bluuebunny/crossref_metadata_2025 huggingface dataset:
Amiloride (Midamor®, Merck, Sharp and Dohme)
Authors: Macfie Helen L. , Colvin Carol L. , Anderson Philip O. , Jackson Eric A. , Cardoni Alex A. , Lebel Marc
Published: December 2017

Amiloride is a potassium-sparing diuretic that is pharmacologically similar to triamterene. It has been widely used abroad for several years, alone and in combination with hydrochlorothiazide. As a potassium-sparing agent, amiloride appears to be approximately as effective as triamterene and spironolactone and to have a longer duration of action than triamterene, allowing once daily dosing. The diuretic effect of amiloride is mild, as are all agents that act at distal tubular sites. Amiloride appears to have an antihypertensive effect approximating that of the thiazides and spironolactone – an advantage over triamterene, which is devoid of antihypertensive effects.

Amiloride will probably be most useful as a potassium-sparing agent in combination with the thiazide and loop diuretics. It should be kept in mind, however, that many patients on thiazide diuretics do not need supplemental potassium or potassium-sparing agents if they have no other complicating factors, such as digitalis therapy. When hypokalemia causes symptoms, a potassium-sparing agent may have advantages over oral potassium supplements in patient tolerance and compliance. Because of the possibility of tumorigenicity and estrogenic side effects, spironolactone's popularity has been decreasing in recent years. Amiloride will probably be a strong competitor of triamterene and spironolactone because of its longer duration of action than triamterene and, from early indications (cf. ticrynafen), more benign side effects than spironolactone. The drug should be used with great caution, if at all, in patients with impaired renal function, however. The benefits of amiloride will have to be weighed against the cost of the drug in individual patients.
Actinomycosis: The Disease and its Treatment
Authors: Robbins Terry S. , Scott Steven A. , Roy Myrella
Published: December 2017

The diagnosis of actinomycosis is often missed because anaerobic cultures are difficult to obtain and the clinical presentation of actinomycosis often resembles several other disease states. The presence of external draining sinuses and/or yellow sulfur granules upon microscopic examination should direct the clinician toward a correct diagnosis. Therapeutic measures usually consist of several weeks of high dose intravenous penicillin followed by weeks to months of oral penicillin, tetracycline, clindamycin, or erythromycin. Abscesses and empyemas require surgical drainage in addition to antibiotic therapy. The prognosis is usually favorable with early detection and proper treatment.

A case of pulmonary actinomycosis is described in a patient who presented with fever, weight loss, and a painful mass on his lower anterior left rib cage. Gram-stain and culture and sensitivity tests performed on the fluid drawn off the chest wall mass revealed Actinomyces israelii as the infecting organism. The patient was successfully treated with long-term penicillin therapy. A review of this rare bacterial disease is presented, emphasizing its treatment and its similarities and differences to other bacterial and fungal diseases.
Diagnosis and Treatment of Five Parasites
Authors: Johnston Timothy S. , Boisvert Alain
Published: December 2017

General descriptions and monographs of the five parasites most likely to be seen in U.S. patients are presented. The appended monographs are designed to be a starting reference for answering drug information questions regarding these parasites. The drugs covered in the monographs are listed in the order of suggested use.
Nalidixic Acid-Induced Photodermatitis after Minimal Sun Exposure
Authors: Boisvert Alain , Barbeau Gilles , Boisvert Alain
Published: December 2017

More than 30 cases of bullous photodermatitis have already been associated with the administration of nalidixic acid. This reaction is reported in a 57-year-old woman whose sun exposure was minimal.

Nalidixic acid-induced photoreactions generally occur in females; they affect mainly the dorsal surfaces of the hands, feet, and legs, and usually do not involve the face. Blistering is always reported, and erythema is common.

Dosage regimen and duration of treatment have little influence on the onset and severity of the reaction, which is probably of allergic nature. Its duration may be long, from three to six weeks, and reexposure to the sun may trigger the reappearance of blistering for several months, even in the absence of a drug rechallenge.
Elevations in Serum Transaminases and Alkaline Phosphatase Secondary to Papaverine Hydrochloride
Authors: Geiger Gail S.
Published: December 2017

A case of papaverine-induced elevated liver function tests occurred in a 58-year-old female with peripheral vascular disease after she received papaverine hydrochloride 150 mg bid over a two- to three-week period. The patient presented with abnormal elevations in serum transaminases (SGOT and SGPT) and alkaline phosphatase. The papaverine was discontinued, and the elevated enzymes returned to normal within three weeks.
Treatment of Nongonococcal Bacterial Septic Arthritis
Authors: Fraser Gilles L.
Published: December 2017

Septic arthritis carries significant morbidity and mortality, necessitating prompt, appropriate therapy with joint fluid aspiration, intravenous antibiotics, and, occasionally, surgical intervention. The initial choice of antimicrobial agent is guided by the results of synovial fluid gram stain, by identification of the pathogenesis of the primary focus, or by epidemiologic factors. Adequacy of therapy is assessed by serial synovial fluid white blood cell counts and by determining antimicrobial concentrations in the joint space. The goal of treatment is a clinically normal and sterile joint.

