bluuebunny/crossref_metadata_2025 huggingface dataset:
Comparison of Two Methods of Delivering Continuously Nebulized Albuterol
Authors: Kelly H William , Keim Kerry A , McWilliams Bennie C
Published: June 2003

OBJECTIVE

To compare the relative delivery of 2 methods for providing continuously nebulized albuterol (CNA): a small-volume nebulizer plus infusion pump versus a large-volume nebulizer.

DESIGN

An open, randomized comparison of 3 hours of CNA administration using an in vitro lung model with a follow-up particle size assessment of the large-volume nebulizer.

METHODS

Six different nebulizers of each type were connected to a lung model via a volume-limited mechanical ventilator and infant ventilator circuitry. Albuterol was nebulized at 10 mg/h for 3 hours in random order. The small-volume nebulizer used was the Airlife Misty Neb (Baxter, Valencia, CA); the large-volume nebulizer was the HEART Nebulizer (Vortran Medical, Orangevale, CA). One large-volume nebulizer was operated over 8 hours for the output and particle sizing study.

RESULTS

The small-volume nebulizer delivered a greater amount of albuterol (mean ± SD percentage of total nebulized) to the model lung (5.75 ± 1.38% vs. 4.12 ± 0.67%; p < 0.025) than the large-volume nebulizer, but demonstrated greater variability. Although total output was not maintained after 8 hours of nebulization with the large-volume nebulizer, the percent of particles in the respirable range remained consistent.

CONCLUSIONS

The large-volume nebulizer evaluated in this study maintains consistent output up to 8 hours and provides an acceptable method for delivering CNA through an infant ventilator circuit.
Octreotide for Sulfonylurea-Induced Hypoglycemia following Overdose
Authors: Carr Roxane , Zed Peter J
Published: June 2003

OBJECTIVE:

To describe the use of octreotide in the management of 2 cases of sulfonylurea-induced hypoglycemia following overdose and to review the literature on the use of octreotide in the management of sulfonylurea overdose.

CASE SUMMARY:

Case 1 describes a 27-year-old woman who ingested 500 mg of glyburide; case 2 describes a 22-year-old woman following ingestion of glyburide 1000 mg. Despite administration of bolus doses of dextrose 50% and infusions of dextrose 10%, both patients demonstrated refractory hypoglycemia. Three doses of octreotide 50 μg were administered subcutaneously spaced 8 hours apart to both patients, resulting in a reduction of hypoglycemic episodes and a reduced need for dextrose administration.

DISCUSSION:

In addition to the 2 cases described, 8 citations involving 23 patients with sulfonylurea overdose in which octreotide was used were identified in the literature. As with our patients, episodes of hypoglycemia and the need for bolus doses of dextrose 50% were reduced following administration of octreotide.

CONCLUSIONS:

The use of octreotide appears to reduce the number of hypoglycemic episodes and glucose requirements, with no reported toxicities associated with its use for sulfonylurea-induced hypoglycemia following overdose.
Pharmacokinetic Interaction between Nortriptyline and Terbinafine
Authors: van der Kuy P-Hugo M , van den Heuvel Harrie A , Kempen Rob W , Vanmolkot Leo M L
Published: June 2003

OBJECTIVE:

To clarify the mechanism of interaction between nortriptyline and terbinafine.

CASE SUMMARY:

Nortriptyline intoxication secondary to terbinafine treatment was observed in a woman with a major depressive disorder. This is the second report of this interaction. A rechallenge was performed during which serum concentrations were measured of nortriptyline and the 2 hydroxy metabolites. To document the case, genotyping of CYP2D6 was also performed.

DISCUSSION:

Metabolism by CYP2D6 is of major importance for the hydroxylation of nortriptyline, making it susceptible to competitive inhibition by terbinafine.

CONCLUSIONS:

The pharmacokinetic interaction between nortriptyline and terbinafine is probably due to inhibition of CYP2D6 of the nortriptyline metabolism by terbinafine. The interaction is not restricted to a subpopulation, but may occur even in persons without deviations in CYP2D6.
Acitretin-Associated Thrombotic Stroke
Authors: Royer Bernard , Ziegler François , Muret Patrice , Davani Siamak , Kantelip Jean-Pierre
Published: June 2003

OBJECTIVE:

To report a case of thrombotic stroke. The etiology was difficult to identify, but was finally ascribed to psoriatic treatment with acitretin.

CASE SUMMARY:

Treatment with acitretin was prescribed for a 52-year-old white woman for long-standing psoriasis. Thirty-four days later, she developed nausea, vomiting, vertigo, and headaches, followed by left lateropulsion, which impeded standing and lying. Both neurologic examination and magnetic nuclear imaging indicated a rectangular infarct in the vermis cerebelli and a small bulbar infarct. Time-of-flight magnetic resonance angiography confirmed the presence of a thrombus at the beginning of the left vertebral artery. After heparin-based treatment and physiotherapy, the evolution was favorable.

DISCUSSION:

Etiology identification of the stroke included cardiogenic pathology and coagulopathy, but acitretin treatment was considered the likeliest explanation. On review of the literature, this seems to be the first case of a thrombotic event associated with acitretin.

CONCLUSIONS:

Acitretin should be considered as a possible cause of thrombotic stroke; this possibility should be kept in mind when patients taking acitretin develop an unexplained thrombotic event.
Alteplase Versus Urokinase for Occluded Hemodialysis Catheters
Authors: Zacharias James M , Weatherston Christine P , Spewak Candace R , Vercaigne Lavern M
Published: June 2003

BACKGROUND

The use of central venous catheters as a source of vascular access in patients undergoing hemodialysis may be complicated by thrombosis. Frequently, thrombolytics are used in an attempt to reestablish blood flow through partially or completely occluded catheters.

