bluuebunny/crossref_metadata_2025 huggingface dataset:
Clinical Pharmacy Service Contributions on a Part-Time Basis
Authors: Self Timothy H. , Eoff James C.
Published: January 2017

Staffing a majority of hospitals with full-time clinical pharmacists is an aim that will not be attainable for many years. In an effort to demonstrate an interim approach to clinical practice that could be applied to a large percentage of hospitals, a part-time clinical pharmacist's services were documented.

Serving a teaching hospital with an average census of 97 patients, the pharmacist, with a 50 percent time allotment for clinical services, monitored 229 total admissions during an eleven week period. The majority of patients were on either a pulmonary medicine or urology service.

The total number of actions taken as a result of pharmacy consultations was 106, with 70 percent of these being related to dosing problems.

It was concluded that a pharmacist providing clinical services to a large patient population on a less than full-time basis can have a positive impact on drug therapy.
Quinidine-Digoxin Interaction
Authors: Small Ralph E. , Marshall James H.
Published: January 2017

A case study of an interaction between digoxin and quinidine is presented and its clinical significance is discussed. The serum digoxin concentration increased during quinidine therapy and the patient showed signs of digitalis toxicity. The proposed mechanism, incidence and manifestations of this rise in digoxin serum level are presented. A method of monitoring for this interaction, and its implications for clinical pharmacists, are also given.
An Evaluation of Dosing Regimens for Insulin in Diabetic Ketoacidosis
Authors: Beck Diane E. , Yost Richard L.
Published: January 2017

A review of the literature was performed to evaluate insulin dosing regimens used in the treatment of diabetic ketoacidosis.

High-dose insulin therapy was demonstrated to be effective in the largest number of patients, but carries the added risks of a high incidence of hypokalemia and hypoglycemia. Low-dose insulin regimens are effective for most patients, and these regimens produce a lower incidence of hypokalemia and hypoglycemia than do the high-dose therapies. Continuous intravenous infusion appears to be preferable to intermittent intramuscular or subcutaneous administration of insulin.

Low-dose insulin therapy is recommended unless the DKA patient presents with shock. Regardless of the dosing regimen or route of administration selected, careful patient monitoring and correction of electrolyte imbalances is most important in the prevention of any complications.
Acquired Immune Deficiency Syndrome and the Management of Associated Opportunistic Infections
Authors: Dozier Nicky , Ballentine Ron , Adams Stephen C. , Okafor Kingsley C.
Published: January 2017

Since the spring of 1981, more than 2300 cases of acquired immune deficiency syndrome (AIDS) have been reported from 41 states to the Centers for Disease Control. Cases also have been reported from 20 foreign countries, and reports are increasing at an alarming rate. More than 900 people (∽40 percent) have died of this disease. AIDS is characterized by skin test anergy to recall antigens, decreased T-helper subset, and inverted helper T-cell: suppressor T-cell ratios in the peripheral blood. Overt AIDS may be preceded by a prodrome that may last for many months and consists of fever, weight loss, and lymphadenopathy. The immune defect in AIDS permits the development of opportunistic infections caused by a number of organisms, including Pneumocystis carinii, Mycobacterium avium-intracellulare. Toxoplasma gondii, and various fungi. Certain malignancies also are associated with AIDS, in particular, Kaposi's sarcoma. Although the etiology of AIDS is unknown, the causative agent appears to be infectious. Lifestyle factors such as drug use and certain sexual activities may play a role. Currently, epidemiologists and others investigating the syndrome believe that AIDS can spread through sexual contact, blood products, or both. AIDS patients include homosexual males, users of intravenous drugs, immigrants from Haiti, hemophiliacs, female partners of males with AIDS, infants born to mothers who have AIDS, and persons who have received blood products from AIDS patients. Thus far, questions about AIDS outnumber the answers. Intensive research is being conducted to develop a rational approach to the treatment of AIDS and a better understanding of the relationship between the immune defense system and cancer.
Allergic Reaction to Purified Pork Insulin
Authors: Janachek Douglas A.
Published: January 2017

A 53-year-old white male diabetic experienced an allergic-like reaction while being switched from non-highly-purified to highly purified pork insulins. The patient, after experiencing his second separate allergic response, came to the emergency room and showed marked improvement when returned to the non-highly-purified insulins he had been taking previously.
Predictability of Serum Digoxin Concentrations in Clinical Practice
Authors: Taketomo Robert T. , Dominguez Andres E. , Landes Robert A.
Published: January 2017

A study was conducted to clarify the reliability of serum digoxin concentration (SDC) predictions in the absence of concurrent quinidine administration. The effects of age, sex, congestive heart failure (CHF), and the method used to estimate creatinine clearance were investigated.

Data were collected from patients who were representative of those seen in clinical practice. Patients admitted to the study were required to have not received quinidine, to have stable renal function, to have been taking digoxin for ten consecutive days—the same dose and route of administration, and to have been categorized as having or not having CHF at the time of the SDC determination.

There were 44 patients who qualified for admission to the study. SDCs were predicted on the basis of four methods for estimating creatinine clearance and four methods for estimating serum concentrations. After simple linear regression analysis, one method was found to have correlation coefficients ranging from 0.72 to 0.79, regardless of the method used to estimate creatinine clearance. In addition, analysis determined that age and presence of CHF were not factors affecting the reliability of predicted SDCs. Female patients had, on the average, a greater difference between measured and predicted SDCs; however, this was not statistically significant.