Factors that may affect antimicrobial joint penetration include the degree of joint tissue inflammation, the degree of drug protein binding, and the chemical characteristics of the drug. Perhaps most important in determining the extent of joint penetration are factors that may affect serum antibiotic concentrations, for example, dose, route of administration, volume of distribution, and rate of elimination.
Evaluating Clinical Programs: Methodological Guidelines
Authors: Fink Arlene , Kosecoff Jacqueline
Published: December 2017

Evaluations can be defined as investigations of the merits of clinical programs, and they provide information about program goals/objectives, processes, outcomes, impact, and costs. How can reliable and credible evaluations be conducted? In this article, criteria are given for posing evaluation questions; selecting samples and research designs; collecting, analyzing, interpreting, and reporting data.
Prescribing Restriction: Implications and Reactions
Authors: Wolfson David J. , Williamson Peter M.
Published: December 2017

The adoption of area antibiotic policies carries with it the restriction of prescribing. The reactions of the medical staff to this potential challenge were assessed by a questionnaire distributed to them and completed anonymously. Results showed that the doctors adopted a generally cooperative and progressive attitude. Their views provided encouragement for the adoption of further prescribing policies which, although producing probable financial savings and the educational benefit of a deeper knowledge of fewer drugs, would place a further restriction on the drugs available for their patients.
New Drug Evaluations: Netilmicin (Netromycin, Schering-Plough)
Authors: Guay David R.P.
Published: December 2017

Netilmicin sulfate, the 1-N-ethyl derivative of sisomicin, is a new aminoglycoside recently released for use in Canada and not yet released in the U.S. Its place in therapeutics, compared with gentamicin (G), tobramycin (T), and amikacin (A), is not yet established. Preliminary work in animals has suggested a lower incidence of nephrotoxicity and ototoxicity than with other aminoglycosides, and in vitro work has suggested some activity against G/T-resistant organisms. However, netilmicin appears to be virtually identical to G,T, and A in antimicrobial spectrum (except for its poorer activity against P. aeruginosa), human toxicity, and clinical use. For G/T-resistant organisms, amikacin is still the aminoglycoside of choice. In summary, netilmicin has not been demonstrated to have significant advantages over other aminoglycosides (G,T,A), and it is more expensive; thus, its potential value is limited.
A Suspected Case of Codeine-Induced Erythema Multiforme
Authors: Ponte Charles D.
Published: December 2017

Erythema multiforme usually presents as an acute inflammatory reaction involving the skin and mucous membranes. Systemic symptoms and organ involvement also can occur. The disease is associated with many illnesses and drugs.

A two-year-old child presented to the Family Practice Center with a probable codeine-induced episode of erythema multiforme. The patient had been treated with Actifed-C Expectorant for a suspected viral upper respiratory tract infection. The rash was characteristic of erythema multiforme, but there was no involvement of mucous membranes. The rash quickly abated after the discontinuation of the drug and the administration of hydroxyzine. A viral cause for the rash could not be ruled out.

When erythema multiforme is precipitated by a particular drug, discontinuation of the offending agent is necessary. The rash should disappear quickly. Adjunctive use of antihistamines may offer some benefit for the patient. Systemic corticosteroids may be necessary for more severe cases.
Treatment of L-Asparaginase Allergic Reaction
Authors: Graves Terri , Correa Sandra P. , Taylor A. Thomas , Guthrie Troy H.
Published: December 2017

The treatment of an allergic reaction to L-asparaginase is discussed in the presentation of a case of a 26-year-old man with chronic myelogenous leukemia who was undergoing methotrexate-L-asparaginase rescue therapy. The possible mechanism of action of L-asparaginase is reviewed, and precautions for use of L-asparaginase in combination therapy with methotrexate are presented.
Geriatrics & Gerontology: Pharmacists' Perceptions of Geriatric Pharmacy Practice
Authors: Lamy Peter P. , Simonson William , Pratt Clara C.
Published: December 2017

Four hundred thirty-two pharmacists from two separate pharmacy organizations associated with geriatric practice were surveyed to determine their perceptions of 51 content areas in terms of their importance for inclusion in pharmacy curricula. The population surveyed was also asked to respond to the question: What do you believe is the most difficult aspect of geriatric pharmacy practice?

Demographic and descriptive information was collected for each respondent, for statistical purposes.

The most important content areas for inclusion in pharmacy curricula were the pharmacist's responsibility in long-term care, patient compliance, drug interactions, adverse drug reactions, and psychotropic medication use.