OBJECTIVE

To compare the efficacy of alteplase (recombinant tissue plasminogen activator) versus urokinase in reestablishing adequate blood flow through partially or completely occluded vascular catheters.

METHODS

Part 1 of the study prospectively investigated the effect of alteplase in reestablishing adequate blood flow through partially or completely occluded vascular catheters in 30 hemodialysis patients. Part 2 of the trial compared the efficacy of alteplase with that of urokinase in 14 of 30 patients who had also previously received urokinase. A 30-minute push-protocol was used to administer thrombolytics in both parts of the study. The primary endpoint was the proportion of patients with partially or completely occluded catheters achieving post-thrombolytic blood flow of ≥200 mL/min.

RESULTS

Part 1 showed a large proportion of partially or completely occluded catheters achieving post-alteplase blood flows ≥200 mL/min (70/76, 92.1% vs. 34/40, 85%, respectively). In Part 2 of the study, the proportion of partially occluded catheters achieving post-thrombolytic blood flows ≥200 mL/min was not significantly different between the alteplase and urokinase groups, (36/41, 87.8% vs. 21/28, 75%, respectively; p = 0.205). The proportion of completely occluded catheters achieving post-thrombolytic blood flows ≥200 mL/min was significantly better with alteplase compared with urokinase (15/17, 88.2% vs. 6/14, 42.8%, respectively; p = .018).

CONCLUSIONS

Alteplase, administered via the 30-minute push-protocol, is an effective thrombolytic for restoring hemodialysis catheter patency. In our study sample, alteplase was generally more effective than urokinase in restoring blood flow through catheters, especially those that were completely occluded.
Irbesartan Substitution for Valsartan or Losartan in Treating Hypertension
Authors: Graham Maqual R , Allcock Nicole M
Published: June 2003

OBJECTIVE:

To determine whether subjects whose therapy was converted from losartan or valsartan to irbesartan maintained equivalent blood pressure measurements, determine the safety and tolerability of irbesartan in the veteran population, and assess the number of subjects attaining their goal blood pressure before and after conversion.

METHODS:

A retrospective review of medical records for subjects whose antihypertensive was converted to irbesartan was conducted. Demographic data were collected, and subjects' past medical histories were used to determine their goal blood pressure. Blood pressures were compared at baseline, 2 weeks, and 2 months after conversion to determine efficacy, and adverse effect occurrence was compared between visits to assess safety.

RESULTS:

Conversion was attempted in 79 subjects; 72 met the criteria for review. Mean baseline, 2-week, and 2-month blood pressures for all subjects were 143/74, 139/72, and 139/73 mm Hg, respectively (p values NS). The number of subjects achieving their goal blood pressure at each assessment visit was similar: 37.5% at baseline, 43.4% at 2 weeks, and 31.9% at 2 months. Thirteen of the 72 subjects discontinued irbesartan due to adverse events.

CONCLUSIONS:

Irbesartan is an appropriate substitution for valsartan or losartan.
Intravenous Proton-Pump Inhibitors versus H2-Antagonists for Treatment of GI Bleeding
Authors: Huggins Rebecca M , Scates Ann C , Latour Joanne K
Published: June 2003

OBJECTIVE:

To evaluate the evidence supporting the use of intravenous proton-pump inhibitors in the treatment of gastrointestinal (GI) hemorrhage in comparison with histamine2 (H2)-receptor antagonists.

DATA SOURCES:

Clinical literature was accessed through a MEDLINE search (1966–October 2002). Data from abstracts and fully published articles were retrieved for analysis. Key search terms included pantoprazole, omeprazole, proton-pump inhibitors, gastrointestinal hemorrhage, histamine2-receptor antagonists, ranitidine, and cimetidine.

DATA SYNTHESIS:

There are limited published clinical outcome data evaluating the use of intravenous pantoprazole in patients with upper GI hemorrhage. However, there are several gastric pH studies suggesting that intravenous pantoprazole is effective in quickly obtaining and maintaining a pH >6. When considering the results from studies of high-dose intravenous omeprazole, in addition to the pantoprazole data, the relative efficacy of intravenous proton-pump inhibitors appears to be superior to that of intravenous H2-receptor antagonists in providing a more predictable and sustained pH control.

CONCLUSIONS:

Intravenous proton-pump inhibitors are suitable, possibly superior, alternatives to intravenous H2-receptor antagonists in treatment of upper GI bleeding.
Adverse Drug Events Associated with Hospital Admission
Authors: Peyriere Hélène , Cassan Stéphanie , Floutard Edith , Riviere Sophie , Blayac Jean-Pierre , Hillaire-Buys Dominique , Le Quellec Alain , Hansel Sylvie
Published: June 2003

OBJECTIVE

To increase the knowledge base on the frequency, causality, and avoidability of adverse drug events (ADEs) as a cause for admission in internal medicine or when occurring during hospitalization.

METHODS

A prospective study was performed for 6 periods of 8 days each. Epidemiologic data (e.g., age, gender, medical history), drug utilization, and adverse drug reactions on patients hospitalized during these periods were collected by a pharmacy student.

