bluuebunny/crossref_metadata_2025 huggingface dataset:
Retrospective Evaluation of a Potential Interaction Between Azithromycin and Warfarin in Patients Stabilized on Warfarin
Authors: Beckey Nick P. , Parra David , Colon Amy
Published: June 2004

Study Objective.To investigate a potential interaction between azithromycin and warfarin.

Design.Retrospective case‐control study.

Setting.Veterans Affairs medical center

Patients.Fifty‐two patients stable on anticoagulation therapy.

Intervention.Patients who received a prescription for azithromycin and warfarin at any time since the hospital was opened, June 1, 1995, to July 22, 1999, were identified through a computerized report generated from the pharmacy prescription package.

Measurements and Main Results.Patients having a stable international normalized ratio (INR; defined as a therapeutic INR ± 0.2) for at least two consecutive visits before receiving an azithromycin prescription were reviewed. Changes in INR from before and after addition of azithromycin were compared with changes in a control group. Controls were identified from a computer‐generated report of patients who received a prescription for terazosin and warfarin at any time since the hospital was opened to July 22, 1999 (terazosin was chosen as it has no known interaction with warfarin). These patients also had a stable INR for at least two consecutive visits before receiving the terazosin prescription. In patients with INRs on record within 14 days after starting azithromycin or terazosin (9 patients/group), the average change in INR was 0.18 ± 0.48 in the azithromycin group and 0.07 ± 0.49 in the terazosin group (p=0.60). For patients with an INR on record within 30 days after starting azithromycin or terazosin (26 patients/group), the average change in INR was 0.25 ± 0.67 in the azithromycin group and 0.05 ± 0.55 in the terazosin group (p=0.18).

Conclusion.An interaction between azithromycin and warfarin was not observed in this retrospective review of patients with a stable INR receiving the combination.
Safety and Efficacy of HMG‐CoA Reductase Inhibitors for Treatment of Hyperlipidemia in Patients with HIV Infection
Authors: Penzak Scott R. , Chuck Susan K. , Stajich Gregory V.
Published: June 2004

Study Objective. To assess the efficacy and safety of HMG‐CoA reductase inhibitors (statins) in patients with human immunodeficiency virus (HIV) infection and hyperlipidemia.

Design. Retrospective analysis.

Setting. HIV clinic.

Patients. Twenty‐six HIV‐infected patients with hyperlipidemia.

Intervention. Five patients received pravastatin, 13 lovastatin, 10 simvastatin, and 2 atorvastatin (total 30 courses).

Measurements and Main Results. Reductions in cholesterol and triglycerides were used to assess efficacy; creatine kinase (CK), liver enzymes, and myalgia were markers of statin toxicity. After a median of 8.2 and 7.2 months of treatment, the agents collectively reduced median baseline total cholesterol 27% (354 to 263 mg/dl) and triglycerides 15% (513 to 438 mg/dl), respectively. Two patients, one with marked CK elevations, experienced myalgias with lovastatin, and two experienced transaminase elevations 3 or more times the upper limit of normal.

Conclusion. Statins are effective in reducing total cholesterol and triglycerides in HIV‐infected patients, although lipid levels infrequently return to normal. Lovastatin should be avoided in patients receiving concomitant drugs that may potentiate skeletal muscle toxicity with this agent.
Retrospective Evaluation of the Conversion of Amlodipine to Alternative Calcium Channel Blockers
Authors: Parra David , Beckey Nick P. , Korman Lisa
Published: June 2004

Study Objective. To evaluate the effectiveness, safety, and costs associated with a formulary conversion from amlodipine to alternative calcium channel blockers.

Design. Retrospective study.

Setting. Veterans Affairs Medical Center.

Patients. One hundred patients with hypertension who were receiving amlodipine.

Intervention. Data from a random sample of 100 patients who were taking amlodipine and converted to a formulary calcium channel blocker from February 1, 1999—October 30, 1999, were entered into an Excel database for evaluation of the conversion.

Measurements and Main Results. Patients were required to have a diagnosis of hypertension and have had two consecutive clinic visits with blood pressure measurements (and no changes in antihypertensive therapy) before conversion. End points were changes in average systolic blood pressure, diastolic blood pressure, and mean arterial pressure (MAP) from the two clinic visits before and after conversion. In addition, data were collected and analyzed with regard to adverse drug reactions, average dosage of the alternative calcium channel blocker, number of additional antihypertensives begun or discontinued, and number of dosage changes in antihypertensives within the two visits after conversion, and the overall cost impact of conversion. Average systolic blood pressure was reduced from 141.6 ± 15.1 to 139.2 ± 15.3 mm Hg after the conversion (NS). Average diastolic blood pressure was significantly reduced from 74 ± 9.5 to 72.6 ± 10.1 mm Hg after conversion (p=0.032), as was MAP (97.0 ± 9.3 to 94.8 ± 10.0 mm Hg, p=0.026). Five patients had other changes in therapy made concurrently at the time of conversion, and 19 had changes after conversion. When these patients were excluded from analysis, the reduction in systolic blood pressure after conversion was significant (141.4 ± 14.5 to 137.7 ± 14.3 mm Hg, p=0.022), as were reductions in diastolic blood pressure (74.4 ± 9.4 to 71.7 ± 9.8 mm Hg, p=0.014) and MAP (96.7 ± 9.1 to 93.7 ± 9.3 mm Hg, p=0.007). Of patients who had postconversion changes in therapy, 8 (42%) were converted to diltiazem ER, nifedipine CC, or doses of felodipine that were 50% of the original dose of amlodipine. The overall cost impact of the conversion was a net savings of $14,858/year for each 100 patients converted.