The most difficult aspects of geriatric pharmacy practice identified included inadequate geriatric knowledge, patient compliance, physician overprescribing, communication with the elderly, and lack of professional and/or financial recognition.
The Therapy of Anaphylactic Shock
Authors: Dasta Joseph F. , Fath John J. , Cerra Frank B.
Published: December 2017

Anaphylaxis is an acute, often life-threatening systemic reaction to mediators released by basophils and mast cells. Histamine, leukotrienes, prostaglandins, and other mediators are responsible for complex and varied reactions in man. Serious cardiovascular or pulmonary involvement can lead to death within minutes. Therapy depends on prompt recognition of the disease and rapid administration of epinephrine. Even in ideal clinical settings, response to therapy may be slow and a long resuscitation necessary. Antihistamines, glucocorticoids, intravascular volume expansion, sympathomimetics, bronchodilators, and controlled ventilation all may be necessary. Taking careful allergy histories; using enteral routes for drug administration when possible; observing patients, who have received injections for at least 20 minutes; and rapidly treating patients with epinephrine are the main means of reducing the incidence and mortality of this disease.
The Argument for Aspirin as the NSAID of Choice in the Management of Rheumatoid Arthritis
Authors: Hadler Nortin M.
Published: December 2017

In view of their costliness, the use of newer NSAIDs is justified if they are demonstrably more effective, less toxic, or better tolerated than aspirin (ASA). However, there is no evidence that any is more effective than ASA, and their widely assumed comparable effectiveness has not been demonstrated convincingly. In terms of clinically meaningful overt and even occult gastrointestinal blood loss, ASA is indistinguishable from the newer NSAIDs. Most NSAIDs evoke fewer unpleasant gastrointestinal symptoms than ASA does, although current recording of such symptoms has magnified the ASA experience. Prescribing a new NSAID before ASA requires a heuristic assertion of comparable effectiveness, misconception of overt toxicities, and belief in the meaningfulness of data demonstrating differential tolerance. The trade-off is increased expense and unknown long-term toxicity.
Other NSAIDs of Choice for Rheumatoid Arthritis
Authors: Ehrlich George E.
Published: December 2017

Aspirin is an effective anti inflammatory and analgesic agent. Pain relief is achieved with relatively modest doses, far below those necessary for inflammation control. The patient reacts to the need for pain relief and will take fewer aspirin than prescribed because the lower dosage is better tolerated and less expensive. This often obviates the wanted effects. This pain-inflammation gap does not exist for most nonsteroidal anti inflammatory drugs (NSAIDs), in which analgesic and anti inflammatory doses approximate each other.

The range of toxic effects from aspirin is larger than that for nonsteroidal drugs. Gastric erosions and bleeding are far more prevalent with aspirin. Other organ systems are involved more by aspirin than by other drugs, and, in osteoarthritis, aspirin actually may militate against recovery by interfering with glycosaminoglycan synthesis.
Nonrheumatologic Uses of NSAIDS
Authors: Evens Ronald P.
Published: December 2017

Nonsteroidal anti inflammatory drugs (NSAIDs) have several salient indications outside of their role in rheumatology. Two major uses are treatment of dysmenorrhea and patent ductus arteriosus. Other established roles encompass treatment of fever, pain, Banter's syndrome, and thromboembolic disorders. Animal and human studies are being done on the use of NSAIDs in cancer, diabetes, psoriasis, and shock, just to name a few investigative areas.

NSAIDs are not a panacea nor are they wonder drugs to be used indiscriminately. When these drugs first were marketed in the 1970s, they were considered safe agents with little toxicity. However, the side-effect profile of the NSAIDs has been, and continues to be, better identified over the past few years and warrants judicious use of these drugs. Their adverse effects potentially include gastric distress (possibly hemorrhage), allergic urticaria or bronchospasm in asthma patients, azotemia, arrested labor, skin reactions, and water retention.

NSAIDs are relatively safe agents with a growing list of new indications. Future clinical evaluation holds the key to the balance between their emerging toxicities and indications.
Major Issues Facing the Pharmaceutical Industry and Their Relationship to Clinical Pharmacy
Authors: Riddiough Michael A.
Published: December 2017

There are two major issues that have potential for positive interactions between the industry and clinical pharmacy. These are drug selection and reimbursement, and clinical research.

The first issue embodies the drug prescribing process, which has been, until recently, almost the sole purview of physicians. For this reason, pharmaceutical manufacturers have marketed their products primarily to this group. Changes are occurring; other licensed practitioners, including clinical pharmacists, are gaining prescribing authority. Schools of pharmacy have trained several thousand clinical pharmacists over the past decade, while the pharmacology component of medical education and the time devoted to clinical therapeutics either has stagnated or declined during the same period. Meanwhile, drug information has increased and the need to monitor drug selection to curtail costs has widened the opportunities for clinical pharmacists to exert an influence. The pharmaceutical industry needs to recognize the role clinical pharmacists play in drug selection. Drug selection decisions obviously influence drug reimbursement decisions, which influence drug sales, which influence profits.

Clinical research is the backbone of a company's financial success and is becoming technologically sophisticated. Companies are becoming aware that many clinical pharmacists are able to collect and analyze clinical drug data as well as, or possibly better than, physicians. Clinical pharmacists can play a significant role in monitoring the safety and efficacy of marketed drugs. Good postmarketing surveillance data collection systems need to be developed.
AMA's Drug Information Data Base: Program Capabilities and Opportunities for Clinical Pharmacy
Authors: Weaver Ross H.
Published: December 2017

The AMA drug information base (AMA-DIB) is reviewed and the impact of computerized drug data bases on the practice of clinical pharmacy is discussed.

The AMA-DIB is an on-line data base derived from the fifth edition of AMA Drug Evaluations. Thus, it represents consensus information. The data base consists of individual drug records, pharmacologic class records, and therapeutic class records. It is accessed via commands using keyword searches.