RESULTS

A total of 156 patients (70 men and 86 women) were included in the study. The patients’ mean age ± SD was 66.5 ± 18.1 years and mean length of stay was 13.2 ± 9 days. Renal and hepatic insufficiency and previous history of drug intolerance were observed in 17.9%, 10.2%, and 2% of the hospitalized patients, respectively. Thirty-eight ADEs occurred in 32 patients; in 15 cases, ADEs were identified as the reason for admission, 10 cases occurred during hospitalization, and 13 cases were present at admission, but were not the cause of admission. The most frequent ADEs involved the neurologic (23.6%), renal (15.7%), and hematologic (13.1%) systems. Among these 38 ADEs, 22 were considered avoidable (57.9%); 20 of these were associated with therapeutic errors (inappropriate administration, drug–drug interactions, dosage error, drug not stopped despite the onset of ADEs). Patients with ADEs stayed longer in the hospital and took more drugs both before and during their hospital stay (p < 0.05).

CONCLUSIONS

Most of the ADEs observed in this study were avoidable. The risk/benefit ratio of administered drugs could be improved with better knowledge of the patients’ medical history and the risk factors of ADEs.
Sensorineural Hearing Loss Associated with Intrathecal Vancomycin
Authors: Klibanov Olga M , Filicko Joanne E , DeSimone Joseph A , Tice David S
Published: June 2003

OBJECTIVE

To report a case of nonreversible bilateral sensorineural hearing loss resulting from administration of intrathecal vancomycin.

CASE SUMMARY

A 63-year-old white man with newly diagnosed pre–B-cell acute lymphocytic leukemia developed Corynebacterium jeikeium meningitis associated with an Ommaya reservoir. The patient was treated with intravenous vancomycin for several days without symptomatic improvement, and intrathecal vancomycin was added to the treatment regimen. Difficulty in the patient's hearing was noted after the first intrathecal dose and he experienced complete hearing loss after the second intrathecal dose. An audiogram was performed and the patient was diagnosed with cranial nerve VIII bilateral sensorineural hearing loss. The Ommaya reservoir was removed and the patient was successfully treated with linezolid.

DISCUSSION

Ototoxicity with intravenous vancomycin has been documented in multiple case reports, but this adverse effect has not been reported with intrathecal vancomycin. Cerebrospinal fluid vancomycin concentrations were not measured in our patient, but there was 1 documented occurrence of supratherapeutic serum vancomycin concentrations. Other drug-related causes of ototoxicity were evaluated and intrathecal vancomycin-induced ototoxicity was considered to be possible according to the Naranjo probability scale.

CONCLUSIONS

The strong temporal relationship that was seen in this case suggests the possibility of an association between administration of intrathecal vancomycin and hearing loss. Healthcare providers should consider the potential for this adverse reaction with the intrathecal route of vancomycin administration.
Proton-Pump Inhibitors for Stress Ulcer Prophylaxis in Critically Ill Patients
Authors: Jung Rose , MacLaren Robert
Published: June 2003

OBJECTIVE:

To evaluate the use of proton-pump inhibitors (PPIs) for stress ulcer prophylaxis in critically ill adults.

DATA SOURCES:

Computerized biomedical literature search of MEDLINE (1966–June 2002) was conducted using the MeSH headings proton-pump inhibitor, ulcer, critical care, and acid. References of selected articles were reviewed. A manual search of critical care, surgery, trauma, gastrointestinal, and pharmacy journals was conducted to identify relevant abstracts.

DATA SYNTHESIS:

Traditional medications used for stress ulcer prophylaxis include antacids, histamine2 receptor antagonists (H2RAs), and sucralfate. Few studies have evaluated PPIs for stress ulcer prophylaxis. The majority of studies have demonstrated that enteral or intravenous administration of PPIs to critically ill patients elevates intragastric pH and consistently maintains pH ≥4.0. PPIs are safe and seem to be as efficacious as H2RAs or sucralfate for prevention of bleeding from stress-related mucosal damage (SRMD) and they may provide cost minimization. The small patient populations limit the results of comparative studies.

CONCLUSIONS:

Available data indicate that PPIs are safe and efficacious for elevating intragastric pH in critically ill patients. PPIs should be used only as an alternative to H2RAs or sucralfate since the superiority of PPIs over these agents for preventing SRMD-associated gastrointestinal bleeding has not been established. Additional comparative studies with adequate patient numbers and pharmacoeconomic analyses are needed before PPIs are considered the agents of choice for stress ulcer prophylaxis.
Concomitant Coumarin–NSAID Therapy and Risk for Bleeding
Authors: Knijff-Dutmer Ellen AJ , Schut Gelte A , van de Laar Martin AFJ
Published: June 2003

OBJECTIVE

To investigate the risk of bleeding complications during the combined use of coumarin derivatives and nonsteroidal antiinflammatory drugs (NSAIDs) compared with the use of coumarin derivatives alone.

SUBJECTS AND METHODS

In this 1-year observational study, the local outpatient anticoagulation office detected all coumarin users with bleeding complications. These patients were sent questionnaires regarding the type and consequences of the bleeding as well as previous NSAID use. The local pharmacists detected patients with concomitant coumarin and NSAID prescriptions (but no bleeding). The relative risk for bleeding due to concomitant coumarin and NSAID use was estimated.

RESULTS

During 1 year, 738 hemorrhages were identified in 681 coumarin users. In 12.2% of these cases, an NSAID was involved. In contrast, in the whole population of coumarin users, 2.5% were prescribed an NSAID. Therefore, the relative risk of NSAID use with regard to bleeding complications was 5.8 (95% CI 2.3 to 13.6).