Thus, in the absence of concurrent quinidine administration, SDCs may be estimated as long as the limitations of the method are acknowledged. Age, CHF, and the common methods used to estimate creatinine clearance do not significantly affect the reliability of predicted SDC values.
Severe Phenytoin Intoxication as a Result of Altered Protein Binding in Aids
Authors: Tbler Steven M. , Wilkerson Marie A. , Porter William H. , Smith Albert J. , Chandler Mary H.H.
Published: January 2017

Alterations in plasma protein binding may alter patient response to pharmaceutical agents because only free drug is considered to be pharmacologically active. Such alterations appear to be more significant with highly bound agents such as phenytoin. Traditionally, most drug assays monitor total drug concentrations and do not quantitate free drug. When binding alterations are present, total drug concentrations may mislead clinicians in evaluating patient response. We describe a case in which profound hypoalbuminemia (0.2 g/dL), associated with focal segmental glomerulosclerosis, produced toxic free phenytoin concentrations (4.9 μg/mL) in an HIV-positive 25-year-old black woman. At such a high serum concentration of free phenytoin, the patient exhibited seizure-like effects. Renal abnormalities and hypoalbuminemia associated with acquired immunodeficiency syndrome (AIDS) may place patients at risk for elevated free fractions of phenytoin and subsequent toxicity.
Dexamethasone Aerosol Use in an Asthmatic Nursing-Home Patient with Parkinson's Disease and Dementia
Authors: Hoffman Nannette B. , Laucka Paul V.
Published: January 2017

Management of asthmatic or emphysematous elderly patients who cannot use metered-dose inhalers with spacers because of severe physical and mental disabilities is difficult. We report a case of a nursing-home patient with dementia and Parkinson's disease who required aerosolized corticosteroids to avoid repeated systemic corticosteroid courses for asthmatic exacerbations. The patient was unable to use a triamcinolone metered-dose inhaler with spacer devices because of his impairments. Therefore, nebulized dexamethasone solution was prepared and administered. Since initiation of nebulized dexamethasone, the patient has not required systemic corticosteroids. In addition, his hypopituitary adrenal axis has remained intact as evidenced by provocative cosyntropin testing. Therefore, nebulized dexamethasone solution may be an alternative to the aerosol corticosteroid metered-dose inhaler when patients are too impaired to use inhalers, even with spacers.
Coagulase-Negative Staphylococci: Incidence, Pathogenicity, and Treatment in the 1990S
Authors: Bailey Elaine M. , Constance Thomas D. , Albrecht Lisa M. , Rybak Michael J.
Published: January 2017

Coagulase-negative staphylococci (CNS), which historically have been viewed as contaminants when recovered in culture media, are now recognized as opportunistic pathogens of increasing importance in hospital-acquired infections. They are frequently found colonizing prosthetic devices and intravenous lines. CNS are capable of producing a variety of infections including deep-seated infections such as endocarditis and meningitis. Staphylococcus epidermidis is the most commonly isolated CNS and it appears to be the most resistant to antibiotics, making antimicrobial therapy challenging. Treatment of the infection will very often require removal of a prosthetic device, if present. An adequate infection control program is imperative in prophylaxis against this infection.
Moricizine: A Novel Antiarrhythmic Agent
Authors: Carnes Cynthia A. , Coyle James D.
Published: January 2017

Moricizine is a phenothiazine derivative with Vaughan Williams class 1 antiarrhythmic properties. It undergoes extensive first-pass metabolism, has a bioavailability of 34–38 percent, and is 95 percent bound to plasma proteins. Moricizine is extensively metabolized and may have pharmacologically active metabolites. A recent clinical study has shown that moricizine is slightly less effective than encainide or flecainide in suppressing ventricular premature depolarizations. Compared with disopyramide and quinidine, moricizine was equally or more effective in suppressing ventricular premature depolarizations, couplets, and nonsustained ventricular tachycardia. Further studies are needed comparing moricizine with other class 1 agents in the treatment of life-threatening arrhythmias; available data suggest that moricizine is comparable with these agents in the treatment of ventricular tachycardias and fibrillation. Moricizine appears to have a low incidence of serious adverse effects compared with other antiarrhythmics. This combination of apparently similar efficacy with a decreased incidence of adverse effects makes moricizine a worthwhile addition to currently available antiarrhythmic agents.
Clinical Use of Biologic Response Modifiers in Cancer Treatment: An Overview Part I. The Interferons
Authors: Balmer Carol McManus
Published: January 2017

Interferons are proteins with antiviral, antiproliferative, and immune-regulating activity. They are classified as alfa, beta, or gamma on the basis of antigenicity and biologic properties. Alfa interferons as single-agent therapy produce clinical improvement in approximately 90 percent of patients with hairy-cell leukemia, and up to 70 percent of patients with chronic myelogenous leukemia (CML) in early-stage disease. Prolonged suppression or elimination of the leukemic cell clone by interferon may ultimately increase survival of patients with CML. Interferon is not effective single-agent therapy for multiple myeloma, but improves response rate when combined with conventional agents. AIDS-associated Kaposi's sarcoma demonstrates a 40 percent objective response rate to interferon, with less risk of immune system suppression than conventional cytotoxics. Other applications of alfa interferon include malignant melanoma and renal cell carcinoma. Beta interferon is similar to the alfa subtype and may have utility in treatment of brain tumors. Gamma interferon is an important immune regulator with qualitative and quantitative differences in its efficacy and toxicity when compared with alfa interferon.
Vancomycin Protein Binding in Patients with Infections Caused by Staphylococcus Aureus
Authors: Albrecht Lisa M. , Rybak Michael J. , Warbasse Lawrence H. , Edwards David J.
Published: January 2017