Conclusion. Conversion from amlodipine to other calcium channel blockers resulted in statistically significant reductions in diastolic blood pressure and MAP, and was safe as well as cost‐effective. Conversion to calcium channel antagonists other than felodipine or less than equal dosages of felodipine may require dosage titration. When converting patients from amlodipine, dosages usually should be equal to those of felodipine; if converting to other calcium channel antagonists, the need for adjustments should be anticipated.
Pharmacotherapy with Botulinum Toxin: Harnessing Nature's Most Potent Neurotoxin
Authors: Bell Mark S. , Vermeulen Lee C. , Sperling Keith B.
Published: June 2004

Botulinum toxin (BTX), a potent biologic neurotoxin, commonly is associated with lethal outbreaks of food poisoning; however, it also plays a role as a therapeutic agent. Since the 1970s physicians have investigated BTX therapy in patients with neurologic disorders. The number of applications greatly expanded over the years to include certain focal dystonias (blepharospasm, torticollis, laryngeal dystonias, writer's cramp), strabismus, and a wide variety of other indications (gastrointestinal disorders, cosmetic wrinkle correction, spasticity, hyperhidrosis). BTX's safety and efficacy are reviewed.
Therapeutic Options in the Treatment of Clozapine‐Induced Sialorrhea
Authors: Rogers Donald P. , Shramko Jennifer K.
Published: June 2004

Clozapine is an effective atypical antipsychotic drug, but its use may be compromised by its side effects. Agranulocytosis may be fatal, but sialorrhea occurs more frequently and plays a major role in patients' noncompliance. A MEDLINE search from 1975–2000 revealed that treatment of clozapine‐induced sialorrhea is predominantly based on case reports. Due to its elusive mechanism, physicians have attempted to treat this side effect with agents that counteract clozapine's adrenergic and muscarinic properties. We evaluated reported treatment options and other possible strategies from a pharmacologic standpoint. Antimuscarinic agents and α‐receptor agonists are both viable options but must be administered and monitored cautiously in patients with psychiatric disorders. Although not yet available in the United States, pirenzepine, a selective muscarinic receptor antagonist, has the most promising mechanism. Other selective, peripherally acting agents must be investigated in controlled clinical trials to determine their efficacy as possible alternatives.
Aldosterone, a New Appreciation of Its Role in Heart Failure
Authors: Cha Amy J. , Malecha Susan E. , Judge Kevin W.
Published: June 2004

Understanding of the role, triggers, and impact of the renin‐angiotensin‐aldosterone system in cardiovascular disease has significantly broadened. In recent years substantial discoveries have been made regarding the pathophysiology of heart failure, particularly in the area of neurohormonal activation. New interest in therapy with aldosterone antagonists was stimulated by results of a 2‐year study of 1663 patients with heart failure that showed a 30% relative risk reduction of death among patients given a subhemodynamic dosage of spironolactone, a nonselective aldosterone antagonist, compared with placebo, in addition to standard therapy of diuretics, angiotensin‐converting enzyme inhibitors, β‐blockers, and digitalis.
Once‐Daily Aminoglycoside in the Treatment of Enterococcus faecalis Endocarditis: Case Report and Review
Authors: Tam Vincent H. , McKinnon Peggy S. , Levine Donald P. , Brandel Susan M. , Rybak Michael J.
Published: June 2004

Once‐daily administration of aminoglycosides (ODA) is effective and safe for many indications. By optimizing pharmacodynamic principles, it enhances bactericidal activity and minimizes toxicity. Its use for the treatment of enterococcal infection is controversial, however, and results of in vitro studies and animal models of endocarditis are conflicting. To date, no case reports or clinical trials have examined its utility in human enterococcal endocarditis. A patient with right‐sided endocarditis caused by Enterococcus faecalis was managed by once‐daily gentamicin. Clinical and bacteriologic cures of this patient raise questions as to whether enterococcal endocarditis should be regarded as contraindication to ODA. The clinical utility of ODA in this disease deserves further investigation.
Acute Hepatitis and Bleeding Possibly Induced by Zidovudine and Ritonavir in an Infant with HIV Infection
Authors: Pai Vinita B. , Koranyi Katalin , Nahata Milap C.
Published: June 2004