CONCLUSIONS

NSAID use during coumarin therapy considerably increases the bleeding risk compared with coumarin therapy alone. Although in daily practice these medications are frequently prescribed concomitantly, our results underscore the contraindication of concomitant use of NSAIDs and coumarin derivatives.
Effect of Soy Milk on Warfarin Efficacy
Authors: Cambria-Kiely Josie A
Published: June 2003

OBJECTIVE:

To describe the effect of soy milk on the international normalized ratio (INR) in a patient treated with warfarin.

CASE SUMMARY:

A 70-year-old white man who was stable on warfarin therapy developed subtherapeutic INR values after ingesting soy protein in the form of soy milk. The subtherapeutic INR values could not be explained by factors known to reduce the INR such as noncompliance, new medications, other alternative therapies, increased physical activity, changes in medication storage, or increased consumption of vitamin K. INR values returned to therapeutic concentrations within 2 weeks after discontinuation of the soy milk. Repeated coagulation test results during the next 2 months remained within the normal range.

DISCUSSION:

Impaired warfarin metabolism may be ascribed to various pharmacodynamic and pathologic factors. Subtherapeutic INR values may also be the result of concomitant administration of metabolic inducers resulting in drug—drug, drug—herb, or drug—food interactions. An objective causality assessment in this case revealed that INR decline in a warfarin-treated patient as a result of soy milk ingestion was in the range of possible to probable. Speculative mechanisms of soy milk—induced INR decline such as changes in warfarin absorption or metabolism resulting from alterations in the P-glycoprotein efflux system or organic anion-transporting polypeptides are discussed.

CONCLUSIONS:

The temporal relationship between the start of soy milk and subtherapeutic INR values in 1 patient suggests that soy milk may have possibly or probably caused a decline in INR. Soy protein food—drug interactions with warfarin may be more common than the literature suggests, and further studies are needed to determine the exact mechanism. Healthcare professionals should be alerted to the potential implications of this food—drug interaction.
Pharmacy Practitioners' Views on Computerized Documentation of Drug-Related Problems
Authors: Westerlund LO Tommy , Handl Wolfgang HA , Marklund Bertil RG , Allebeck Peter
Published: June 2003

OBJECTIVE:

To evaluate the practice by community pharmacy practitioners of computerized documentation of drug-related problems (DRPs) and pharmacy interventions in nonprescription drug consumers.

METHODS:

A questionnaire was administered in December 1999 to pharmacy practitioners in 45 community pharmacies of different sizes and locations across Sweden to survey their attitudes and experiences after participation in a 10-week period of computerized DRP documentation.

RESULTS:

The participants (n = 376, response rate 84%) found the development of computerized documentation of DRPs and pharmacy interventions to be very important. The instrument was perceived as easy to learn and to work well in daily practice. The documentation made many practitioners more attentive to the drug-related needs of self-care consumers and changed their perception of good quality in self-care counseling. The weighted multiple linear regression analysis showed no correlation between the proportion of practitioners experiencing time constraints and the DRP documentation rate of their work site. However, the magnitude of interest in the documentation practice had a significant effect on the documentation rate, regardless of the extent of the time constraints experienced (p = 0.004).

CONCLUSIONS:

The positive findings of the evaluation speak in favor of an expanded implementation of computerized documentation of DRPs and pharmacy interventions. Commitment among participating pharmacy practitioners to the new practice is essential and appears to overcome possible time constraints.
Possible Liposomal Amphotericin B–Induced Nephrogenic Diabetes Insipidus
Authors: Canada Todd W , Weavind Lisa M , Augustin Kristan M
Published: June 2003

OBJECTIVE

To report the development of nephrogenic diabetes insipidus (NDI) associated with the use of high-dose liposomal amphotericin B.

CASE SUMMARY

A 38-year-old white man with relapsed acute myelogenous leukemia underwent a matched unrelated donor allogeneic bone marrow transplant with adequate engraftment and mild graft-versus–host disease responding to corticosteroids. Approximately 11 months after transplant, the patient was admitted to the hospital with suspected fungal pneumonia and started on liposomal amphotericin B (baseline serum creatinine 1.4–1.5 mg/dL). The dose was increased due to his immunosuppression and poor response, as the fungal etiology was identified as Torulopsis glabrata. The patient required mechanical ventilation due to biopsy-proven bronchiolitis olbiterans organizing pneumonia. Additionally, he developed diffuse alveolar hemorrhage and received intravenous desmopressin, with a reduction in bloody secretions. He also developed hypernatremia (serum sodium 155 mEq/L) on day 3 of the desmopressin and had an inappropriately increased urine output consistent with NDI. The most likely etiology for the NDI was liposomal amphotericin B and its associated hypokalemia.

DISCUSSION

The observation of worsening hypernatremia (serum sodium increased from 135 to 164 mEq/L) with polyuria was associated with an increasing cumulative dosage of liposomal amphotericin B for fungal pneumonia despite the concurrent use of intravenous desmopressin. Aggressive water replacement was an effective treatment option in this patient. The Naranjo probability scale classified this as a possible adverse reaction because of the temporal sequence of NDI after high-dose liposomal amphotericin B and previously reported cases of NDI associated with amphotericin B desoxycholate.

CONCLUSIONS

Amphotericin B desoxycholate has been implicated as an etiology for NDI, and the use of the newer liposomal amphotericin B reportedly avoids this rare complication. We observed the development of NDI despite the use of liposomal amphotericin B in a critically ill patient with bone marrow transplant.
Dispensing Error Leading to Alendronate Ingestion
Authors: Carrière Benoit , Bailey Benoit , Chabot Gilles , Lebel Denis
Published: June 2003

OBJECTIVE

To report a case of medication dispensing error by administration of similarly packaged drugs.