Computerized on-line drug data bases will have an impact on the practice of clinical pharmacy. Information resource services will either discontinue or proliferate, depending on the quality of the service and the ability of the directors to adapt to future needs. Patient monitoring services will discover that these data bases allow easier access to more information, but the computer will not be able to transfer the data to direct patient care. Thus, their professional roles will remain intact. Clinical pharmacy researchers, in contrast, will notice little or no impact on their practice.
Agranulocytosis and Hepatitis as a Result of Mexican Drug Therapy
Authors: Jacknowitz Arthur I. , Walker Brian K.
Published: December 2017

A 26-year-old woman with debilitating juvenile rheumatoid arthritis was treated at a Mexican arthritis clinic with two unknown medications. She subsequently developed agranulocytosis and cholestatic hepatitis as an adverse reaction to these drugs, later identified as oxyphenbutazone and diazepam. The etiology of these drug-induced problems is reviewed, and the dangers of this unorthodox form of medical therapy are discussed.
Adverse Dermatologic Reaction to Transdermal Nitroglycerin
Authors: Letendre Peter W. , Barr Charles , Wilkens Kim
Published: December 2017

The incidence of adverse effects from transdermal nitroglycerin systems is reported to be very low. A cutaneous reaction from Transderm-Nitro is described. The patient in this case was a 63-year-old male with a history of chronic obstructive lung disease, adult onset diabetes mellitus, peptic ulcer disease, congestive heart failure, and angina pectoris.

Seven weeks after having used a Transderm-Nitro-5 patch daily, the patient was found to have two macular erythematous areas on his chest that corresponded to the exact sites of the nitroglycerin patch. Follow-up with the same patient, using a placebo Transderm-Nitro, elicited a reaction similar in appearance.

The exact causative agent is unknown, but it is believed to be from the transdermal delivery system and not the nitroglycerin.
Lactulose-Induced Hypernatremia
Authors: Nanji Amin A. , Lauener Roland W.
Published: December 2017

We describe severe hypernatremia in a patient with hepatic encephalopathy, who was treated with lactulose.

Lactulose produces hypernatremia via its osmotic effect and its degradation to organic acids. We recommend that patients who receive large quantities of lactulose and who lack access to free water have their electrolytes monitored and the dose tapered as quickly as possible.
Cancer Chemotherapy and Contraceptive Counseling
Authors: Parrish Richard H.
Published: December 2017

Contraceptive counseling for patients receiving antineoplastic agents is illustrated by the case of a patient with Hodgkin's disease. After the patient began treatment, he married his girlfriend and desired to have children in the near future. Clinicians are alerted to the sexual needs of the cancer patient and the need for contraception assessment in patients of reproductive years. An outline for informing cancer patients about contraception is provided.
Hematologic Abnormalities Associated with Vidarabine
Authors: Lyon Ronald A. , Swigart Scott
Published: December 2017

A report of hematologic abnormalities associated with administration of vidarabine in a neonate is presented. High doses of vidarabine (30 mg/kg/d) for the treatment of herpes simplex infection may have caused a decrease in hematocrit and platelet count. This case demonstrates the need to monitor hematologic indices during administration of vidarabine. The use of doses >15 mg/kg/d is questioned.
Drug-Related Admissions to a Veterans' Administration Psychiatric Unit
Authors: Salem Ronald B. , Keane Terence M. , Williams James G.
Published: December 2017

Forty-one consecutive admissions to an inpatient psychiatric service were monitored prospectively for drug-related problems. During the four-month study, 22 (54 percent) of the admissions were determined to be drug-related; in 12 (29 percent) admissions, a drug-related problem was identified as the primary cause of hospitalization. Significant differences were found in the length of hospitalization, age, and race when the group with drug-related problems was compared with a group with non-drug-related problems.
Systemic Side Effects Associated with the Ophthalmic Administration of Timolol
Authors: Munroe Wendy P. , Rindone Joseph P. , Kershner Robert M. , D'Arcy P.F.
Published: December 2017

Since the introduction of ophthalmic timolol solution in 1978 there have been numerous reports of systemic toxicity associated with its use. The majority of the systemic side effects reported are the same as those associated with oral timolol. Several cases of respiratory distress have been described generally in patients with underlying restrictive airway disease. Cardiovascular effects range from effects on resting pulse rate to the development of overt bradycardia and heart failure. Central nervous system effects reported include fatigue, confusion, depression, and hallucinations. A variety of other systemic effects have also been described. Caution should be used when ophthalmic timolol is administered to elderly patients or those patients with contraindications to systemic β-blockers.
Neutropenia Associated with Mezlocillin and Piperacillin
Authors: Kirkwood Craig F. , Lasezkay George M.
Published: December 2017

Neutropenia associated with β-lactam antibiotics has been widely reported since the first case was described in 1946. Cross-reactivity between β-lactam antibiotics for this phenomenon rarely has been reported. This case describes the development of neutropenia after a course of mezlocillin, resolution upon discontinuation, and recurrence promptly after initiation of piperacillin, with resolution subsequent to discontinuation. Clinical practitioners should be aware that this adverse drug reaction has been associated with the newer β-lactam antibiotics and that cross-reactivity may occur between these antibiotics.
Drug-Induced Erythema Multiforme: A Possible Immunologic Pathogenesis
Authors: Delafuente Jeffrey C.
Published: December 2017

