV DQG LQĂ XHQ]D virus are the predominant pathogens. Simple colonization within the tracheobronchial tree will usuDOO\ EH LQVXIĂ€FLHQW WR HYRNH DFXWH episodes of bronchospasm, and asthmatic attacks occur only when symptoms of an ongoing respiratory tract infections are, or recently have been, present. Viral infections are perhaps the only stimuli that can produce constant symptoms for weeks. Exercise. Exercise is a common stimulant of acute asthma attacks. Exercise differs from other naturally occurring provocations, such as antigens, viral infections and air pollutants, in that it neither evokes long-term sequelae, nor increases airway reactivity. Attacks that follow exertion typically do not occur during it. Critical variables that determine severity of the postexertional airway obstruction include the level of ventilation achieved and the temperature and
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humidity of the inspired air. The higher the ventilation rate and the lower the temperature of the air, the greater the response. The mechanism involved in exerciseinduced obstruction may be related to a thermally produced hyperemia (excess blood in a part) and capillary leakage in the airway wall.
Adult Asthma
Since antiquity, asthma has been described as a disease of adults. Its clear recognition as a childhood disease appears to date only from around 1760. In recent years, however, the pediatric onset of the illness has generally been emphasized with relatively little attention being paid to asthma in elderly subjects, even though the problem has been noted to be relatively common. Indeed, asthma is given scant attention in standard textbooks on geriatric medicine. Asthma in adults and at older DJH LV DVVRFLDWHG ZLWK VLJQLĂ€FDQW morbidity and mortality. Most asthma-related deaths, in fact, occur in older adults. Although most patients with asthma develop their disease as children or younger adults, late-onset asthma may appear at any age, even in the eighth and ninth decades. Asthma onset at an advanced age correlates with symptoms that are typical of younger adults, but medication requirements for older patients often are greater than those for younger patients. Overall, there is no relationship between severity and age of onset of asthma or duration of disease. Asthma in older adults is associated with considerable morbidity and lowered quality of life when compared with individuals of the same age who do not have the disease. Asthma is often underdiagnosed in this group and is frequently associated with allergic triggers. A major objective of healthcare should be to preserve a satisfactory quality of life in persons with asthma, just as this has become an essential component of the healthcare protocol of patients with other chronic disorders. Numerous
27
investigations support the notion that health-related quality of life in patients with asthma should be measured and actively pursued in addition to conventional clinical parameters. Long-Standing Versus LateOnset Asthma. Older asthmatic patients can be divided into two categories: those diagnosed as children who carry the disease throughout life (long-standing asthma) and those who develop new symptoms later in life, that is, at age 65 years and older. This second group is challenging to recognize and accounts for the majority of undiagnosed cases. Numerous studies have suggested that individuals with long-standing asthma have shorter symptom-free periods, a greater number of emergency interventions and hospitalizations, and a marked reduction in lung function than those who develop asthma at age 65 and older. Others suggest that there is no relationship between disease duration and severity. This theory is gaining broad acceptance, although some GHÀQLWLRQV RI ´ODWH RQVHW DVWKPD¾ include symptom appearance as early as age 30. Atopy in Older Adults with Asthma. Atopic (extrinsic) asthma is associated with disease that is diagnosed primarily during childhood. Its role in older adults with asthma is less well understood. The well documented triad (asthma, eczema and hay fever) of atopic asthma results in a number of cases, although isolated high IgE level against an allergen does not automatically result. The role of atopy in the pathogenesis of asthma is well established, and a high serum IgE level has been shown to be a risk factor for development of obstructive airway disease. Such an association is independent of smoking, but smoking does intensify symptoms. Atopy is age related with a high incidence in childhood, moderate risk in mid-life, and lower occurrence in older age. Therefore, high IgE levels at any age increase the tendency for asthma to occur later in life. A past history
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Table 4 Asthma education resources Allergy & Asthma Network Mothers of Asthmatics www.breatherville.org American Academy of Allergy, Asthma and Immunology www.aaaai.org American Association For Respiratory Care www.aarc.org American College of Allergy, Asthma, and Immunology www.acaai.org American Lung Association www.lungusa.org Association of Asthma Educators www.asthmaeducators.org Asthma and Allergy Foundation of America www.aafa.org Food Allergy & Anaphylaxis Network www.foodallergy.org National Heart, Lung, and Blood Institute Information Center www.nhlbi.nih.gov National Jewish Health (Lung Line) www.nationaljewish.org U.S. Environmental Protection Agency National Center for Environmental Publications www.airnow.gov
of atopy is one of the predictors of asthma that onsets at an older age. The Normative Aging Study showed that late-onset hypersensitivity to cat dander predicted asthma onset in older patients. Allergen sensitization in later life does occur and may be considered a predictor of asthma. It can be concluded that atopy is important in some but not all cases of older-age asthma. Moreover, rarely does an environmental source provoke an asthma attack in an older person.