CASE SUMMARY

A 6-year-old East Indian boy with asthma was mistakenly given alendronate, a bisphosphonate, for 3 months instead of montelukast, a leukotriene-receptor antagonist. Symptoms of esophageal irritation developed and disappeared on discontinuation of alendronate.

DISCUSSION

Alendronate and montelukast have very similar packaging and are available in dosages that also can be similar for some patients. Alendronate caused symptoms of irritative gastritis in this child before the error was identified. This case report emphasizes one of the possible sources of medication dispensing errors: a mistaken identification due to similar packaging (confirmation bias). Manufacturers can help to prevent medication errors in many ways; in this case, more distinct packaging would have decreased the risk of error. A standard bar-coding scheme among manufacturers could lead to an important improvement in the safety of medication dispensation. Practitioners are also encouraged to report such errors to the United States Pharmacopoeia Medication Errors Reporting Program.

CONCLUSIONS

With increased awareness of medication errors, healthcare practitioners, manufacturers, and patients should take precautionary steps to prevent dispensing errors and their consequences.
Pseudodementia Associated with Use of Ibuprofen
Authors: Bernstein Allan L , Werlin Ann
Published: June 2003

OBJECTIVE

To report a case of dementing syndrome resulting from ibuprofen use.

CASE SUMMARY

A 76-year-old white man with normal mental status became confused, was lost in familiar places, and showed short-term memory loss after beginning a therapeutic regimen of ibuprofen 600 mg 3 times daily for osteoarthritis in anticipation of embarking on a foreign trip. Symptoms of dementia began within 1 week after taking ibuprofen and resolved completely within 1 week after the ibuprofen regimen was stopped. This pattern was repeated 6 months later, when the patient again traveled abroad. Consistently before, during, and after these events, the patient took atenolol, clonidine, lisinopril, aspirin, vitamin C, lecithin, vitamin E, and multivitamins.

DISCUSSION

Using the Naranjo probability scale, we reasoned that the patient's dementia-like syndrome could be attributed to the use of ibuprofen because pseudodementia appeared after the suspected drug was administered, improved when the drug was discontinued, reappeared when the drug was readministered, had no apparent alternative cause, manifested similarly after each exposure to ibuprofen, and was confirmed by the family's observation after both episodes. Objective causality assessment revealed that the adverse drug reaction was probable.

CONCLUSIONS

Use of ibuprofen must be considered during clinical evaluation of any patient with new onset of dementing illness. The Naranjo probability scale may be clinically useful for evaluating other pharmaceutical agents that may be contributing to development of dementia-like conditions.
Possible Anaphylaxis after Propofol in a Child with Food Allergy
Authors: Hofer Kristi N , McCarthy Michelle W , Buck Marcia L , Hendrick Anne E
Published: June 2003

OBJECTIVE:

To report a case of anaphylaxis due to propofol in a child with allergies to egg and peanut oil.

CASE SUMMARY:

A 14-month-old boy with a history of reactive airway disease was hospitalized for treatment of respiratory symptoms. The patient had documented allergies to egg, peanut oil, and mold. Within the first few hours after admission, acute respiratory decompensation occurred, and arrangements were made to transfer the patient to our tertiary-care hospital. Prior to transfer, he was emergently intubated under sedation and paralysis with propofol and rocuronium. When emergency air transport arrived, the patient was hypotensive and tachycardic. His symptoms of anaphylaxis were managed throughout the flight and, upon arrival at our institution, the patient was admitted to the Pediatric Intensive Care Unit. He improved over a 5-day hospital course, and his caregivers were instructed to avoid propofol in the future. The patient's anaphylactic reaction following propofol was rated as a possible adverse drug reaction using the Naranjo probability scale.

DISCUSSION:

The use of propofol in pediatric patients for procedural sedation has gained increased favor. Since the propofol formulation contains both egg lecithin and soybean oil, its use is contraindicated in patients with hypersensitivities to these components. Several other drugs have a food component, resulting in contraindications and warnings in product labeling.

CONCLUSIONS:

Propofol should be avoided in patients with allergies to egg and/or soybean oil, if possible. Clinicians should consider the potential for adverse drug events in patients with select food allergies.
Combination Risperidone and SSRI–Induced Serotonin Syndrome
Authors: Karki Shyam D , Masood Gule-Rana
Published: June 2003

OBJECTIVE:

To report 2 cases of serotonin syndrome associated with combined therapy of risperidone and selective serotonin-reuptake inhibitors (SSRIs) in elderly patients.

CASE SUMMARIES:

An 86-year-old white man was admitted to the emergency department because of increased confusion and generalized weakness over the past several days. His medication history indicated paroxetine 10 mg/d and risperidone 0.25 mg/d. The patient's confusion worsened and underwent acute changes that resembled delirium. He was placed in a geri chair and he became extremely agitated. He was then treated with escalating doses of risperidone. The patient died on day 5 of admission, at which time he was being treated with risperidone 2–3 mg/d. A 78-year-old white female nursing home resident was admitted to the emergency department because of increased confusion and generalized weakness. She was being treated with paroxetine for depression and risperidone for agitation. Her risperidone dose was increased to manage agitation. The patient's agitation worsened with increasing doses of risperidone; she developed tremor, dizziness, and muscle incoordination. After psychopharmacologic consultation, the risperidone and paroxetine were discontinued and she was treated with lorazepam. The patient recovered, returned to baseline status in 2 days, and was later transferred back to the nursing home.

