bluuebunny/crossref_metadata_2025 huggingface dataset:
E5 Monoclonal Immunoglobulin M Antibody for the Treatment of Gram-Negative Sepsis
Authors: Olsen Keith M. , Campbell G. Douglas
Published: January 2017

Despite the advent of aminoglycoside and beta-lactam antibiotics and early antimicrobial intervention, overall morbidity and mortality associated with gram-negative sepsis and bacteremia remain high. Complications of sepsis have been related to the release of endotoxin from the cell walls of gram-negative bacilli. Although antibiotics can effectively kill gram-negative bacteria, they have no effect on lipopolysaccharide (LPS) and may, in fact, enhance its release when cell lysis occurs. Lipid A, the lipid portion of LPS, is composed of glucosamines, polar phosphate groups, and fatty acids. It represents the endotoxic component of gram-negative bacteria and is responsible for host responses to LPS, including fever, hypotension, and shock. E5 is a murine monoclonal immunoglobulin M antibody directed against the lipid A portion of the cell-wall endotoxin that is common to clinically important gram-negative bacilli. A clinical evaluation program of E5 included patients who were moderately to severely ill with clinical evidence of an infection usually caused by gram-negative bacteria. In pharmacokinetic and safety studies, laboratory tests revealed no evidence of antibody-mediated toxicity and serum antibody concentrations in the desired therapeutic range (>5 μg/mL) were found as late as 72 hours after initial infusion of E5. In a Phase II study, mortality rates at seven days in patients with documented gram-negative infection were 22 percent in the placebo group compared with 7 percent in the Estreated groups. In a large Phase III multicenter trial of patients who had not progressed to refractory shock, those treated with E5 were significantly more likely to survive; these patients also experienced significantly greater resolution of organ failures than those who were given placebo. E5 appears to be well tolerated; no antibody-mediated toxicity has been noted in any studies to date. Minor allergic reactions were the most common adverse effect observed in the 247 patients given at least part of one dose of E5 (less than two percent incidence). No drug interactions have been reported with E5. Overall, infusions of E5 administered in clinical trials as an adjunct to antibiotics and supportive therapy have enhanced resolution of organ failure associated with gram-negative sepsis and have reduced mortality in patients not in refractory shock.
Use of Intravenous Immune Globulin Therapy: An Overview
Authors: Wordell Cindy J.
Published: January 2017

The intravenous immune globulin (IGIV) preparations are reviewed with respect to method of preparation, pharmacokinetics, clinical uses (with emphasis on the labeled indications), and adverse reactions; a brief review of the immune system also is provided. IGIV preparations are approved for the treatment of hypogammaglobulinemia, recurrent bacterial infections due to B-cell chronic lymphocytic leukemia, and idiopathic thrombocytopenic purpura (ITP). The mechanism of action in the first two indications is passive replacement of antibodies, but in ITP the mechanism is not clearly established. The clinical literature on the use of IGIV for these indications is summarized. In patients with ITP, platelet counts return to safe levels and the number of infections is reduced in patients with primary humoral immunodeficiency treated with IGIV. The use of IGIV in pregnant women and premature infants is controversial. Adverse reactions are primarily related to infusion rate, activation of complement, and anaphylactic reactions to a component of the product. There is minimal to no risk of viral transmission with IGIV therapy. IGIV also has been administered safely on an outpatient or homecare basis. This has led to a feeling of greater control by patients over their chronic illness. Other uses of IGIV are under investigation. As our understanding of the immune system and the pharmacology of immune globulin increases, the uses of IGIV will expand.
Pharmacologic Treatment of Cocaine Abuse
Authors: Lacombe Sylvia , Stanislav Steven W. , Marken Patricia A.
Published: January 2017

The recent surge in the use of cocaine has imposed increased financial burdens on society in terms of cocaine-related crimes, and funding for hospitalization/medical treatment and long-term rehabilitation programs. Unfortunately, healthcare costs secondary to chronic cocaine use are likely to increase in the future as drug research into cocaine abuse and effective treatment programs are severely lacking. This article reviews existing literature on treatment of cocaine abuse and is intended to serve as a practical guide to the general clinician involved in drug management of cocaine abuse. Antidepressant agents and the dopamine agonists are emphasized because most of the studies showing benefit have used these agents. Advantages and disadvantages of various interventions are objectively assessed. Additionally, specific implications for both acute and chronic management of cocaine abuse are given along with discussion and recommendations regarding comorbidity.
Are There Beta-Adrenergic Receptor Response Differences between Racial Groups?
Authors: Rutledge David R.
Published: January 2017

Beta-adrenergic receptor (BAR) agonists and antagonists are among the most widely used drugs in America today. This review highlights the importance of cross-racial studies in evaluating BAR effects because heterogeneity in pharmacologic response among humans exists. Clinicians and basic scientists in the drug development industry need to acknowledge racial differences in antihypertensive drug responses and prevent various racial groups from being underrepresented in clinical trials. This article reviews the influence of race on BAR responses with emphasis on blacks and whites. Information from patients with hypertension, healthy volunteers, and in vitro studies is presented.
Monitoring Chronic Outpatient Infections: Providing Comprehensive Home Healthcare Pharmacy Services
Authors: Ackerman Bruce H. , Wolfe Jonathan J.
Published: January 2017