A 37-year-old female developed erythema multiforme 17 days after beginning carbamazepine for complex partial seizures. The carbamazepine was discontinued and Phenytoin begun. A new rash developed and Phenytoin therapy was stopped. In vitro immunologic studies were conducted in an effort to understand the pathogenesis of the rashes. Enhancement of stimulated in vitro lymphocyte proliferation from the patient occurred in the presence of carbamazepine and Phenytoin. Neither drug had an enhancing effect on lymphocyte proliferation from a control subject. These data, together with clinical data, strongly suggest an immunologic pathogenesis for drug-induced erythema multiforme.
The Antiemetic Activity of Droperidol Administered by Intramuscular Injection during Cisplatin Chemotherapy: A Pilot Study
Authors: Cersosimo Robert J. , Bromer Richard , Hoffer Susan , Welch Janet , Abrahamson Martin , Hong Waun Ki
Published: December 2017

The antiemetic activity of escalating doses of droperidol was evaluated in ten patients undergoing chemotherapy with cisplatin regimens. Major antiemetic activity was achieved in five patients, two patients had less nausea and vomiting as compared with prior prochlorperazine therapy, and three patients were refractory to droperidol. No dose-response relationship was observed. Sedation occurred in nine patients, and two patients experienced dystonic reactions. Droperidol is a relatively safe and effective antiemetic for patients undergoing chemotherapy with cisplatin.
The Effect of In-Line Filtration on Tobramycin Delivery
Authors: Elenbaas Julia K. , Lander Roger D. , Elenbaas Robert M.
Published: December 2017

The purpose of this study was to determine if the presence of an in-line 0.22 μ cellulose ester membrane filter would hamper the delivery of a common adult dose of tobramycin sulfate. Solutions of tobramycin sulfate 80 mg in 100 ml D5W were assayed after 30 minute infusions through unfiltered and filtered administration sets; solutions post-flush of filtered sets were also assayed. Assay was done by Emit-QST. The results indicated that there was no significant difference in the delivery of tobramycin sulfate, regardless of the presence of an in-line filter. Solutions post-flush contained about ten percent of the drug, reflecting the amount in solution that remained in the tubing. Since ten percent can alter pharmacokinetic monitoring for patient dosing, a consistent procedure for flushing filtered administration sets should be adopted to enhance accuracy of such determinations.
A Rapid, Universal TI-59 Model-Independent Pharmacokinetic Analysis Program based on Statistical Moment Theory
Authors: Reitberg Donald P. , Smith Ian L. , Love Steven J. , Lewin Harry M. , Schentag Jerome J.
Published: December 2017

A model-independent program for pharmacokinetic analyses based on statistical moment theory is presented and demonstrated. The program uses an inexpensive and portable TI-59; a PC-100A printer adds convenience but is optional. The program may be used in analysis of blood, serum, or plasma concentration vs. time curves originating from iv, im, po, si, or sc administration. Drug input can be zero or first order; both single-dose and multiple-dose steady-state conditions can be evaluated. A comparison between results generated using moment analysis and traditional two-compartment nonlinear regression showed excellent agreement.
A Survey of State Board of Pharmacy Members and Continuing Education Providers' Views on Continuing Education
Authors: Osterhaus Jane T. , Gagnon Jean Paul
Published: December 2017

Legally accountable to the public, state boards of pharmacy are continually confronted with the problem of maintaining the quality of pharmacy practice. One approach to accomplishing this task has been to implement mandatory continuing education requirements for relicensure. This study evaluated the perceived effectiveness and deficiencies of various states' continuing education regulations. A 40-question survey was mailed to 600 pharmacy board members and continuing education providers to determine their attitudes toward continuing education, support of mandatory continuing education, and their opinion of alternative methods for improving the quality of pharmacy practice. Responses from approximately one-half of those surveyed indicate board members and continuing education providers were positively disposed toward continuing education. However, there was room for improvement in most states' mandatory continuing education regulations. A relicensure examination was considered to be the best method to ensure competency, while mandatory continuing education was viewed as acceptable to pharmacists, and relatively easy to administer. The consequences of the study's findings for modifying state continuing education regulations is discussed.
Factors Associated with the Elderly Falling in Intermediate Care Facilities
Authors: Lamy Peter P. , Wells Barbara G. , Middleton Bruce , Lawrence Gene , Lillard David , Safarik Jana
Published: December 2017

In intermediate care facilities, the records of 41 patients who had fallen and 36 controls were reviewed retrospectively, and the two groups compared for demographics, diagnoses, blood pressures over the prior two months, and prescribed medication. Seven of the sample had a recent weight loss recorded; all seven were in the group that fell. The mean number of medications prescribed for the group of fallers was significantly greater than the mean prescribed for the control group. The mean number of medication changes during the two weeks prior to the fall was significantly greater than the mean number of medication changes during the two weeks prior to data collection for the control group. Our data suggest that caution should be exercised in multiple drug prescribing for patients in intermediate care facilities and that recent weight loss and medication changes may be risk factors for falling.
Definition of Clinical Pharmacy as a Specialty in Clinical Practice
Authors:   The Committee on Clinical Pharmacy as a Specialty, Elenbaas Robert M. , Evans William E. , Gerbino Philip P. , Kelly Kim L. , Kinnard William J. , Miller William A. , Parker Paul F. , Perrier Donald G. , Rodman John H. , Perrier Donald , Evans William E.
Published: December 2017