DISCUSSION:

We believe that in both cases, serotonin syndrome was precipitated by risperidone in combination with SSRI antidepressants. A literature search indicated one report of serotonin syndrome with a combination of risperidone and paroxetine.

CONCLUSIONS:

An objective causality assessment revealed that the adverse drug event was probable in the first patient and definite in the second patient. We caution clinicians treating elderly patients with combined risperidone and SSRIs to include serotonin syndrome in differential diagnosis if the patient is showing signs of increasing agitation with escalating doses of risperidone.
Flumazenil and Dialysis for Gabapentin-Induced Coma
Authors: Butler Toni C , Rosen Raquel M , Wallace Allison L , Amsden Guy W
Published: June 2003

OBJECTIVE

To describe a case of gabapentin-induced coma that was reversed with flumazenil and hemodialysis.

CASE SUMMARY

We describe an 83-year-old dialysis-dependent white man who became comatose after a single dose of gabapentin for phantom limb pain. The patient was successfully revived from the coma with administration of flumazenil, which was then followed by hemodialysis. Serum concentration data before and 4 hours after dialysis document the effectiveness of hemodialysis for gabapentin toxicity.

DISCUSSION

An objective causality assessment revealed that this adverse event was probably related to the gabapentin that the patient received. To our knowledge, this is the first documented case of not only gabapentin-induced coma, but also the effectiveness of flumazenil for treatment of this type of coma. Although therapeutic hemodialysis has been previously described, our case report is strengthened by the serum concentration monitoring accompanying it.

CONCLUSIONS

This report underscores the importance of initiating gabapentin therapy at low doses in dialysis-dependent patients and introduces a novel treatment for those who experience toxicity.
Ramipril for the Prevention and Treatment of Cardiovascular Disease
Authors: Vuong April D , Annis Laura G
Published: June 2003

OBJECTIVE:

To evaluate the effectiveness of ramipril in the prevention and treatment of cardiovascular disease and determine its need for inclusion on a formulary.

DATA SOURCES:

A MEDLINE and PubMed database search was conducted (1987–May 2002). Only journals written in the English language were selected for review.

DATA EXTRACTION AND STUDY SELECTION:

Articles reporting the use of ramipril in humans were evaluated. Emphasis was placed on randomized, controlled trials assessing efficacy.

DATA SYNTHESIS:

Ramipril is an angiotensin-converting enzyme (ACE) inhibitor that exerts its effects through inhibition of the renin–angiotensin–aldosterone system. It exhibits a safety profile that is similar to that of other ACE inhibitors and is comparable in cost to the majority of the available agents. Clinical trials have proven the effectiveness of ACE inhibitors in the treatment of hypertension, heart failure, and nephropathy. Ramipril, however, is the only ACE inhibitor currently approved for the prevention of cardiovascular events in high-risk patients without evidence of left-ventricular dysfunction or heart failure, based on the results of the HOPE (Heart Outcomes Prevention Evaluation) trial. Whether this effect is specific to ramipril has yet to be proven. This article emphasizes the major trials involving ramipril including the AIRE (Acute Infarction Ramipril Efficacy), REIN (Ramipril Efficacy in Nephropathy), and HOPE trials.

CONCLUSIONS:

Although similar to other ACE inhibitors in many aspects, it cannot be assumed that the benefits shown with ramipril in the HOPE trial are a class effect. Ongoing trials should help to clarify this matter. Until this time, current evidence justifies the inclusion of ramipril on a formulary.
Ipratropium Treatment of Acute Airways Disease
Authors: Peterson Gregory M , Boyles Peter J , Bleasel Martin D , Vial Janet H
Published: June 2003

OBJECTIVE:

To examine the use of ipratropium bromide in adults with acute exacerbation of either asthma or chronic obstructive pulmonary disease (COPD) during admission and at discharge from 3 teaching hospitals.

METHODS:

An extensive range of clinical and demographic data was retrospectively extracted from the medical records of consecutive patients aged ≥12 years admitted to the medical wards of the hospitals during 1999–2001 with acute exacerbations of asthma or COPD, either as a primary diagnosis or as a major comorbidity.

RESULTS:

Data were gathered for 302 patients (97 with asthma, 205 with COPD). Almost 90% of all patients received ipratropium bromide during their hospital admission. The indication for using ipratropium bromide during hospitalization was considered appropriate in 84% of the asthma patients and 68% of the COPD patients. Over 20% of the patients with asthma had been using ipratropium bromide prior to the hospital admission, and almost one-third of the patients with asthma were discharged with ipratropium bromide, even though its role in chronic asthma is limited. More than 90% of the patients received nebulized drug therapy during their hospital stay, with 41% being prescribed nebulized therapy at discharge. This was often considered inappropriate, given that >50% of all patients had been using inhaler devices and nebulizers concurrently while hospitalized.

CONCLUSIONS:

In the majority of cases, ipratropium bromide had been used during hospitalization in accordance with guidelines for the management of acute exacerbations of asthma or COPD. However, there was also evidence of potentially inappropriate prolonged use of the agent in the community setting, particularly for asthma. Also of concern was the relatively high use of nebulized drug therapy when delivery via other means was appropriate.
Psychosis Associated with Interferon Alfa Therapy for Chronic Hepatitis B
Authors: Tamam Lut , Yerdelen Deniz , Ozpoyraz Nurgul
Published: June 2003

OBJECTIVE:

To report a case of persistent psychosis that developed during interferon alfa (IFN-α) therapy for chronic hepatitis B.