Management of acute illness has been increasingly shifted to community practitioners. Expansion of community pharmacy into home healthcare has brought new opportunities and responsibilities to community practitioners. These practitioners are gaining expertise in total parenteral nutrition, intravenous infusion systems, intravenous catheters, parenteral antibiotics, and clinical pharmacokinetics—areas historically managed by hospital and long-term care facility pharmacists. This shift to community pharmacy-based care has brought with it the need for community pharmacists to develop expertise in therapeutic monitoring of chronic disease states. Dose adjustment of medications based upon careful analysis of blood concentrations is no longer limited to institutional pharmacy practice. Community pharmacists now must master basic infectious disease principles and possess internal medicine knowledge to ensure appropriate monitoring of their patients. This article discusses several disease states currently managed with community pharmacy-based home healthcare, summarizing basic monitoring parameters for comprehensive patient care, and provides sample supply lists and documentation forms for home healthcare providers.
Update on the Right to Refuse Antipsychotic Medication
Authors: Williams Karl G.
Published: January 2017

The legal history and current developments in the right to refuse antipsychotic medication are reviewed. In Washington v. Harper the US Supreme Court analyzed the right to refuse antipsychotic medication under the due process clause of the Fourteenth Amendment to the US Constitution. A narrow issue was clarified but substantial uncertainty remains. As a result, law and policy problems at both state and institutional levels have become evident and may need to be addressed by drug policy decision makers.
Neonatal Thrombosis: Treatment with Heparin and Thrombolytics
Authors: Reed Michael D. , Gal Peter , Ransom J. Laurence
Published: January 2017

Thrombotic events are a serious and potentially fatal complication during the neonatal period. Despite clinically serious thromboses in up to one percent of neonates and less severe complications (e.g., catheter malfunction secondary to clots) in a much higher percentage, well-designed studies on prevention and treatment of thromboses are lacking. Treatment approaches are largely anecdotal and involve the use of heparin and, occasionally, thrombolytics. Proper monitoring of anticoagulant and thrombolytic effects is difficult because of the limited blood volumes available from neonates and the relatively large sample volumes needed for most coagulation studies. Activated clotting times (ACTs) are preferred because they use low blood volume and are a rapid bedside test. Heparin should be administered with an initial loading dose of 50–100 units/kg followed by a continuous infusion of 20 units/kg/h. Further doses should then be adjusted based on the ACT, targeting a value of 1.5–2.5 times the control. Thrombolytics also have been used in several case reports and are guided by both clinical response and serial D-dimer values. We prefer urokinase 100 units/kg/h for local infusion to the thrombus and urokinase 1000–10 000 units/kg/h for systemic therapy.
Parenteral and Oral Fluconazole for Acute Cryptococcal Meningitis in Aids: Experience with Thirteen Patients
Authors: Stern John J. , Pietroski Nancy A. , Buckley R. Michael , Braffman Michael N. , Rinaldi Michael G.
Published: January 2017

OBJECTIVE:

Cryptococcus neoformans infections of the central nervous system affect up to ten percent of AIDS patients. Standard therapy with amphotericin B with or without 5-flucytosine has a high rate of failure, relapse, and toxicity. Fluconazole is a new triazole antifungal agent available in both oral and intravenous forms that has shown efficacy in the primary and maintenance treatment of cryptococcal meningitis in AIDS patients. In this open, noncomparative trial, we evaluated the safety and efficacy of intravenous fluconazole followed by oral fluconazole in the treatment of acute cryptococcal meningitis in AIDS patients.

METHODS:

Thirteen AIDS patients with acute cryptococcal meningitis, or relapse after successful primary therapy, received 400 mg of intravenous fluconazole daily for 12–16 days followed by oral fluconazole 400 mg/d for the duration of primary therapy. If cerebrospinal fluid (CSF) cultures converted to negative within 32 weeks of treatment, the fluconazole dose was decreased to 200 mg/d as maintenance therapy.

RESULTS:

Fluconazole therapy was successful in six patients (46 percent) and unsuccessful in seven (54 percent). Of the seven patients considered unsuccessful, one demonstrated clinical improvement but remained CSF-culture positive, five were clinical failures and were switched to amphotericin B therapy, and one died after two weeks secondary to cryptococcal meningitis. No patient experienced any adverse reactions necessitating discontinuation of therapy.

CONCLUSIONS:

In this small group of patients, moderate doses of parenteral and oral fluconazole for acute cryptococcal meningitis in AIDS patients demonstrated failure rates similar to those reported in other studies with fluconazole and with amphotericin B. As there was no difference in initial Karnofsky scores or the severity of disease in treatment successes versus failures, it is difficult to determine who might respond to fluconazole as initial therapy or who should be treated initially with another agent. Further studies and clinical experience are needed.
Possible Correlation between Glycemia and Blood Pressure in Black, Diabetic, Hypertensive Patients
Authors: Jaber Linda A. , Melchior Wayne R. , Rutledge David R.
Published: January 2017

OBJECTIVE:

To determine if there is any association between glycemia and blood pressure in black patients with hypertension and diabetes mellitus whose antihypertensive medications had been unchanged for six months.

DESIGN:

Retrospective, from March 1990 through February 1991.

SETTING:

Internal medicine ambulatory clinic at Detroit Receiving Hospital/University Health Center.