Specialty credentialing has been discussed extensively and debated within pharmacy for more than ten years. Within the profession, there now appears to be a consensus on the need for and appropriateness of acknowledging professional practice areas as unique, defined entities. However, there remain substantive differences on how the definition of specialty practice should be constructed. One approach is to identify practice areas by functional activity (e.g., nuclear pharmacy, drug information) and/or therapeutic focus (e.g., psychopharmacy, clinical pharmacokinetics). A second approach is to define clinical pharmacy as a specialty practice that would, at least initially, coalesce clinical practitioners with the common denominator of an active role in the therapeutic decision-making process. The following document was developed by the Committee on Clinical Pharmacy as a Specialty (CCPS). The CCPS is independent of any formal organizational affiliations. It will serve as the preface to a petition that will be submitted to the Board of Pharmaceutical Specialties requesting recognition of clinical pharmacy as a specialty. The intention of the committee is to resolve the question of specialty status for clinical pharmacy through the Board of Pharmaceutical Specialties' review process. It is then hoped that pharmacy can move forward on the important issue of specialty credentialing.
Peripheral Vascular and Lymphatic Systems
Authors: Longe R. Leon , Patrias John M. , Calvert Jon C.
Published: December 2017

This article discusses normal anatomy and physiology of the peripheral vascular and lymphatic systems. Physical examination techniques are described and monitoring principles are illustrated by a case study.
Doxorubicin: Alteration of Dose Scheduling as a Means of Reducing Cardiotoxicity
Authors: Lum Bert L. , Svec Jennifer M. , Torti Frank M.
Published: December 2017

The long-term therapeutic potential of doxorubicin is often limited by the predictable development of a dose-related cardiomyopathy. Empiric limitations of cumulative doses to 450–550 mg/m2 minimize the incidence of this potentially fatal toxicity. This review presents recent studies performed to examine the potential for altered dose schedule to reduce or delay this toxicity and maintain therapeutic efficacy.

Altering doxorubicin's dosing schedule from the standard three-weekly regimen to a continuous infusion or weekly schedule has been shown to delay cardiotoxicity. Data presented suggest that doxorubicin administered on a weekly schedule significantly reduces cardiotoxicity as compared with a three-weekly schedule and allows approximately 160 mg/m2 more of the drug to be administered to reach the same level of cardiotoxicity as measured by endomyocardial biopsy. This corresponds clinically to two additional months of therapy. Cumulated response data suggest that continuous infusion or weekly schedules of doxorubicin are equally efficacious as the standard three-weekly schedule.
Evaluation of Antibiotics for Home Care Programs
Authors: Reed Michael D.
Published: December 2017

A number of antimicrobial agents have been used successfully to treat patients with chronic infectious diseases in the home health care environment. This diversity in types of antibiotics used reflects more than ten years' development of active home medical care programs. With continuing experience, it is clear that the number and types of antibiotics available on formulary for routine use in home programs can be condensed. Since a patient should in most cases be treated in the home environment with the same antibiotic that has demonstrated efficacy and safety upon initial therapy during hospitalization, the selection of available antibiotics will affect the hospital's formulary selection process. This process must critically evaluate the documented efficacy and safety of each agent, since the drug's primary use will be in a relatively uncontrolled environment, devoid of continuous professional assessment. The β-lactam antibiotics appear to be preferred agents for outpatient use, particularly as monotherapy. These agents offer desirable in vitro activity and potency, ease of administration, overall efficacy, and safety. However, despite a preference for β-lactam antibiotics, additional and alternative agents must be routinely available in program formularies.
Exercise and β-Blocking Agents
Authors: Golightly Larry K. , Sutherland Earl W. , Conner Christopher S.
Published: December 2017

β-adrenoceptor-blocking agents produce noticeable effects on exercise performance. In patients with coronary heart disease, exercise capacity may in some cases increase during β-blockade. Training effects (increased functional capacity, increased maximal oxygen uptake) may be somewhat attenuated in relatively healthy individuals taking β-blockers, although with vigorous exercise programs, physiologic adaptations to exercise probably do occur.
A Comparative Study of Gentamicin and Netilmicin in the Treatment of Gram-Negative Infections
Authors: Lefrock Jack L. , Carr Bernice B. , Blais Francis , Schell Ronald F. , Dematteo Carl , Tillotson James R.
Published: December 2017

Netilmicin is active in vitro against a wide variety of gram-negative bacteria, including certain gentamicin-resistant isolates, and Staphylococcus aureus. This study presents the results of a prospective, randomized, double-blinded protocol designed to determine the relative efficacy and toxicity of netilmicin and gentamicin in the therapy of gram-negative infections. The demographic make-up of both treatment groups was similar. Cure rates were 96.7 percent with netilmicin and 94.4 percent with gentamicin. Possible transient nephrotoxicity developed in nine patients receiving netilmicin and in eight patients receiving gentamicin.
The use of Veterinary Clinics for the Education of Pharmacy Students
Authors: Scalley Robert D. , Forney Stuart D.
Published: December 2017