The protein binding of vancomycin has been reported to range from less than 10 percent to 82 percent. We examined the binding of vancomycin in 34 patients (14 intravenous drug abusers, 10 burn patients, and 10 control patients) with Staphylococcus aureus infections. Blood samples were collected serially over an 8- or 12-hour dosing interval following a one-hour infusion. In vitro studies were also performed using albumin solutions of varying concentrations. Binding characteristics were determined through ultrafiltration with vancomycin concentrations analyzed by fluorescence polarization immunoassay. The unbound fraction of vancomycin ranged from 0.41 to 0.77 with a mean of 0.54 ± 0.08. Unbound fraction was significantly correlated with serum albumin concentration (r=-0.344, p<0.046) and renal clearance (r=0.394, p<0.021) but not with total body clearance or volume of distribution. In vitro data also showed an association between albumin concentration and unbound fraction (r=−0.94, p<0.017). Although vancomycin protein binding changes with serum albumin, this finding may have limited clinical significance.
Intravenous Esmolol in Acute Aortic Dissection
Authors: Mohindra Subodh K. , Udeani George O.
Published: January 2017

Acute aortic dissection is a devastating condition requiring prompt intensive pharmacologic management geared toward control of blood pressure and reduction in myocardial contractility (change in velocity/change in time). The treatment of choice currently is sodium nitroprusside and intravenous propranolol hydrochloride. During acute aortic dissection, hemorrhage may spread into the interatrial septum, extending to the atrioventricular junctional tissues, thus causing conduction abnormalities. Adverse effects of long-acting beta-blockers, including bradycardia, heart failure, and bronchospasm, may limit their usefulness because these effects persist for a long time after discontinuation. This may be detrimental, especially in patients with compromised cardiac function, bronchospastic disease, or both. We report a case of a 64-year-old woman with compromised cardiac function and aortic dissection who was successfully treated with esmolol hydrochloride (an ultrashort-acting beta-blocker) and sodium nitroprusside.
Stability of Ceftriaxone Sodium in Peritoneal Dialysis Solutions
Authors: Nahata Milap C.
Published: January 2017

Continuous ambulatory peritoneal dialysis is used commonly in patients with endstage renal disease. Infection is the most frequent complication of this dialysis. To treat certain infections caused by gram-negative microorganisms, ceftriaxone sodium may be added to the peritoneal dialysate fluid. No data are available, however, about ceftriaxone's stability at various temperatures in dialysate solutions containing dextrose 1.5 and 4.25%. The objective of this study was to determine the stability of ceftriaxone in dialysis solutions containing dextrose 1.5 and 4.25% over 14 days at 4 °C, 5 days at 23 °C, and 24 hours at 37 °C. Ceftriaxone 500 mg was added to 36 dialysate bags (500 mL); six bags of each of two dextrose concentrations were stored at each of the three temperatures. The samples were collected at 0, 3, 7, 10, and 14 days at 4 °C; 0, 1, 2, and 5 days at 23 °C; and 0, 6, 12, and 24 hours at 37 °C. Ceftriaxone was measured by a specific, stability-indicating HPLC method. A clinically significant loss of potency was defined as a greater than ten percent decrease from its initial concentration. The mean ceftriaxone concentration was 90 percent or more of the initial concentration for 14 days at 4 °C, 24 hours at 23 °C, and 6 hours at 37 °C. Thus, ceftriaxone can be stored in dialysate solutions for 14 days under refrigeration, 24 hours at room temperature, and 6 hours at body temperature.
Human Monoclonal Antibody against Endotoxin
Authors: Zarowitz Barbara J.
Published: January 2017

Little progress has been made over the past several years in the treatment of gram-negative bacteremia and septic shock. Advances in biotechnology have led to the development of human monoclonal antibody against endotoxin (HA-1A), a toxic mediator of the septic response. HA-1A is an immunoglobulin M antibody to the lipid A component of the endotoxin molecule. It distributes into an apparent volume of distribution 10–20 percent larger than plasma volume and has a circulating half-life of 16.0 hours. In a major, multicenter, double-blind trial of HA-1A 100 mg administered intravenously versus placebo, mortality was greatly reduced in HA-1A recipients with gram-negative bacteremia. Increased survival was noted early and was sustained throughout the 28-day study period in patients with and without shock at the time of enrollment. HA-1A has an excellent safety profile; thus far only two minor hypersensitivity reactions and no drug interactions have been reported. Based on currently available information, the release of HA-1A as adjunct therapy for patients with gram-negative bacteremia with or without shock represents a significant therapeutic advance. Investigations are underway to define the optimal dose of HA-1A and its duration of action. Comparative trials between HA-1A and competitive products are necessary.
Vitamin D Therapy in Psoriasis
Authors: Araujo Oscar E. , Flowers Franklin P. , Brown KimDebra
Published: January 2017