PATIENTS:

Patients seen during this period with hypertension and type II diabetes. Of the 639 possible subjects, 124 met the following criteria: (1) no change in antihypertensive medications for six months, (2) absence of secondary hypertension, and (3) weight change (if any) was less than five percent. Changes in antihypertensive medication(s) excluded 388 patients, secondary hypertension excluded 3, weight changes of more than five percent excluded 94, and lack of matching postprandial capillary blood glucose (PCBG) values excluded 30. The mean age of the subjects was 66.8 years, mean diabetes duration was 12.0 years, mean PCBG was 10.7 mmol, mean systolic blood pressure (SBP) was 154.3 mm Hg, mean diastolic blood pressure (DBP) was 90.1 mm Hg. There were 28 men in the study and 96 women; 90 were obese (body mass index >25 kg/m2) and 34 were nonobese. The diabetes was managed with insulin in 67 patients, with sulfonylureas in 50, and with diet in 7. intervention: None

MAIN OUTCOME MEASURES:

SBP and DBP versus PCBG at matching times both at baseline and at six months.

RESULTS:

There was a positive association between blood pressure measurements and glycemia. Overall change in SBP was strongly correlated with PCBG changes (r=0.745, p<0.0001). Improved glycemia correlated with improved SBP control (r=0.330, p<0.0024). Deterioration of glycemia correlated with a worsening of SBP control (r=0.445, p<0.0053). The method of blood glucose control had no statistically significant effect (ANOVA) on these results.

CONCLUSIONS:

Glycemia is positively associated with blood pressure.
Acceptance of a Pharmacy-Based, Physician-Edited Hospital Pharmacy and Therapeutics Committee Newsletter
Authors: Ritchie David J. , Manchester Robert F. , Rich Michael W. , Rockwell Mary M. , Stein Paul M.
Published: January 2017

OBJECTIVE:

To assess the level of physician acceptance and perceived usefulness of a pharmacy-prepared, physician-edited pharmacy and therapeutics (P&T) committee newsletter.

DESIGN:

Two separate surveys conducted after 7 and 24 months of publication, respectively.

SETTING:

500-bed, university-affiliated, tertiary-care hospital.

MAIN OUTCOME MEASURES:

The initial survey was mailed to physicians after 7 months of publication and they were requested to rate various aspects of the newsletter, including timeliness of articles, usefulness of articles, quality of writing and design, and overall value of the publication on a scale of 1–4: (1 = excellent, 2 = good, 3 = fair, 4 = poor). Physicians were also asked to rank different categories of articles (articles on new drugs, drug-class reviews, topical reviews, formulary news, and articles providing P&T committee information) and were encouraged to provide comments. A separate follow-up survey conducted at 24 months asked physicians to indicate whether they (1) regularly received the newsletter, (2) regularly read the newsletter, (3) found the information in the newsletter to be useful, and (4) desired to continue receiving the newsletter.

RESULTS:

Initial survey results yielded mean newsletter quality scores ranging from 1.54 to 1.66. Respondents preferred, in descending order, articles on new drugs, drug-class reviews, topical reviews, formulary news, and P&T committee information. The 24-month survey revealed that 96 percent of the physicians regularly receiving and reading the newsletter found the information useful and 97 percent felt that the newsletter should continue to be published. Favorable comments were also received from several prominent physicians.

CONCLUSIONS:

The results indicate strong physician acceptance of a pharmacy-prepared, physician-edited newsletter and provide information about the types of articles preferred by physicians in a university hospital setting.
Development of a Questionnaire for Detecting Potential Adverse Drug Reactions
Authors: Corso Diane M. , Pucino Frank , DeLeo James M. , Calis Karim A. , Gallelli Joseph F.
Published: January 2017

OBJECTIVE:

To develop a comprehensive list of symptoms categorized by body system as part of a questionnaire for detecting potential adverse drug reactions.

DATA SOURCES:

A preliminary list of symptoms in lay terminology was extracted from the “Side Effects” section of all drug monographs contained in the United States Pharmacopeia Dispensing Information (USP DI) computerized database ( Volume II, Advice for the Patient) using natural language processing software. The list was sorted alphabetically and duplicate terms were eliminated. Symptoms were then categorized by body system or anatomic region. A preferred term for each symptom was selected when multiple synonyms and related words were listed. Finally, all of the symptom terms were incorporated into a thesaurus from which the questionnaire was derived.

RESULTS:

The questionnaire will be used as part of a computer-assisted interview, developed to solicit information from patients regarding their medication regimens and to systematically query them regarding the presence of salient symptoms or complaints. The computer system will eventually interface with the USP DI database to identify drugs from a patient's regimen that may be associated with adverse symptoms. The symptom thesaurus will provide the link to the USP DI database. Preliminary experience with the questionnaire in a limited number of patients has been encouraging.

CONCLUSIONS:

The questionnaire can assist clinicians in identifying drug-related symptoms including unreported adverse clinical effects of newly marketed or investigational therapeutic agents. When the questionnaire is computerized and linked to a comprehensive database, it can be more widely used to alert healthcare providers of potential adverse drug reactions that may otherwise go undetected.
Mercaptopurine-Induced Fever in a Patient with Crohn's Disease
Authors: Rehr Eric L. , Swanson Keith A. , Kern Jay A.
Published: January 2017

OBJECTIVE:

To report a case of mercaptopurine-induced fever.

CASE SUMMARY:

A patient with Crohn's disease was treated with mercaptopurine (6-MP) for an exacerbation of his illness. The patient developed fever and chills. After thorough diagnostic examinations and failure to respond to antimicrobial therapy, symptoms were attributed to an allergic-type reaction to 6-MP. The patient defervesced after 6-MP withdrawal. Fever and chills, along with arthralgias, recurred upon rechallenge with a single dose of 6-MR

DISCUSSION:

Adverse effects attributable to 6-MP therapy in inflammatory bowel disease were reviewed in the literature. Drug-induced fever has been previously reported; however, it is an uncommon adverse effect and is difficult to diagnose. It is also difficult to predict which patients will have the reaction. It is a diagnosis of exclusion requiring a thorough investigation.