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Nonatopic (intrinsic) asthma is much more common in older patients, especially those with late-onset disease. When bronchial biopsies from the two groups are FRPSDUHG D PRUH LQWHQVH LQà DPmatory response can be seen in nonatopic asthma. A reason for this may include airway activation in response to viral or other unknown in vivo antigens. Individuals with late-onset asthma often present with initial symptoms leading to a subsequent diagnosis during or following upper respiratory tract infections. Age-Related Changes in Lung Function. The chest wall becomes stiffer and less compliant with aging. This is likely due WR FDOFLÀFDWLRQ RI FRVWDO FDUWLODJH and rib-vertebral articulations (joined together) and narrowing of intervertebral disc spaces. Because of age-related osteoporosis with subsequent vertebral collapse, the shape of the thorax changes, leading to greater dorsal kyphosis (abnormal backward curvature of the spine) and anteroposterior diameter. Not only is the chest wall more À[HG EXW WKH OXQJV QRZ KDYH D mechanical disadvantage. Since the GLDSKUDJP LV à DWWHQHG LWV DELOLW\ to generate negative intrathoracic pressure is compromised. In addiWLRQ WKHUH LV D VLJQLÀFDQW GHFUHDVH in the strength of the diaphragm in older persons. Along with the anatomical changes in the chest wall and its greater stiffness, this reduces the force-generating capacity of the diaphragm. Nutritional VWDWXV ZKLFK LV RIWHQ GHÀFLHQW LQ older patients, is also believed to contribute to altered respiratory muscle strength. The normal aging process is associated with reduced elastic recoil of the lung parenchyma (the functional elements of an organ, versus its structural tissue), the precise mechanism for this being unclear. During expiration, therefore, there is greater tendency for small airways to collapse, with resultant air trapping and an increase in residual volume. The stiff, poorly compliant chest wall of older
28
patients results in less outward recoil, especially marked at high lung volumes. This reduced recoil pressure leads to reduced vital capacity, which is balanced by the increase in residual volume. Older patients, therefore, have greater functional residual capacity with the net effect that they breathe at higher lung volumes than younger patients. This places increased elastic load on the chest wall and an additional burden on the respiratory muscles. This all leads to an increase in metabolic demand and symptoms.
Expert Panel Report 3
A major event to help in the understanding and controlling of asthma was publication in August 2007 of the updated National Asthma Education and Prevention Program (NAEPP) treatment guidelines prepared by the National Institutes of Health. This report, the Expert Panel Report 3 (EPR 3): Guidelines for the Diagnosis and Management of Asthma provided updated information to improve the care of patients with asthma. Compared with its predecessor reports, EPR 3 included (1) more comprehensive discussion of asthma severity with expanded descriptions of impairment and risk, (2) increased focus on asthma control as a goal of therapy, and (3) expanded discussion of pharmacotherapy for asthma with updated treatment algorithms. The completeness of the report was an indication of how far our understanding of the clinical syndrome that is called asthma has progressed in the past decade. The full 487-page report including a complete bibliography can be downloaded without charge at www. nhlbi.nih.gov/guidelines/asthma/ asthgdln.htm. A 74-page summary is also available at the same site and is recommended reading for pharmacists who wish to pursue in-depth study of asthma that goes beyond this CE lesson. The EPR 3 Guidelines are impressive, but it is important to remember that the update has been assembled based on a multitude of studies conducted
May 2011
worldwide that have led to current insights into pathophysiologic mechanisms, clinical medicine, evidence-based treatment recommendations, and novel therapies. Valuable information on asthma is available at the websites listed in Table 4.
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Overview and Summary
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Asthma is a common chronic afĂ LFWLRQ RI ERWK FKLOGUHQ DQG DGXOWV that bears a high economic burden on the U.S. healthcare system. Asthma begins primarily during infancy. However, it is not uncommon for it to occur later in life and involve severe and persistent ventilatory impairment. The release of the EPR 3 guidelines from the NAEPP provides healthcare professionals with updated information to improve the care of patients of all ages who suffer with asthma.