The use of vitamin D3 in the treatment of psoriasis is discussed with emphasis on positive and negative results of many clinical trials. Investigations indicate that treatment with topical vitamin D3 provides consistently more rapid clinical improvement than its oral counterpart, with no reported adverse effects. Studies have shown that 68 of 83 patients exhibited significant improvement of their psoriatic lesions with the topical application of vitamin D3 analogs, including 1,24-dihydroxycholecalciferol, calcitriol, and MC 903. Clinical trials involving 35 patients treated with oral vitamin D3 analogs resulted in moderate improvement in 24 of the patients. Adverse effects can be minimized by bedtime dosing and possibly the use of new noncalciotropic analogs. Vitamin D3 analogs appear to provide one more promising treatment option for psoriasis.
Clinical and Economic Impact of Oral Ciprofloxacin as Follow-up to Parenteral Antibiotics
Authors: Hartzema Abraham G. , Porta Miquel S. , Tilson Hugh H. , Grasela Thaddeus H. , Paladino Joseph A. , Schentag Jerome J. , Huepenbecker Dawn , Rybacki James , Purcell Jeffrey B. , Fiedler Jill B.
Published: January 2017

This study assessed the effects of switching to ciprofloxacin hydrochloride in patients initially treated with parenteral antibiotics for respiratory tract (TOT), skin or skin structure (SSS), bone or joint (BJI), or urinary tract infection (UTI). A total of 766 patients from 54 institutions were concurrently monitored and the projected effect of ciprofloxacin on duration of hospitalization and parenteral therapy was assessed based on previous experiences with each type of patient. The median duration of parenteral antibiotic therapy prior to oral ciprofloxacin was 4, 6, 6, and 7.5 days; the median duration of oral ciprofloxacin prior to discharge was 2, 2, 2, and 4 days for UTI, RTI, SSS, and BJI, respectively. It was estimated that more than 70 percent of patients would have continued parenteral antibiotics on an inpatient basis and only 10 percent would have received an alternative oral agent if ciprofloxacin were not available. Use of oral ciprofloxacin significantly affected both duration of parenteral therapy and duration of hospitalization. It was estimated that 16 732 doses of parenteral antibiotics were avoided and, after subtracting the cost of oral ciprofloxacin, resulted in a likely net savings of $187 146.50. An estimated total of 2266 hospital days were saved in 418 patients, resulting in estimated savings of $793 100. Total drug plus hospitalization cost savings were projected to be $980 246.50. Further research is required to determine if, and where, more aggressive intervention will achieve additional cost savings.
Cefaclor-Associated Serum Sickness-Like Disease: Eight Cases and Review of the Literature
Authors: Vial Thierry , Pont Jacqueline , Pham Emmanuel , Rabilloud Muriel , Descotes Jacques
Published: January 2017

OBJECTIVE:

To describe the clinical features of serum sickness-like diseases (SSLD) in cefaclor-treated patients.

DESIGN:

Analysis of a case series spontaneously reported to Lyons Pharmacovigilance Center.

SETTING:

General and hospital practitioners and the French Network of Regional Pharmacovigilance Centers (FNRPC).

PATIENTS:

All reported cases with a possible causative relationship between cefaclor treatment and SSLD.

MAIN RESULTS:

Eight cases of SSLD following cefaclor treatment are described. The clinical features included cutaneous reactions, arthralgias, and moderate hyperthermia. In 50 percent of the patients, hospitalization was required because of incapacitating symptoms. The outcome was benign in all cases following discontinuation of the offending drug. All eight cases were reported in children under five years of age. Among 137 cefaclor-associated drug reactions collected by FNRPC, 27 cases of SSLD have been reported; 23 of these patients were younger than five years of age. A literature survey confirmed the higher reporting of SSLD in children with cefaclor compared with other antibiotics and suggested an incidence of 0.024–0.2 percent of SSLD per drug course of cefaclor.

CONCLUSIONS:

The case reports and epidemiologic studies confirmed the presumed role of age (patients under five years of age) in cefaclor-induced SSLD and the benign outcome despite severe clinical presentations in some reports.
Evaluation of Medication Knowledge in Elderly Patients
Authors: O'Connell Mary Beth , Johnson June F.
Published: January 2017

OBJECTIVE:

To identify problems with medication knowledge, self-estimated compliance, and recall of medication education in a group of elderly patients.

DESIGN:

Survey.

SETTING:

Medicine and geriatric clinics at a county hospital.

PATIENTS:

Patients ≥60 years old and taking at least one prescription medication.

MAIN OUTCOME MEASUREMENTS:

Medication knowledge, self-estimated compliance, and recall of medication education.

RESULTS:

The percent of geriatric patients correctly stating 76–100 percent of their medication doses, uses, and frequencies was 30, 64, and 66 percent, respectively. Fifteen patients (34 percent) stated they never missed a medication dose and 27 (61 percent) remembered to take their medications by memory alone. Sixteen and 86 percent, respectively, of the patients from the medicine and geriatric clinics could not recall receiving verbal or written educational material. Only 27 percent of patients recalled having been told about possible adverse reactions. The most frequently cited providers of medication information were physicians.

CONCLUSIONS:

Specially designed multidisciplinary medication education programs with repeated written and verbal reinforcement for elderly patients may improve patients' knowledge about their medications, recognition and management of adverse reactions, and compliance.
Hypersensitivity Immune Reaction as a Mechanism for Dilevalol-Associated Hepatitis
Authors: Maria Vasco A.J. , Victorino Rui M.M.
Published: January 2017

OBJECTIVE:

To assess lymphocyte reactivity to dilevalol and to serum containing putative ex vivo dilevalol antigens or metabolites in a case of dilevalol-induced liver injury.

PATIENT:

A 58-year-old woman with a clinical diagnosis of dilevalol-induced liver injury.