CONCLUSIONS:

Drug-induced fever should be considered when confronted with fever and chills in patients with inflammatory bowel disease being treated with 6-MP. This case report shows the difficulty in differentiating between an infectious process and an adverse reaction to a medication.
Possible Intraoperative Anesthetic-Sparing Effect of Parenteral Ketorolac
Authors: Moss Jeffrey T. , Baysinger Curtis L. , Boswell Garry W. , Sayson Samual
Published: January 2017

OBJECTIVE:

Because the analgesic effects of ketorolac are equivalent to those of narcotic analgesics, we investigated the possibility that this non-steroidal antiinflammatory drug might also exhibit anesthetic-sparing properties similar to those described for narcotic agents.

DESIGN:

A nonrandomized, double-blind convenience sample. The treatment group received a preoperative dose of ketorolac 60 mg im 45 minutes prior to the induction of anesthesia. All other preoperative medications were identical.

SETTING:

Brooke Army Medical Center, a primary care setting.

PARTICIPANTS:

Six women requiring vaginal hysterectomies from American Society of Anesthesiologists class I/II, all of similar age, weight, and body surface area.

OUTCOME MEASURES:

End-tidal concentrations of the anesthetic gas were measured at five-minute intervals using a gas analyzer. A mean percent end-tidal concentration versus time curve was generated for each group.

RESULTS:

The area under the concentration curves for the anesthetic gas in the ketorolac and control group were 15.9 ± 5.1 and 52.3 ± 13.4, respectively (p=0.006).

CONCLUSIONS:

Ketorolac exhibits an anesthetic-sparing quality similar to that observed with narcotic analgesics.
Propafenone-Induced Liver Injury
Authors: Spinier Sarah A. , Elder Cheryl A. , Kindwall K. Elizabeth
Published: January 2017

OBJECTIVE:

To describe propafenone-induced liver injury.

DESIGN:

Retrospective case report.

SETTING:

Referred care in a large tertiary care center. Laboratory tests were performed at the auxiliary site and the tertiary care center.

PATIENT:

A 71-year-old woman with atrial fibrillation developed elevations of greater than two times the upper limit of normal in alkaline phosphatase (ALK), alanine aminotransferase (ALT), aspartate aminotransferase (AST), and gamma glutamyltransferase (GGT) after initiation of propafenone therapy.

INTERVENTIONS:

Studies included serial measurements of ALK, ALT, AST, and GGT.

RESULTS:

The patient developed elevations of greater than two times the upper limit of normal in ALK, ALT, and AST, one month after initiating propafenone therapy. The propafenone dose was decreased from 900 to 675 mg/d and, ten days later, the ALK, ALT, and AST were decreased slightly, but still above the upper limit of normal. One month later, serum transaminases had returned to baseline, but propafenone therapy was discontinued because of recurrent atrial fibrillation, persistent elevation in ALK, and elevation in GGT. Two months after discontinuing propafenone, serum aminotransaminase and ALK concentrations had normalized and GGT had decreased and remained only slightly elevated.

CONCLUSIONS:

The occurrence of liver injury secondary to propafenone therapy is rare. Reported cases appear to be secondary to hepatocellular injury, cholestasis, or a combination of the two. In this case, the pattern demonstrated by elevations in liver enzymes may be classified as acute cholestatic liver injury. Because the reported incidence is 0.1–0.2 percent and there are no known fatalities secondary to propafenone liver injury, routine monitoring of liver function tests in all patients receiving propafenone cannot be recommended at this time. Baseline liver function tests prior to initiating propafenone therapy with follow-up laboratory studies one month later are recommended in patients with known liver dysfunction. If elevations are noted, a reduction in dose may result in lower liver enzyme concentrations, although discontinuation of therapy may be required in some cases.
Pentostatin: An Adenosine Deaminase Inhibitor for the Treatment of Hairy Cell Leukemia
Authors: Kane Bud J. , Kuhn John G. , Roush Maura K.
Published: January 2017

OBJECTIVE:

To review the pharmacology, pharmacokinetics, adverse effects, and various dosage regimens of pentostatin, and to evaluate the role of pentostatin in the treatment of hairy cell leukemia (HCL).

DATA IDENTIFICATION:

Articles were identified via an English-language literature search of MEDLINE (1966–91) and an extensive search of bibliographies from identified articles.

STUDY SELECTION:

Human clinical trials and case reports were selected for evaluation.

DATA EXTRACTION:

The literature was assessed for quality, methodology, and outcome information.

DATA SYNTHESIS:

At dosages of 4 mg/m2 administered every other week for 6–9 months, pentostatin has been shown to successfully induce a complete response in 58–90 percent of patients and to produce a partial response in up to 30 percent of patients with HCL. The median time to achieve a response is 4.7 months. Long-term remissions of at least 14 months' duration have occurred in some patients. Compared with interferon alfa alone, total response rates are not significantly different when pentostatin and interferon alfa are used in combination. When dosed appropriately, pentostatin is generally well tolerated. Common adverse effects include nausea, vomiting, myelosuppression, fever, and infection.