The pharmacies of rural communities often include veterinary products; however, many pharmacists have little knowledge about animal diseases and the pharmacokinetics of drugs in animals. The Colorado State University at Fort Collins has developed an elective one-week rotation for pharmacy students through the University Veterinary Teaching Hospital. The four objectives of the program are: (1) to observe the various aspects of veterinary medicine and its use in different animal species; (2) to work with the student of veterinary medicine to plan and evaluate a drug therapy course; (3) to understand species variance in absorption, metabolism, and elimination of drugs; and (4) to plan and evaluate a course of therapy for an assigned animal, using the Problem Oriented Medical Record (POMR) format.
Imipenem/Cilastatin: The First Carbapenem Antibiotic
Authors: McLeod Donald C. , Lyon James A.
Published: December 2017

Imipenem/cilastatin is the first of a new class of β-lactam antibiotics called carbapenems. The antibacterial spectrum of imipenem exceeds any antibiotic investigated to date and includes gram-positive, gram-negative, and anaerobic organisms. Only methicillin-resistant organisms, Strep. faecium, Pseudomonas cepacia, and Pseudomonas maltophilia have been shown to be resistant. Imipenem is administered in a 1:1 ratio with cilastatin, which inhibits a renal enzyme (dehydropeptidase) and improves urinary recovery of imipenem. The elimination half-life of both compounds is 1.0 hours and recommended doses are 0.25–0.5 g iv q6h. Adverse events are similar in nature and incidence to β-lactam antibiotics, with phlebitis/thrombophlebitis, diarrhea, nausea, skin rash, and elevations of hepatic enzymes most common.

Clinical studies in phase II and III trials have shown imipenem/cilastatin to be effective in soft tissue infections, endocarditis, obstetrics and gynecology, complicated urinary tract infections, mixed anaerobic-aerobic infections, osteomyelitis, bacteremias, and pneumonias. Several comparative clinical trials have shown imipenem/cilastatin to be equal in efficacy to combination therapy. Imipenem/cilastatin may prove to be an alternative to combination antibiotic therapy because of its extremely broad spectrum of activity.
Acetaminophen: Acute Overdose Toxicity in Children
Authors: Conner Christopher S. , Rumack Barry H. , Morand Brenda R. , Depot Michelle
Published: December 2017

The use of acetaminophen in young children has increased, in part due to concerns over the association of Reye's syndrome with aspirin. Accidental ingestion of acetaminophen in this age group has also increased, and treatment of overdose in children has been controversial. Recommendations for treatment of adolescents and young children are presented, based on the acetaminophen nomogram. It is recommended that children in the highest risk group (above the upper nomogram line) be treated with N-acetylcysteine, even though treatment may be unnecessary in many.
Regression to the Mean: A Potential Source of Error in Clinical Pharmacological Studies
Authors: Spector Reynold , Park Glen D. , Carrasquillo Ana E. Velez , Demers Denyse
Published: December 2017

The design and interpretation of clinical trials in clinical pharmacology must avoid certain pitfalls to be useful in guiding drug therapy decisions. Here, we discuss one important problem in clinical trial design, the problem of regression to the mean. Because certain disease states tend to wax and wane in severity and because patients tend to present for treatment when disease activity is high, the expected course of the disease is improvement. Therefore, any treatment begun will appear to lessen disease activity. We give four examples of diseases where improper and inadequate recommendations for drug therapy have been made based on clinical trials that ignored the problem of regression to the mean: vasospastic angina, rheumatoid arthritis, chronic congestive heart failure, and renal stones. Studies of drug therapy in diseases such as these should be conducted with concurrent placebo controls rather than having each patient serve as his own control.
Bleomycin Pneumonitis Potentiated by Oxygen Administration
Authors: Cersosimo Robert J. , Matthews S. James , Hong Waun Ki , Feliu Juan F. , Bally Michele
Published: December 2017

A case of a 53-year-old man who developed acute pneumonitis after bleomycin and moderate oxygen administration is presented. The patient received bleomycin 189 U over five days for preoperative control of a squamous cell carcinoma of the right tongue and tonsil. Surgery to remove the remaining tumor was performed 19 days later. The highest intraoperative oxygen concentration was 33 percent, but 40 percent oxygen was administered for four days postoperatively. He became febrile and developed a productive cough and pulmonary infiltrates on postoperative day 4. Despite antibiotic therapy, his pulmonary function deteriorated and 100 percent oxygen was required to maintain adequate oxygenation. He sustained a myocardial infarction on postoperative day 7 and progressively deteriorated and expired five days later. Autopsy findings were consistent with bleomycin and oxygen-induced pulmonary damage. Oxygen potentiation of bleomycin-induced pulmonary toxicity is discussed.
A Possible Case of Carbamazepine-Induced Pancreatitis
Authors: Soman Michael , Swenson Claudia , Morand Brenda R. , Larouche Marie
Published: December 2017

At least 25 different drugs have been implicated in drug-induced pancreatitis. For some drugs the evidence is strong, but for many a contradictory or incomplete association exists between their administration and the occurrence of pancreatitis. To our knowledge, carbamazepine has not been associated with pancreatitis.