METHODS:

Peripheral blood mononuclear cells collected from the patient were cultured in the presence of a solution of dilevalol and also with sera collected from a volunteer before and after dilevalol intake. A similar protocol was performed with lymphocytes from a healthy subject.

RESULTS:

No lymphocyte proliferation was observed either in the patient or in the healthy volunteer in the presence of dilevalol solutions. A significant proliferative response to serum collected after dilevalol intake was observed in the case of the patient compared with the proliferative response to the serum collected before the drug intake. No reactivity was found when lymphocytes from the healthy subject were tested under similar conditions.

CONCLUSIONS:

The methodology used allowed the detection of lymphocyte sensitization to sera containing ex vivo-prepared dilevalol antigens, suggesting the involvement of an immunologic mechanism in dilevalol-induced liver injury.
Treatment of Herpesvirus Infections in Hiv-Infected Individuals
Authors: Fletcher Courtney V.
Published: January 2017

OBJECTIVE:

To discuss strategies available for the treatment of herpesvirus infections in individuals infected with HIV.

DATA SOURCES:

Information was obtained from controlled and uncontrolled clinical trials, abstracts, conference proceedings, and review articles.

STUDY SELECTION:

Emphasis was placed on controlled investigations in subjects infected with HIV.

DATA EXTRACTION:

Data from human studies were extracted by the author and evaluated according to the patient population studied, sample size, dosage regimen, and therapeutic response.

DATA SYNTHESIS:

Herpes group viruses are common opportunistic pathogens in HIV-infected individuals. Zoster, caused by varicella-zoster virus (VZV), is an early indication of the loss of cell-mediated immunity and HIV disease progression. Anorectal mucocutaneous disease is the most common manifestation caused by herpes simplex virus (HSV). Acyclovir is the drug of choice for treatment of both VZV and HSV infections. Cytomegalovirus (CMV) is the most common life-threatening viral infection in patients with AIDS; retinitis is the most frequent clinical manifestation. The response rate of CMV retinitis to initial treatment with either ganciclovir or foscarnet is equivalent, approximately 60–90 percent. Recent data suggest that the survival benefit may be greater with foscarnet.

CONCLUSIONS:

Advances in the development and application of antiviral drugs for herpes group viruses have made treatment and, in some cases, prevention of infections possible. Future efforts, aimed at earlier intervention and suppression of latent virus, may offer additional improvement in quality of life for the HIV-infected individual.
Selective Decontamination of the Digestive Tract in Intensive Care Patients: Review and Commentary
Authors: Gomez Eleanor C. , Markowsky Susan J. , Rotschafer John C.
Published: January 2017

OBJECTIVE:

To evaluate the benefits, risks, and costs of antimicrobial regimens used for selective decontamination of the digestive tract (SDD) in intensive care unit (ICU) patients.

DATA SOURCES:

Information was obtained from clinical trials, review articles, abstracts, and textbooks. Key indexing terms included antibiotics, selective decontamination, and infections.

STUDY SELECTION:

Research articles describing controlled clinical trials of SDD in medical or surgical ICU patients were reviewed. Trials that investigated transplant, cirrhotic, leukemic, or oncology patient populations were excluded.

DATA EXTRACTION:

The details of studies that evaluated nosocomial infection or nosocomial pneumonia rates were extracted. These included study design, demographics, SDD regimens, severity of illness scores, and colonization, infection, and mortality rates.

DATA SYNTHESIS:

The use of SDD in mechanically ventilated surgical or trauma ICU patients reduces the incidence of colonization, nosocomial pneumonia, and overall infection rates, but does not change the overall mortality rate. Administration of antibiotic and antifungal agents in a nasogastric suspension is required for SDD. The addition of systemic prophylactic antibiotics or oropharyngeal paste was not required to decrease nosocomial infections. The most frequently studied SDD regimen (colistin/amphotericin B/tobramycin) is not feasible for use in the US because of exorbitant drug costs. Less expensive alternatives include norfloxacin/nystatin, or colistin/nystatin/gentamicin.

CONCLUSIONS:

Additional research is required before SDD regimens can be routinely recommended in surgical and trauma ICU patients. A multicenter study is warranted to determine the long-range benefits, potential for resistance, and cost-effectiveness of SDD.
Hepatic and Renal Dysfunction following Nafcillin Administration
Authors: Lestico Mitchell R. , Vick Karen E. , Hetsko Cyril M.
Published: January 2017

OBJECTIVE:

To review four cases of combined hepatic and renal toxicity that may be associated with the administration of nafcillin in adults. This type of adverse event with the use of nafcillin has not been previously documented in the literature.

DATA SOURCES:

References from pertinent articles are identified throughout the text.

DATA SYNTHESIS:

Nafcillin is a widely used penicillinase-resistant penicillin. In four patients receiving nafcillin doses greater than 9 g/24 hours, changes in renal and hepatic function markers were noted within 72 hours of the initiation of nafcillin therapy. Laboratory values returned toward baseline when nafcillin therapy was discontinued. Elevations in blood urea nitrogen, creatinine, total bilirubin, and lactate dehydrogenase have been previously described in the literature for penicillin-like agents other than nafcillin. The exact mechanism for such toxicities as well as patient risk factors have not been clearly established.

CONCLUSIONS:

Caution should be taken when initiating nafcillin therapy. Evaluation of renal and liver function tests prior to initiating nafcillin therapy and within the first 72 hours appears warranted. If hepatic and/or renal toxicity is observed, discontinuation of nafcillin should be considered.
Contribution to the Issue of Essential Drugs in Czechoslovakia
Authors: Kolář Josef V. , Foltán Viliam J.
Published: January 2017

OBJECTIVE:

To determine the ratio represented by essential drugs (EDs) in the total consumption of drugs in Czechoslovakia in 1989.