CONCLUSIONS:

Pentostatin is a purine analog that inhibits adenosine deaminase, a key enzyme necessary for purine salvage. Pentostatin has received labeling approval for the treatment of HCL refractory to a minimum of three to six months of treatment with interferon alfa. Based on current data, pentostatin will be a useful addition to the therapeutic agents presently available to patients with HCL. Ongoing trials are evaluating the effectiveness of pentostatin as first-line therapy for patients with HCL.
Psychotropic Drug-Related Rhabdomyolysis
Authors: Jermain Donna M. , Crismon M. Lynn
Published: January 2017

OBJECTIVE:

The objective of this review is to discuss the pathophysiology and potential etiologies of rhabdomyolysis in psychiatric patients, with an emphasis on psychotropic drug-induced rhabdomyolysis.

DATA SOURCES:

References were obtained through an on-line search of MEDLINE, using English-language and human literature only.

STUDY SELECTION:

Because the topic is a potential drug-induced adverse effect, no controlled studies are available. Most of the literature are case reports and series of case reports.

DATA EXTRACTION:

The quality of case reports was assessed using the Food and Drug Administration guidelines for assessing the causality of a potential adverse drug reaction.

DATA SYNTHESIS:

The results of this review are based on qualitative data and indicate that rhabdomyolysis in psychiatric patients can be from multiple etiologies, including agitation, dehydration, and intramuscular injections, as well as an adverse effect of psychotropic medications. Although the deficiencies of this type of data are recognized, it is the only type of data often available to assess the etiology and causality of an uncommon adverse event.

CONCLUSIONS:

Rhabdomyolysis in psychiatric patients can be caused by many factors, both drug- and non—drug-related. Rhabdomyolysis is more likely to occur when patients are faced with a combination of risk factors. When combinations of factors are present (e.g., aggression and restraints, intramuscular injections, and extrapyramidal effects), or when muscle trauma from an individual factor is sufficiently traumatic, muscle necrosis may occur to the point that rhabdomyolysis ensues.
Metoclopramide: An Analysis of Inappropriate Long-Term Use in the Elderly
Authors: Stewart Ronald B. , Cerda James J. , Moore Mary T. , Hale William E.
Published: January 2017

OBJECTIVE:

To present a case of possible metoclopramide-induced tardive dyskinesia and document the frequent use of metoclopramide for inappropriate lengths of treatment in elderly, ambulatory subjects.

DESIGN:

Descriptive study that identified long-term users of metoclopramide among a population of 4515 elderly subjects.

SETTING:

Participants in an ambulatory health-screening program in Florida (Florida Geriatric Research Program).

PARTICIPANTS:

Individuals (2898 women and 1617 men) over the age of 65 years who volunteered for annual health screening.

INTERVENTIONS:

All medication histories for participants were reviewed to identify subjects who reported metoclopramide use on at least one visit to the program.

RESULTS:

Thirty-four participants (0.75 percent) reported the use of metoclopramide during at least one visit. Eleven subjects (32.4 percent) reported that they had used this drug for longer than one year. Nine of the 34 subjects (26.5 percent) also reported the use of metoclopramide at their next annual visit.

CONCLUSIONS:

Results from this study suggest that metoclopramide is frequently prescribed inappropriately to treat gastrointestinal disorders. Long-term use of this drug exposes patients to an unnecessary risk of adverse drug reactions.
Short- and Long-Term Retention of a Nursing Home Education Program on Metered-Dose Inhaler Technique
Authors: O'Connell Mary Beth , Hewitt Jeanne M. , Lackner Thomas E. , Pastor John D. , Wong Marietta T. , Bishop Allen L.
Published: January 2017

OBJECTIVE:

To evaluate an education program on metered-dose inhaler (MDI) technique designed for nurses and trained medication aides (TMAs).

DESIGN:

The education program included a handout, a lecture incorporating a videotape on correct inhaler and device technique, and hands-on experience with placebo inhalers. The participants' ability to verbalize and demonstrate correct MDI technique was assessed by the same two-person teams before, immediately after, and two months after the program.

SETTING:

Five nursing homes.

PARTICIPANTS:

Fifty-six nurses and TMAs practicing in nursing homes.

MAIN OUTCOME MEASURES:

Learning and retention.

RESULTS:

The participants' mean (±SD) verbal and demonstration scores increased immediately after the program by 68 ± 18 points for verbalization and 47 ± 16 points for demonstration. The participants were always better at demonstrating than verbalizing MDI technique. The participants' baseline verbal and demonstration scores correlated with the amount learned. Learning was influenced by the individual nursing home (verbal and demonstration) and personal use (demonstration only), but not by academic degree, previous training, past instruction of a patient, or current care of a patient who was receiving inhaler therapy. After two months, the scores were lower than immediately after the program test by 0–92 points for verbalization and 10–80 points for demonstration; however, the mean scores were still significantly greater (p<0.05) than the baseline scores. Retention of knowledge on the correct technique was greater for the demonstration component. Retention was influenced only by the nursing home in which the participant worked, and not any of the other variables.

CONCLUSIONS:

Our structured education program significantly improved inhaler technique; however, to maintain retention of the material, the program should be frequently repeated.
Effect of Dronabinol on Nutritional Status in HIV Infection
Authors: Struwe Melissa , Kaempfer Suzanne H. , Geiger Constance J. , Pavia Andrew T. , Plasse Terry F. , Shepard Kirk V. , Ries Kristen , Evans Thomas G.
Published: January 2017

OBJECTIVE:

To examine the effect of dronabinol (delta-9-tetrahydrocannabinol) on appetite and nutritional status in patients with symptomatic HIV infection and weight loss.