We report a case of a 73-year-old female on carbamazepine 200 mg bid for partial complex seizures who developed nausea, fatigue, anorexia, malaise, headache, and increased thirst. After carbamazepine discontinuation, the patient noted an almost immediate decrease in all symptoms. Her seizures are now treated successfully with Phenytoin.
Long-Term Experience with Lofexidine in the Treatment of Mild-To-Moderate Essential Hypertension
Authors: Lopez Larry M. , Mehta Jawahar L. , Burgos Glenda Sobrino , Laplante Suzanne
Published: December 2017

This study describes sustained efficacy and safety of lofexidine in hypertensive patients. Twenty-one male patients (mean age 55 ± 9 yr) who had previously completed a short-term trial of lofexidine entered this open-label trial. The daily dose of lofexidine was titrated over three months to a maximum of 1.6 mg or an erect diastolic blood pressure <90 mm Hg. Hydrochlorothiazide was added when necessary. Thereafter, each patient was evaluated for blood pressure (BP) response, compliance, side effects, hepatic, renal, or hematological abnormalities every three months for two years. Sustained BP reduction with lofexidine was achieved but not without concomitant diuretic therapy. There were no clinically important changes in heart rate or hepatic, renal, or hematological profiles. Side effects were frequent but severe enough to warrant discontinuation in only four patients. The side-effect profile was similar to that of Clonidine. We recommend concurrent diuretic use to maximize effectiveness of lofexidine.
The Effects of Activated Charcoal on Digoxin and Digitoxin Clearance
Authors: Park Glen D. , Goldberg Mark J. , Spector Reynold , Johnson George F. , Feldman Ross D. , Quee Connie K. , Roberts Pamela , Feliu Juan F. , Lukosevicius Ina
Published: December 2017

The effect of multiple oral doses of activated charcoal on digitalis glycoside kinetics was studied to determine whether an activated charcoal regimen might have utility in treating patients with digitalis toxicity. Normal subjects were given intravenous infusions of digoxin 0.75 mg/70 kg or digitoxin 1 mg/70 kg iv followed by either water alone or water with activated charcoal in divided doses in a randomized crossover design. A subject with chronic renal failure was also given digoxin 0.5 mg/70 kg iv followed by water alone or water with activated charcoal.

In six normal subjects, treatment with activated charcoal did not increase digoxin clearance (Cl) significantly (16.79 ± 1.70 vs. 22.68 ± 3.51 L/h). However, digitoxin Cl did increase significantly, from 0.24 ± 0.01 to 0.47 ± 0.04 L/h. In the renal failure subject, digoxin Cl increased from 3.6 L/h to 10.1 L/h. We conclude that the activated charcoal regimen is probably useful in patients with digitoxin toxicity. Although similar benefit is limited in patients with normal renal function who develop digoxin toxicity, it is possible that activated charcoal will be useful in patients with prolonged digoxin elimination due to renal dysfunction.
Systemic Hypertension Associated with Cyclosporine: A Review
Authors: Weidle Paul J. , Vlasses Peter H.
Published: December 2017

Use of the immunosuppressive agent cyclosporine has been associated with an increased incidence of hypertension. The incidence, onset, duration, and severity of the associated blood pressure elevation varies greatly depending on the therapeutic indication for cyclosporine use. This paper reviews the disparity in the reports of cyclosporine-associated hypertension and the factors evaluated for possible association. Possible mechanisms involved in the blood pressure elevation as well as treatment approaches that have been employed are discussed. Further research efforts are needed to clarify conflicting information regarding mechanisms, associated factors, and rational treatment.
Use of Histamine2-Receptor Blocking Agents and Sucralfate in a Health Maintenance Organization following Continued Clinical Pharmacist Intervention
Authors: Mead Robert A. , McGhan William F.
Published: December 2017

The effect of continued clinical pharmacist intervention on the proper use of histamine2-receptor blocking agents and sucralfate in a health maintenance organization was studied. New prescriptions written for Cimetidine, famotidine, ranitidine, and sucralfate in January 1986 (preintervention), October 1986 (postintervention), and February 1987 (follow-up), and the medical record of each patient were analyzed for appropriateness using approved criteria. Clinical pharmacist intervention occurred throughout the study. There was a significant decrease (p < 0.005) in the rate of inappropriate prescribing in the postintervention (42.4 percent) and follow-up (48.7 percent) periods versus the preintervention period (81.5 percent), and in the average number of refills authorized per patient in the postintervention (1.2 ± 1.54) and follow-up (1.3 ± 1.00) periods versus the preintervention period (3.0 ± 3.67). There were no significant differences in these areas between the postintervention and follow-up periods (p > 0.05). A benefit-to-cost ratio of 4.3:1 was generated from this study which demonstrated that continued clinical pharmacy interventions can have a positive, cost-effective impact on the proper use of these commonly prescribed medications.