CASE SUMMARY:

A 26-year-old man who was diagnosed with active chronic hepatitis B began treatment with IFN-α. Five months after initiation of therapy, he developed acute psychosis with prominent persecutory delusions and auditory hallucinations. Despite discontinuation of IFN-α therapy and addition of antipsychotic drug treatment, only partial recovery from psychosis was observed after 4 months of hospitalization.

DISCUSSION:

Unlike many previously reported cases, this patient showed only partial recovery from psychosis, despite the discontinuation of IFN therapy. Except for receiving a relatively high dose of IFN-α (10 million units 3 times/wk), the patient did not have any previously proposed risk factors for developing psychiatric adverse effects. The Naranjo probability scale indicates a probable relationship between the acute psychosis and IFN therapy.

CONCLUSIONS:

Despite its rare occurrence, psychosis can emerge during IFN-α therapy. This adverse effect may persist for several months, even after appropriate medical management. IFN-α should be used with careful monitoring of patients' psychiatric status during all stages of therapy.
Recurrent Cholestasis Due to Ampicillin
Authors: Köklü Seyfettin , Yüksel Osman , Filik Levent , Üsküdar Oğuz , Altundağ Kadri , Altiparmak Emin
Published: June 2003

OBJECTIVE:

To present a single case of ampicillin-induced recurrent cholestasis and a literature review.

CASE SUMMARY:

A 23-year-old man was hospitalized due to recurrent and self-limited cholestatic symptoms. He had used ampicillin before each cholestatic attack. He became well clinically and biochemically each time after cessation of the drug. One year after his recovery and discontinuance of ampicillin, the patient has had no recurrence of cholestasis. An objective causality assessment revealed that the adverse drug reaction was probable.

DISCUSSION:

Ampicillin-related hepatotoxicity is very rare, with injury being mainly hepatocellular. To our knowledge, there is only 1 case report in the literature referring to chronic cholestatic-type hepatotoxicity related to ampicillin.

CONCLUSIONS:

Ampicillin, which is one of the most widely used antibiotics, may cause recurrent cholestatic hepatitis. Clinicians should be aware of this adverse effect, and it should be kept in mind during diagnostic workup of liver injury.
Bioterrorism Web Sites for Pharmacists
Authors: Misita Caron P , Boosinger Andrea B , Kendrach Michael G
Published: June 2003

OBJECTIVE

To identify Internet Web sites for ease of accessibility to bioterrorism-related information, comprehensive provision of bioterrorism-related information, and provision of bioterrorism information that specifically pertains to the pharmacy profession.

DATA SOURCES

Web sites of national pharmacy organizations, US government agencies, and medical organizations, as well as Web sites related to bioterrorism.

DATA SYNTHESIS

Pharmacists need access to relevant bioterrorism information in a timely manner. An evaluation of Web sites was performed to identify those that include a discussion of the potential infectious microorganisms and prevention and treatment methods, as well as unique features for pharmacy practice.

RESULTS

The American Society of Health-System Pharmacists and American Pharmaceutical Association Web sites provide pharmacy-specific recommendations. The Centers for Disease Control and Prevention provides biological agent information and health department contact numbers. Additional agent-specific data are provided by the American Medical Association, The Johns Hopkins University, and the Food and Drug Administration (FDA) Web sites. Information addressing food safety is provided by the FDA.

CONCLUSIONS

Pharmacy-specific bioterrorism information is available only at selected national pharmacy organization Internet Web sites. However, other Web sites provide comprehensive bioterrorism information useful for pharmacists.
Possible Captopril-Induced Toxic Epidermal Necrolysis
Authors: Alkurtass Delal A , Al-Jazairi Abdulrazaq S
Published: June 2003

OBJECTIVE:

To report a case of toxic epidermal necrolysis (TEN) possibly induced by captopril.

CASE SUMMARY:

An 11-week-old boy was referred to our hospital for tetrology of fallot surgical repair, performed on admission day 2. On day 3, the patient developed third-degree heart block, necessitating pacemaker connection and oral theophylline 3 mg/kg 3 times daily. Captopril 1 mg orally twice daily, intravenous furosemide 7 mg every 12 hours, and oral aldactone 7 mg twice daily were started. On day 5, the patient developed scaling erythematous skin lesions. On day 7, his temperature spiked to 37.8 °C, and pus discharge from the pacing wire site was noticed. Intravenous vancomycin 80 mg 3 times daily and intravenous ceftazidime 200 mg 3 times daily were initiated. On the same day, captopril was discontinued because we suspected that it had induced the skin reaction. On day 15, the infant's skin problem progressed. The dermatologist diagnosed partial TEN. On that day, theophylline and furosemide were also discontinued. On day 16, the patient still had some blisters, but the skin started to show signs of healing, until complete healing occurred on day 22. The infant was discharged on oral medications: furosemide 7 mg twice daily, aldactone 7 mg twice daily, and enalapril 0.1 mg twice daily. Three weeks later, he was followed up. No recurrences were observed.

CONCLUSIONS:

This case suggests captopril induces TEN when combined with other sulfonamide medications. An objective causality assessment revealed that the adverse drug event was possible. Although it is a rare complication, healthcare providers should be familiar with its potential to occur and take appropriate treatment and prevention measures.
Self‐discrepancy in body dysmorphic disorder
Authors: Veale David , Kinderman Peter , Riley Susan , Lambrou Christina
Published: June 2003

Objectives: According to self‐discrepancy theory (SDT), depression, social anxiety, eating disorders and paranoia result from different types of conflicting self‐beliefs. Body dysmorphic disorder (BDD) consists of a preoccupation with imagined or slight defects in one's appearance, which is often associated with a depressed mood and social anxiety. SDT was therefore applied to BDD patients to further understand their beliefs about their appearance.