DESIGN:

Retrospective analysis of the assortment and consumption of EDs in 1989.

SETTING:

Department of the Organization and Management of Pharmacy, Faculty of Pharmacy, Bratislava.

MAIN OUTCOME MEASURES:

Consumption of drugs and/or pharmacotherapeutic groups, expressed by the number of formulations, number of units, and in financial terms.

RESULTS:

EDs constitute approximately one-third of the total consumption of drugs in Czechoslovakia (both in terms of volume and finances); almost 60 percent of EDs have dosage forms and concentrations identical to those shown in the World Health Organization Model List of Essential Drugs (Sixth List).

CONCLUSIONS:

The results obtained indicate that there is need for a regular updating of the drug policy within the public health branch of the government to more effectively regulate the production and import of drugs.
Comparative Trial in Volunteers to Investigate Possible Ethanol-Ranitidine Interaction
Authors: Kleine Michael-W. , Ertl Doris
Published: January 2017

OBJECTIVE:

To assess the effect of ranitidine on ethanol absorption after ethanol 0.5 g/kg is given in three single doses of 0.167 g/kg to simulate normal social drinking.

DESIGN:

A double-blind, placebo-controlled, crossover trial was performed in 16 healthy men. Ethanol serum concentrations were measured on day 6 of each of the three treatment periods (placebo, ranitidine 150 mg bid, or ranitidine 300 mg bid).

METHODS:

Ethanol 0.167 g/kg was administered followed by a standard meal at 1700. The last tablet of the test medication was given 15 minutes later. Thirty and 60 minutes after the first intake, the same amount of ethanol was given again. Serum ethanol concentrations were measured multiple times during the four-hour period following oral ingestion of the first dose.

RESULTS:

Comparison of median serum ethanol concentrations, the areas under the curve, peak and time to peak serum ethanol concentrations showed no significant differences during medication with placebo, ranitidine 150 mg bid, or ranitidine 300 mg bid. Peak ethanol concentrations (median values) were 153, 140, and 155 mg/L, respectively.

CONCLUSIONS:

This study shows that treatment with ranitidine, in a dose up to 300 mg bid, has no significant effect on serum ethanol concentrations, even when ethanol was given in divided doses to simulate normal patterns of social drinking. This implies that concomitant dosing with ranitidine will not increase the adverse effects of moderate doses of ethanol on concentration and psychomotor function.
Baclofen-Induced Bronchoconstriction
Authors: Dicpinigaitis Peter V. , Nierman David M. , Miller Albert
Published: January 2017

OBJECTIVE:

To report the occurrence of acute bronchospasm in one asthmatic patient and increased bronchial reactivity in another following the administration of a single dose of oral baclofen.

CASE SUMMARY:

On two separate occasions, a 46-year-old asymptomatic asthmatic man developed dyspnea and chest tightness one hour after the ingestion of baclofen 40 mg. Pulmonary function studies revealed a significant decrease in airflow relative to baseline. A 33-year-old asymptomatic woman with a history of exercise-induced dyspnea and wheezing displayed bronchial hyperresponsiveness to inhaled methacholine 2 hours after ingesting 40 mg of baclofen. The patient had had a negative methacholine challenge test 72 hours earlier.

DISCUSSION:

The gamma-aminobutyric acid-agonist baclofen has been shown to reduce airway responsiveness to various bronchoconstricting agents in animal studies. The etiology of this seemingly paradoxical response in two patients is unclear, but may offer insight into the neurally mediated airway constriction that occurs in asthma.

CONCLUSIONS:

Clinicians should be aware of the possibility of baclofen-induced bronchospasm, especially in asthmatic patients.
Vancomycin Administration into the Cerebrospinal Fluid: A Review
Authors: Luer Mark S. , Hatton Jimmi
Published: January 2017

OBJECTIVE:

To discuss administering vancomycin directly into the cerebrospinal fluid (CSF) to treat serious central nervous system (CNS) infections.

DATA SOURCES:

References were obtained through an online search of MEDLINE, limited to material published in English. In addition, information was extracted from clinical trials, review articles, abstracts, and textbooks.

STUDY SELECTION:

Systematic evaluation of this topic in humans has not been done in a prospective manner. Related research articles describing the pathophysiology of CNS infections, intrathecal drug administration, and case reports of CSF vancomycin administration were reviewed.

DATA EXTRACTION:

Case reports regarding CSF vancomycin dosing were evaluated and included: Drug dosing, infecting organism, infectious disease state, infectious outcome, CSF dynamics/flow abnormalities, methods of drug administration, drug monitoring, and toxicities.

DATA SYNTHESIS:

The results of this review are based on qualitative evaluations of anecdotal case reports and a basic understanding of intrathecal and intraventricular drug dosing principles. CSF administration of vancomycin is an effective means of bypassing the blood-brain barrier to achieve greater drug concentrations within the CSF. Current limitations to the CSF administration of vancomycin include a lack of data describing its safety, efficacy, and pharmacokinetics.