DESIGN:

Double-blind, randomized, placebo-controlled, crossover trial with two five-week treatment periods separated by a two-week washout period. Patients received dronabinol 5 mg twice daily before meals or placebo.

SETTING:

A university-based HIV/AIDS clinic and a large infectious disease private practice largely devoted to care of patients with HIV.

PARTICIPANTS:

Twelve HIV-infected patients who had had at least a 2.25-kg weight loss participated in the study. Five patients completed the protocol, and seven withdrew (two because of drug intolerance, two because of disease progression, two because of noncompliance, and one because of experimental antiretroviral therapy).

MAIN OUTCOME MEASURES:

Main outcome measures included caloric intake, weight, percent body fat, serum prealbumin, and symptom distress.

RESULTS:

During dronabinol treatment, subjects experienced increased percent body fat (one percent, p=0.04); decreased symptom distress (p=0.04); and trends toward weight gain (0.5 kg, p=0.13), increased prealbumin (29.0 mg/L, p=0.11), and improved appetite score (p=0.14).

CONCLUSIONS:

In a selected group of HIV-infected patients with weight loss, short-term treatment with dronabinol may result in improvement in nutritional status and symptom distress.
Drug-Related Hospital Admissions
Authors: Einarson Thomas R.
Published: January 2017

OBJECTIVE:

To review and summarize studies reporting rates of drug-related hospital admissions.

DATA SOURCES:

Manual and computerized literature searches using MEDLINE, Index Medicus, and International Pharmaceutical Abstracts as databases (key words: Drug, drug-related, or iatrogenic; admission, hospital admission, or hospitalization; and ADR or adverse drug reaction). References from retrieved articles were searched to locate further studies.

STUDY SELECTION:

Included were English-language studies of humans admitted to the hospital because of medications. Problems investigated were admissions prompted by adverse drug reactions (ADRs) when drugs were used by the patient and admissions resulting from a patient's noncompliant or unintentionally inappropriate drug use. Excluded were cases involving drug abuse, alcoholism, suicide attempts, intoxication, or inadequate prescribing.

DATA SYNTHESIS:

Between 1966 and 1989, ADR rates from 49 hospitals or groups of hospitals in a variety of international settings were published in 36 articles. Sample sizes ranged from 41 to 11 891 patients, with a median of 714 (interquartile range [IQR] 275-1245) and a mean of 1412 (SD 2233). The prevalence of reported admissions resulting from ADRs ranged from 0.2 to 21.7 percent; the median was 4.9 percent (IQR 2.9–6.7 percent) and the mean was 5.5 percent (SD 4.1 percent). The weighted meta-analytic estimate was 5.1 percent (95 percent confidence interval 4.4–5.8). Of those ADR admissions, 71.5 percent were side effects, 16.8 percent excessive effects, 11.3 percent hypersensitivity reactions, and 0.4 percent idiosyncratic; 3.7 percent of patients admitted for ADRs died. Eleven reports indicated that 22.7 percent of ADR hospitalizations were induced by noncompliance.

CONCLUSIONS:

Drug-induced hospitalizations account for approximately five percent of all admissions. Results apply only to people from highly developed industrialized countries. Economic analyses have not been performed. Future research should include the Third World and nonindustrialized nations as well as specific cultural groups.
Theophylline Disposition following Parenteral Feeding of Malnourished Patients
Authors: Cuddy Paul G. , Bealer John F. , Lyman Elizabeth L. , Pemberton L. Beatty
Published: January 2017

OBJECTIVE:

To investigate the effect of parenteral nutrition on theophylline disposition in malnourished patients.

DESIGN:

Before-after trial.

SETTING:

Tertiary care center.

PATIENTS:

Ten patients with historic, anthropometric, and laboratory evidence of malnutrition.

INTERVENTIONS:

Patients received two 5-mg/kg intravenous infusions of theophylline separated by at least 48 hours of glucose-based parenteral nutrition providing the entire estimated nutritional requirements.

MAIN OUTCOME MEASURES:

Following each theophylline administration, serum theophylline samples were collected over a 24-hour period for delineation of maximum plasma concentrations, volume of distribution, elimination rate constant, clearance, and area under the curve.

RESULTS:

Peak plasma theophylline concentrations were significantly lower prior to feeding (5.3 μmol/L, 95 percent confidence interval [CI] 0.78–10.0 μmol/L, p=0.028). Volume of distribution decreased after parenteral feeding (0.08 L/kg, 95 percent CI 0.006–0.15 L/kg, p=0.037). The elimination rate of theophylline increased after parenteral feeding reflected by an increase in the elimination rate constant (0.06 h1, 95 percent CI 0.01–0.10 h−1, p=0.023).

CONCLUSIONS:

This study suggests that parenteral nutrition using a glucose-based solution acutely influences theophylline disposition in malnourished patients.
Pharmacists' Interventions Using an Electronic Medication-Event Monitoring Device'S Adherence Data versus Pill Counts
Authors: Matsuyama Joy R. , Mason Barbara J. , Jue Sandra G.
Published: January 2017

OBJECTIVE:

To compare adherence data from an electronic medication-event monitoring device (MEMS, Aprex) with pill counts in assisting pharmacists in making recommendations regarding diabetes therapy.

DESIGN:

Two-month, double-blind, randomized, controlled trial.