Design: Using a comparative group design, BDD patients were compared against a non‐patient control group.

Method: A sample of 149 participants, consisting of three groups ‐ BDD (72), BDD preoccupied with their weight and shape (35), and controls (42) ‐ completed a modified version of the Selves Questionnaire (Higgins, Bond, Klein, & Strauman, 1986) requiring them to list and rate physical characteristics according to the following standpoints: (a) self‐actual; (b) self‐ideal; (c) self‐should; (d) other‐actual; and (e) other‐ideal.

Results: BDD patients displayed significant discrepancies between their self‐actual and both their self‐ideal and self‐should. However, there were no significant discrepancies in BDD patients between their self‐actual and other‐actual or other‐ideal domains. Analysis of variance using depression and social anxiety scores as covariates revealed a significant difference for both the self‐ideal and self‐should discrepancy.

Conclusion: The results suggest that BDD patients have an unrealistic ideal or demand as to how they should look. BDD patients are more like depressed patients (rather than social phobics or bulimics), being more concerned with a failure to achieve their own aesthetic standard than with the perceived ideals of others.
Effects of Rofecoxib or Naproxen vs Placebo on Alzheimer Disease Progression
Authors: Aisen Paul S. , Schafer Kimberly A. , Grundman Michael , Pfeiffer Eric , Sano Mary , Davis Kenneth L. , Farlow Martin R. , Jin Shelia , Thomas Ronald G. , Thal Leon J. ,   for the Alzheimer's Disease Cooperative Study
Published: June 2003

Context

Laboratory evidence that inflammatory mechanisms contribute to neuronal injury in Alzheimer disease (AD), along with epidemiological evidence, suggests that nonsteroidal anti-inflammatory drugs (NSAIDs) may favorably influence the course of the disease.

Objective

To determine whether treatment with a selective cyclooxygenase (COX) -2 inhibitor (rofecoxib) or a traditional nonselective NSAID (naproxen) slows cognitive decline in patients with mild-to-moderate AD.

Design

Multicenter, randomized, double-blind, placebo-controlled, parallel group trial, with 1-year exposure to study medications.

Setting

Forty ambulatory treatment centers affiliated with the Alzheimer's Disease Cooperative Study consortium.

Participants

Participants with mild-to-moderate AD (Mini-Mental State Examination score of 13-26) were recruited from December 1999 to November 2000 using clinic populations, referrals from community physicians, and local advertising. Stable use of cholinesterase inhibitors, estrogen, low-dose aspirin, and vitamin E was allowed. Participants with inflammatory diseases that might respond to the study medications were excluded. Of 474 participants screened, 351 were enrolled.

Interventions

Once-daily rofecoxib, 25 mg, or twice-daily naproxen sodium, 220 mg, or placebo.

Main Outcome Measures

The primary outcome measure was the 1-year change in the Alzheimer Disease Assessment Scale-Cognitive (ADAS-Cog) subscale score. Secondary outcome measures included the Clinical Dementia Rating scale sum-of-boxes, the Neuropsychiatric Inventory, the Quality of Life-AD, and the time to attainment of significant end points (4-point decline from baseline ADAS-Cog score, 1-step worsening on the global Clinical Dementia Rating scale, 15-point decline on the ADCS activities of daily living inventory, institutionalization, or death).

Results

The 1-year mean (SD) change in ADAS-Cog scores in participants treated with naproxen (5.8 [8.0]) or rofecoxib (7.6 [7.7]) was not significantly different from the change in participants treated with placebo (5.7 [8.2]). Results of secondary analyses showed no consistent benefit of either treatment. Fatigue, dizziness, and hypertension were more commonly reported in the active drug groups, and more serious adverse events were found in the active treatment group than in the placebo group.

Conclusion

The results of this study indicate that rofecoxib or low-dose naproxen does not slow cognitive decline in patients with mild-to-moderate AD.
Professional Development in Adult Basic Education
Authors: Marceau Georges
Published: June 2003

A regional director of a staff development consortium provides his perspective on current adult basic education practice.
Changes, Challenges, and the Future
Authors: Lawler Patricia A. , King Kathleen P.
Published: June 2003

Bringing together the themes and perspectives presented in this sourcebook, the authors offer a new vision for professional development and recommendations to help prepare those who work with teachers of adults to meet the challenges and changes.
Trends and Issues in the Professional Development of Teachers of Adults
Authors: King Kathleen P. , Lawler Patricia A.
Published: June 2003

This chapter introduces the distinct perspective that this sourcebook brings to the literature and practice of professional development while placing it in the context of current trends and issues in the field.
A Case for Learner‐Centered Teaching and Learning
Authors: Daley Barbara J.
Published: June 2003

This chapter discusses how to create learner‐centered approaches to teacher development by analyzing educators' teaching and learning orientations as well as their career stages.
Fostering Motivation in Professional Development Programs
Authors: Wlodkowski Raymond J.
Published: June 2003

The Motivational Framework for Culturally Responsive Teaching is presented as a guide to foster participation, learning, and transfer throughout a professional development program for all participants.
Learning the New Technologies: Strategies for Success
Authors: King Kathleen P.
Published: June 2003

Educators of adults come to professional development in educational technology with many needs and concerns. The model presented in this chapter provides principles, insights, and strategies to meet these needs and prepare educators for lifelong learning in this challenging area.