CONCLUSIONS:

CNS infections may require the CSF administration of vancomycin for successful eradication. Recommendations for dosing in the literature vary. Because of the potential toxicities associated with elevated CSF concentrations of vancomycin, dosing should be conservative.
Ceftazidime Dosing in the Elderly: Economic Implications
Authors: Vlasses Peter H. , Bastion Wynette A. , Behal Raj , Sirgo Mark A.
Published: January 2017

OBJECTIVE:

This study evaluated the prevalence and resulting costs of ceftazidime dosing in excess of product labeling recommendations in elderly hospitalized patients. Ceftazidime is a beta-lactam antibiotic excreted via glomerular filtration. According to product labeling, ceftazidime dosing can frequently be decreased in the elderly because glomerular filtration declines with age.

METHODOLOGY:

A multicenter, retrospective utilization audit involving 11 US academic medical centers examined 221 medical records of patients 65 years of age or older receiving ceftazidime (any brand, any indication). The creatinine clearance of each patient was estimated using the Cockcroft-Gault formula.

RESULTS:

Renal insufficiency, defined as an estimated creatinine clearance of less than 50 mL/min, was present in 111 of the patients (50 percent). Ceftazidime dosing in excess of product labeling recommendations was noted in 75 of those 111 (68 percent). The cost of excess ceftazidime dosing for those 75 patients (i.e., extra drug acquisition, preparation, administration) was $13 822.50.

CONCLUSIONS:

Although the dosage of ceftazidime required in a specific patient is based on many factors, ceftazidime is frequently overdosed in the elderly because renal function is not considered. Ceftazidime dose-adjustment in the elderly, based on the estimated creatinine clearance, can lead to cost savings. In the US, where hospital reimbursement by Medicare is based on diagnosis, institutions can realize direct cost savings.
Prescription of Antimicrobial Drugs to Hospitalized Children
Authors: Kolář Josef V. , Kadáková Eva
Published: January 2017

OBJECTIVE:

To analyze with regard to age, gender, and diagnosis, the profile, frequency of prescribing, and cost of antimicrobial drugs (AMDs) in hospitalized children.

DESIGN:

Retrospective study of medical records of children hospitalized during 1987 and 1988.

SETTING:

First Pediatric Clinic, Children's Teaching Hospital, Bratislava, Czechoslovakia (now Slovakia).

PATIENTS:

One thousand randomly selected hospitalized children.

MAIN OUTCOME MEASURES:

Patterns of AMD prescribing. Consumption is expressed by the number of drugs and cost per child.

RESULTS:

AMDs were prescribed to 69.9 percent of the patients (average 1.91 per patient). Ampicillin was the drug most frequently prescribed (20.0 percent), followed by oxacillin (12.8 percent). The mean length of stay was 15.9 days. An average of 3.61 drugs from other pharmacotherapeutic categories were prescribed per patient. Most children who received AMD treatment were in the 1-year group (patients between six months and 1.5 years of age [88.6 percent]).

CONCLUSIONS:

This study provides an overview of the prescribing of AMDs and other drugs in hospitalized children in Bratislava.
Serum Aldosterone Concentrations and Urine Output in Oliguric Intensive Care Unit Patients Receiving Low-Dose Dopamine
Authors: Dick Michael , Dasta Joseph F. , Choban Patricia S. , Sinha Renu , Flancbaum Louis
Published: January 2017

OBJECTIVE:

To determine whether the diuretic and natriuretic effects of low-dose dopamine (2.5 μ/kg/min) are associated with changes in serum aldosterone concentration.

DESIGN:

Prospective clinical study.

SETTING:

Surgical intensive care unit (SICU) of a university hospital.

PARTICIPANTS:

Oliguric (urine output <0.5 mL/kg/h) SICU patients. All patients were resuscitated to pulmonary artery occlusion pressure > 10 mm Hg, mean arterial pressure >65 mm Hg, and cardiac index >2.5 L/min/m2. Patients with a serum creatinine concentration > 176.8 μmol/L (2.0 mg/dL.), those who received diuretics within 12 hours prior to entry into the study, and renal transplant recipients were excluded.

MAIN OUTCOME MEASURES:

Hourly urine output (mean ± SD) was recorded 2 hours before and for 6 hours after the initiation of lowdose dopamine. Urine sodium and serum aldosterone concentrations were obtained prior to and 6 hours after the start of low-dose dopamine.

RESULTS:

Fifteen patients were enrolled in the study. Urine output (mean ±SD) increased from 0.31 ± 0.11 mL/kg/h before to 0.80 ± 0.34 mL/kg/h following low-dose dopamine (p<0.01). Urine sodium concentrations increased from 46 ± 32 mmol/L baseline to 72 ± 53 mmol/L following low-dose dopamine (p<0.05), and serum aldosterone concentrations decreased from 415.82 ± 341.48 pmol/L prior to low-dose dopamine infusion to 256.04 ± 204.17 pmol/L (p<0.05). Cardiac output, pulmonary artery occlusion pressure, mean arterial pressure, and heart rate did not change.

CONCLUSIONS:

Low-dose dopamine significantly increases urine output and urine sodium excretion in oliguric, critically ill, surgical patients, and is associated with a decrease in serum aldosterone concentration. The diuretic and natriuretic effects of low-dose dopamine may be, in part, related to a dopamine-mediated inhibition of aldosterone secretion.
Assessment of 24-Hour Gastric pH Measurements in Trauma Patients Receiving Intravenous Famotidine by Intermittent Bolus versus Continuous Infusion Administration
Authors: Jones Lori A. , Gonzalez Edgar R. , Reines H. David , Venitz Jurgen
Published: January 2017

OBJECTIVE:

To compare the effects of intermittent bolus versus continuous infusion intravenous famotidine on gastric pH in critically ill trauma patients.