SETTING:

Veterans Affairs Medical Center ambulatory care clinics.

PATIENTS:

Forty-seven patients with poor to fair metabolic control of diabetes mellitus were enrolled. Patients were excluded if they were receiving insulin, had a concurrent infection, required child-resistant caps or medication reminder devices, or could not return for follow-up visits. Twenty patients were randomized to the MEMS and 27 to the control group (pill counts). Fasting plasma glucose concentrations were measured monthly and glycohemoglobin concentrations were measured at baseline and 60 days. Thirty-two patients were evaluable: 15 using MEMS and 17 using pill counts.

INTERVENTION:

Investigators made pharmacologic or educational recommendations to the patient's healthcare provider based on both laboratory data and MEMS readings in the treatment group or laboratory data and pill counts in the control group.

MAIN OUTCOME MEASURE:

Quantities and types of recommendations regarding diabetes therapy made by pharmacists using adherence data from the two methods were tabulated.

RESULTS:

In the MEMS group, 47 percent of the recommendations related to patient education compared with 12 percent in the control group (p=0.028). MEMS data would have changed four recommendations in the control group to involve patient education.

CONCLUSIONS:

MEMS data resulted in different numbers and types of recommendations than pill counts. Pharmacists then could make specific recommendations regarding patient education before resorting to pharmacologic manipulations.
Design, Implementation, and Use of a New Antimicrobial Order Form: A Descriptive Report
Authors: Lipsy Robert J. , Smith Gary H. , Maloney Marie E.
Published: January 2017

OBJECTIVE:

To describe the development, implementation, and use of an antimicrobial order form. The article provides the design of the form and the rationale for including key aspects, and a report of the authors' experiences with the form over a three-year period. An analysis of compliance with the form and its impact on selected prescribing practices is also presented.

DESIGN:

Three thousand five hundred antimicrobial orders in four discrete sets over a three-year period were analyzed to assess compliance and characterize prescribing patterns with respect to duration of therapy and dosing frequency.

SETTING:

The setting of the study was a 300-bed, university-affiliated, tertiary-care, teaching hospital.

MAIN OUTCOME MEASURES:

Analysis of the forms was organized into the following sections: (1) compliance with use of the form, (2) duration of therapy, and (3) impact on antimicrobial dosing intervals.

RESULTS:

Use of the form was essentially 100 percent. Seventy-eight percent of the forms had all required data elements completed in the period following implementation; this fell to 67 percent at the end of three years. Duration of surgical prophylaxis went beyond the recommended 24 hours in 10 percent of all cases in period 1, and in 18, 8, and 4 percent in periods 2, 3, and 4, respectively. Declines in inappropriate dosing frequency were seen with cefazolin (from 14 to 2.3 percent), ceftriaxone (from 23 to 4 percent), cefuroxime (from 21 to 0 percent), and clindamycin (from 43 to 7 percent).

CONCLUSIONS:

Our experience with implementation and use of the form was very positive. Significant difficulties with compliance were not encountered. Benefits of the form included reductions in the duration of surgical prophylaxis and in the frequency of inappropriate dosing intervals.
Response to Pancuronium after Loss of Atracurium-Induced Neuromuscular Blockade
Authors: Kelly Karl J. , Clarens Diann M. , Kohls Philip R. , Nahum Avi , Vance-Bryan Kyle
Published: January 2017

OBJECTIVE:

To describe a previously unreported event in which a patient became refractory to atracurium-induced neuromuscular blockade, but subsequently was adequately paralyzed with a standard dosage of pancuronium.

CASE SUMMARY:

A previously healthy 17-year-old woman who sustained multiple trauma developed tolerance to an atracurium infusion she was receiving while undergoing mechanical ventilation. On day 3 of neuromuscular blockade, she became unresponsive to atracurium as evidenced by excessive physical movement, increased peak airway pressures, and overbreathing assist control ventilation. Repeat boluses and increases in the atracurium infusion rate to a maximum of 1.27 mg/kg/h failed to provide a desired clinical response. A bolus dose of pancuronium 0.15 mg/kg was administered and the constant infusion was then changed to pancuronium 0.078 mg/kg/h. Within minutes, decreased respirations, peak airway pressures, and agitation were noted. The pancuronium infusion rate was then tapered to 0.045 mg/kg/h over 72 hours and continued to maintain adequate neuromuscular blockade.

DISCUSSION:

Potential pharmacokinetic and pharmacodynamic causes of loss of neuromuscular blockade in this patient are postulated. Possible explanations for loss of neuromuscular blockade include increased degradation of atracurium and/or a change in acetylcholine receptor physiology.

CONCLUSIONS:

The development of resistance to a specific neuromuscular blocking agent in the intensive care setting does not necessarily imply cross-tolerance or resistance to alternative agents. Also, loss of respiratory control by one neuromuscular blocking agent may be overcome by changing agents.
Evaluation of Plasmapheresis in the Treatment of an Acute Overdose of Carbamazepine
Authors: Kale Pramodini B. , Thomson Peter A. , Provenzano Robert , Higgins Martha J.
Published: January 2017

OBJECTIVE:

To report the use of plasmapheresis in the treatment of an acute overdose of carbamazepine.

CASE SUMMARY:

A 21-year-old black man was admitted unresponsive and combative following a carbamazepine overdose. The total body load of carbamazepine was approximated at 5.91 g using an assumed volume of distribution of 1.4 L/kg. The patient underwent three plasmapheresis treatments. A total of only 335.82 mg of carbamazepine was removed by this process.