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The authors, the Ohio Pharmacists Foundation and the Ohio Pharmacists Association disclaim any liability to you or your patients resulting from reliance solely upon the information contained herein. Bibliography for additional reading and inquiry is available upon request.
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This lesson is a knowledge-based CE activity and is targeted to pharmacists in all practice settings. Please turn to Correspondence Course Quiz on page 27.
Program 0129-0000-11-001-H01-P Release date: 1-15-11 Expiration date: 1-15-14
CE Hours: 1.5 (0.15 CEU)
The Ohio Pharmacists Foundation Inc. is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.
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continuing education quiz
Please print.
Program 0129-0000-11-001-H01-P 0.15 CEU
Name________________________________________________
Understanding Asthma in Children and Adults: A Primer for Pharmacists
Address_____________________________________________ City, State, Zip______________________________________ Email_______________________________________________
1. The occurrence of asthma increases to the greatest extent during adulthood in: a. females. b. males.
Return to Correspondence Course, OPA, 2155 Riverside Drive, Columbus, OH 43221-4052 or fax to 614.586.1545
2. The single largest risk factor for the development of asthma is: a. atony. c. atoxia. b. atopy.
6. The triad of symptoms in patients with asthma includes all of the following EXCEPT: D EURQFKRGLODWLRQ F GLIÀFXOW EUHDWKLQJ b. coughing. d. wheezing.
3. The condition referred to in question #2 involves a capacity to produce excessive amounts of: a. IgA. c. IgE. b. IgC. d. IgG.
7. As an asthma attack begins, patients note a sense of constriction in the chest, often with a: a. productive cough. b. nonproductive cough.
4. A patient with asthma who has an abnormal susceptibility to a substance that is peculiar to that individual has: a. autoimmune asthma. c. eosinophilic asthma. b. congenital asthma. d. idiosyncratic asthma.
8. Exacerbations of asthma in children and young adults in northern climates peak in: a. December. c. March. b. June. d. September. 9. A perennial form of asthma is one that is: a. nosocomial. c. nonseasonal. b. syncratic. d. rheumatoid.
5. When activated, eosinophils become a rich source of: a. chemokines. c. leukotrienes. b. immunoglobulins. d. prostaglandins.
10. There is a great amount of cross-reactivity between aspirin and other NSAIDs that inhibit cyclooxygenase type 1. a. True b. False
&RPSOHWHO\ ÀOO LQ WKH OHWWHUHG ER[ FRUUHVSRQGLQJ WR your answer. 1. 2. 3. 4. 5.
[a] [a] [a] [a] [a]
[b] [b] [b] [b] [b]
6. [a] [c] 7. [a] [c] [d] 8. [a] [c] [d] 9. [a] [c] [d] 10. [a]
[b] [c] [d] [b] [b] [c] [d] [b] [c] [d] [b]
11. [a] 12. [a] 13. [a] 14. [a] 15. [a]
11. Which of the following is one of the most important infectious agents that evoke acute exacerbations of asthma in young children? a. Bacilli c. Pneumococci b. Haemophili d. Rhinovirus
[b] [c] [d] [b] [b] [c] [d] [b] [b]
12. Most asthma-related deaths occur in: a. pediatric patients. b. older adults.
I am enclosing $5 for this month’s quiz made payable to: Ohio Pharmacists Association.
13. The well documented triad of atopic asthma includes all of the following EXCEPT: a. asthma. c. hay fever. b. eczema. d. psoriasis.
1. Rate this lesson: (Excellent) 5 4 3 2 1 (Poor) 2. Did it meet each of its objectives? yes no If no, list any unmet_______________________________ 3. Was the content balanced and without commercial bias? yes no 4. Did the program meet your educational/practice needs? yes no 5. How long did it take you to read this lesson and complete the quiz? ________________ 6. Comments/future topics welcome.
14. Nonatopic asthma refers to: a. extrinsic asthma. b. intrinsic asthma. 15. The normal aging process is associated with reduced elastic recoil of lung: a. parenchyma. b. mesentery.
To receive CE credit, your quiz must be postmarked no later than January 15, 2014. A passing grade of 80% must be attained. CE statements of credit are mailed February, April, June, August, October, and December. Send inquiries to opa@ohiopharmacists.org.
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