DESIGN:

Twenty patients were randomized to receive famotidine by intermittent bolus or continuous infusion for 24 hours. Patients fasted during the study period. Hourly gastric pH measurements were made using an indwelling sensor/sump tube.

SETIING:

The study was conducted in a university teaching hospital.

PARTICIPANTS:

Adult patients admitted to the neurosurgical or surgical/trauma intensive care unit within 72 hours of traumatic injury were enrolled in the study if they had two consecutive hourly gastric pH readings of <4 without receiving antacids, sucralfate, or histamine2-antagonists.

MAIN OUTCOME MEASURES:

Groups were compared with regard to (1) total dose of famotidine received/24 hours, and (2) number of dosage changes required to maintain a gastric pH value of ≥4.

RESULTS:

The median dose of famotidine required to maintain a gastric pH ≥4 was 50 mg/24 h (25th–75th percentiles = 40–55 mg) in the intermittent bolus group compared with 42 mg/24 h (25th–75th percentiles = 42–52 mg) in the continuous infusion group (p=0.9577). A dosage increase was required by 5 of 8 patients (62 percent) receiving intermittent bolus therapy, whereas only 2 of 8 patients (25 percent) in the continuous infusion group required a dosage adjustment (p=0.315, power=0.318).

CONCLUSIONS:

Intravenous famotidine (40–50 mg/d) effectively controlled gastric pH in critically ill trauma patients. Patients treated with intermittent bolus therapy required slightly more drug and more frequent dosage adjustments to achieve a gastric pH ≥4. These differences did not reach statistical significance.
Close Clinical Observation Minimizes the Complications of Beta-Blocker Withdrawal
Authors: Eisele George , Gilmore Linda L. , Blanchard Edward B.
Published: January 2017

OBJECTIVE:

To determine whether beta-blocker withdrawal under close medical supervision poses undue risks.

DESIGN:

Retrospective case review. Data extracted from previous study.

SUBJECTS:

114 hypertensive subjects tapered from beta-blocker therapy. Subjects were a subset of patients originally studied for blood pressure medication withdrawal and biofeedback training.

MAIN OUTCOME MEASURES:

Frequency of symptoms and adverse effects reported by subjects during medication taper to the study nurse.

RESULTS:

Symptoms were no more likely to occur with beta-blocker withdrawal than with withdrawal of other types of antihypertensive medications. Most adverse effects were classified as minor. Two subjects experienced major symptoms. One subject required reinstitution of beta-blockers for palpitations, and another exhibited angina upon beta-blocker withdrawal.

CONCLUSIONS:

In well-screened patients under careful monitoring, withdrawal from beta-blockers appears to present a small, manageable risk.
Implementation and Evaluation of a Standardized Herpes Simplex Virus Prophylaxis Protocol on a Leukemia/Bone Marrow Transplant Unit
Authors: Rayani Shelina A. , Nimmo Cindy J. Reesor , Frighetto Luciana , Martinusen Shelagh M. , Nickoloff Donna M. , Reece Donna E. , Jewesson Peter J.
Published: January 2017

OBJECTIVE:

To assess the impact of a standardized acyclovir prophylaxis protocol for the prevention of herpes simplex virus (HSV) infection and disease in bone marrow transplant and leukemic patients.

DESIGN:

Two-phase, open sequential study involving prospective patient monitoring and retrospective health record review.

SETIING:

Tertiary care teaching hospital.

PATIENTS:

Fifty-seven patients (35 preprotocol, 22 postprotocol) who received acyclovir for HSV prophylaxis during an 18-month study period.

INTERVENTIONS:

An acyclovir HSV prophylaxis protocol was developed and implemented. Under this protocol, all HSV immunoglobulin G-seropositive hematology patients received an acyclovir regimen of 125 mg/m2 iv q6h or 600 mg po q6h (if tolerated) from day −5 to day 30. Regimens not matching protocol were modified by pharmacists in conjunction with the prescriber. All treatment courses were followed daily by pharmacists to modify dosage according to renal function and assess appropriateness of the iv route. Tablets, capsules, or suspensions were promoted if the patient was considered tolerant of the oral route.

MAIN OUTCOME PARAMETERS:

Outcome parameters included (1) incidence of parenteral, oral, or combined therapy; (2) total prophylactic acyclovir dose per patient; (3) mean prophylactic acyclovir daily dose; (4) mean duration of acyclovir prophylaxis; and (5) HSV reactivation rate.

RESULTS:

Following implementation of the protocol, the mean total iv acyclovir dose per patient decreased from 20.1 g (range 3.6–109.5) to 11.7g (range 1.0–43.0; p=0.1162). The mean cumulative oral dose increased from 12.1 g (range 0.4–70.0) to 33.1g (range 2.4–93.6; p=0.00(7). Mean duration of therapy increased from 27.6 to 33.5 days (p=0.23). The mean duration of oral therapy increased from 10.5 days (±SD 10.9) to 17.2 days (±SD 12.1) (p=0.034). The appropriateness of use of the iv dosage form increased from 53 to 88 percent of treatment days (p=0.013). No difference in HSV reactivation rate was observed when comparing patients prior to and following protocol implementation. A drug acquisition savings of $1112.00 (CON) per patient was realized.

CONCLUSIONS:

The implementation of a standardized HSV acyclovir prophylaxis protocol has resulted in significant drug acquisition cost savings without an apparent negative impact on patient outcome.