DISCUSSION:

Case reports in the literature were reviewed and compared. Carbamazepine concentrations lack correlation with the clinical outcome. Our patient's symptoms were consistent with the Weaver classification system. Carbamazepine clearance increased by almost 70 percent above its natural clearance during plasmapheresis. However, a significant rebound effect was observed after plasmapheresis: 40.1 percent after the first and 18.3 percent after the second treatment.

CONCLUSIONS:

Plasmapheresis did not seem to have a great impact on the patient's clinical status. Under the circumstances we find it extremely difficult to recommend plasmapheresis in the treatment of an acute overdose of carbamazepine.
Intrathecal Administration of Amikacin for Treatment of Meningitis Secondary to Cephalosporin-Resistant Escherichia Coli
Authors: Preston Sandra L. , Briceland Laurie L.
Published: January 2017

OBJECTIVE:

To report a case of gram-negative bacillary meningitis (GNBM) secondary to cephalosporin-resistant Escherichia coli that was treated with intrathecal and intravenous amikacin and intravenous imipenem/cilastatin (I/C).

CASE SUMMARY:

A patient who had undergone two recent neurosurgical procedures developed GNBM and bacteremia. He was treated empirically with ceftazidime. Both bloodstream and cerebrospinal fluid isolates were identified as E. coli, resistant to third-generation cephalosporins, penicillins, tobramycin, and gentamicin. The patient was subsequently treated with intravenous and intrathecal amikacin plus intravenous I/C He experienced subjective and objective improvement on days 2–4 of antimicrobial therapy; two generalized tonic-clonic seizures occurred on days 7 and 12. Intrathecal amikacin was discontinued after 6 days, and intravenous amikacin and I/C were discontinued after 23 and 27 days, respectively. The patient's mental status did not completely return to premeningitis baseline.

DISCUSSION:

Third-generation cephalosporins are the treatment of choice for GNBM. In the case reported herein, bacterial resistance to these agents prompted the use of a therapy that has not been well studied and is also considered to be less safe and perhaps less efficacious. Treatment of GNBM with an intrathecally administered aminoglycoside or with intravenous I/C plus an aminoglycoside is reviewed.

CONCLUSIONS:

Patients with GNBM secondary to third-generation cephalosporin-resistant organisms may require therapies that may be less effective and more toxic. Further study of alternative agents is warranted.
Oculogyric Crisis Possibly Related to Pentazocine
Authors: Burstein Aaron H. , Fullerton Terence
Published: January 2017

OBJECTIVE:

To report and describe the apparent first case of acute oculogyric crisis following administration of pentazocine, and to discuss the possible mechanism for this reaction.

DATA SOURCES/CASE SUMMARY:

Patient case and relevant review of literature. The patient, a 39-year-old woman, developed acute oculogyric crisis following administration of Talacen (pentazocine and acetaminophen) for pain relief. The crisis resolved after discontinuation of the medication and administration of intravenous diphenhydramine 50 mg.

CONCLUSIONS:

Based on the temporal relationship of drug administration to occurrence of the event, pentazocine is implicated as the cause of this acute oculogyric crisis. A plausible mechanism for precipitation of this crisis is the agonism of pentazocine on sigma opiate receptors, with postulated subsequent modulation of dopamine receptors.
Cefuroxime-Induced Fever
Authors: Mevorach or , Lossos Izidore S. , Oren Ran
Published: January 2017

OBJECTIVE:

To report on three patients with cefuroxime-induced fever.

CASE SUMMARIES:

Recurrence of fever was noted in three patients after five to seven days of cefuroxime sodium therapy for acute exacerbation of chronic obstructive pulmonary disease. No source of infection was found and the fevers resolved within 30 hours of drug discontinuation. One patient was rechallenged; the same pattern of fever resulted.

DISCUSSION:

Fever secondary to cephalosporin administration is reviewed and the place of cephalosporins in the differential diagnosis of fever is postulated.

CONCLUSIONS:

Cefuroxime should be added to the list of cephalosporins that induce fever.
Clindamycin-Induced Lip and Nasal Passage Swelling
Authors: Segars Larry W. , Threlkeld Kathy R.
Published: January 2017

OBJECTIVE:

To report a severe case of clindamycin-induced lip and nasal passage swelling.

DESIGN:

Single case report.

SETTING:

Six hundred eighty-four-bed community hospital.

CASE SUMMARY:

A 34-year-old, insulin-dependent diabetic white man with worsening cellulitis and osteomyelitis of the left great toe was admitted for treatment with intravenous antibiotics. Intravenous clindamycin was the first agent administered. Within 5 minutes after initiating the drug (600-mg dose) the patient began to sneeze and his eyes began to tear and itch. Within 10 minutes, his lips and nasal passages began to swell. By the end of the infusion (approximately 20 min), the patient's lips were severely swollen and his nasal passages were completely closed off secondary to the swelling. The patient did not have difficulty breathing through his mouth and denied any shortness of breath. He did not develop a rash. His vital signs remained stable and no pharmacologic agents were administered for this reaction. No subsequent doses of clindamycin were given and complete resolution of all symptoms occurred within 24 hours.

CONCLUSIONS:

Severe lip and nasal passage swelling is an uncommon adverse reaction associated with the use of intravenous clindamycin. We believe this to be the first published case of nasal passage swelling and only the second case reporting lip edema associated with the intravenous form of this agent. Clinicians should be aware of this uncommon but potentially severe reaction.