Acute hepatitis led to abnormal coagulopathy, bleeding, and death in a nonhemophiliac infant infected with the human immunodeficiency virus, possibly due to zidovudine or ritonavir or both. Acute hepatitis during ritonavir treatment and episodes of spontaneous bleeding have been reported in patients with hemophilia. Zidovudine is associated with elevated liver enzymes, elevated bilirubin, and hepatomegaly leading to abnormal coagulopathy, bleeding, and death in adults. A temporal relationship between the start of combination antiretroviral therapy and onset of hepato‐splenomegaly and rise in liver enzymes suggests that zidovudine or ritonavir, or both, are the likely cause of this adverse event. Ritonavir is believed to cause direct hepatotoxicity, probably by inducing acute mitochondrial toxicity, and may hasten reverse transcriptase inhibitor‐induced liver toxicity. Liver function of patients receiving a combination of nucleoside reverse transcriptase inhibitor and protease inhibitors should be closely monitored.
Control of Glycopeptide‐Resistant Enterococci in an Oncology Unit
Authors: Bradley Susan J.
Published: June 2004

Enterococci are responsible for 10–12% of nosocomial infections. Since 1987 the incidence of glycopeptide‐resistant enterococci (GRE; termed vancomycin‐resistant enterococci in the United States) has increased dramatically. The mechanism of GRE is well understood and involves mutation of a single terminal amino acid in a peptidoglycan precursor leading to reduced vancomycin affinity. Studies implicated antibiotic selection pressure as a major risk factor for GRE infection and colonization. In the hematology unit of a London hospital, GRE emerged in December 1993, with 38% of patients positive in a point prevalence study. Between December 1993 and June 1995, 13 patients acquired GRE bacteremia, five of whom died. Between 1995 and 1996 a prospective sequential study was undertaken to determine the effect of changing antibiotic treatment of febrile neutropenia (FN). All patients admitted to the hematology unit were enrolled in the study. In phase 1, treatment continued with ceftazidime monotherapy. In phase 2, piperacillin‐tazobactam replaced ceftazidime, and enhanced infection control measures were encouraged. In phase 3, therapy returned to ceftazidime. In phase 1, 57% of patients became colonized or infected with GRE. Phase 2, which was divided into two 4‐month cohorts, showed a significant reduction in GRE acquisition, falling to 8% colonization and no clinical infections in the second 4 months. In phase 3, despite heightened infection control procedures, the acquisition rate rose to 36%.
β‐Lactamase Inhibitor Combinations with Extended‐Spectrum Penicillins: Factors Influencing Antibacterial Activity against Enterobacteriaceae and Pseudomonas aeruginosa
Authors: Lister Philip D.
Published: June 2004

Production of β‐lactamases is the most common mechanism by which gram‐negative bacteria express resistance to β‐lactam antibiotics. One successful method of circumventing the threat of plasmid‐encoded β‐lactamases is to combine inhibitors of these enzymes with a penicillin. Currently, four inhibitor‐penicillin combinations are in clinical use: ampicillin‐sulbactam, amoxicillin‐clavulanate, ticarcillin‐clavulanate, and piperacillin‐tazobactam. Of these, ticarcillin‐clavulanate and piperacillin‐tazobactam have the broadest spectra of activity that includes Pseudomonas aeruginosa. Many factors influence the activity and pharmacodynamics of these combinations, including potency of both agents, pharmacokinetics of the inhibitor, type and quantity of β‐lactamase produced by the target bacterium, and potential for the inhibitor to induce expression of chromosomal cephalosporinases in the target bacterium. Although ticarcillin‐clavulanate and piperacillin‐tazobactam have similar spectra of activity, they have many differences. Most notable are increased potency of piperacillin against Enterobacteriaceae and P. aeruginosa, increased activity of piperacillin‐tazobactam against gram‐negative pathogens producing penicillin‐sensitive enzyme (PSE)‐class β‐lactamase or hyperproducing other plasmid‐encoded β‐lactamases, and the more favorable pharmacokinetics of tazobactam. In the treatment of P. aeruginosa infections, the potential for clavulanate to induce expression of chromosomal cephalosporinase and antagonize antibacterial activity of ticarcillin is a concern, especially in patients who lack protective host defenses. These are not concerns with piperacillin‐tazobactam.
Preclinical Pharmacology of GAR‐936, a Novel Glycylcycline Antibacterial Agent
Authors: Projan Steven J.
Published: June 2004

GAR‐936 is an analog of minocycline, a semisynthetic derivative of tetracycline. It has broad‐spectrum antibacterial activity in vitro and in vivo. The new class of tetracyclines to which GAR‐936 belongs is named the glycylcyclines. Tetracyclines act by inhibiting protein translation in bacteria, presumably by binding to the 30S ribosomal subunit and blocking entry of amino‐acyl transfer RNA molecules into the A site of the ribosome. This prevents incorporation of amino acid residues into elongating peptide chains. In general, tetracyclines are considered bacteriostatic and the critical therapeutic parameter is the area under the concentration‐time curve. GAR‐936 has bactericidal activity; at 4 times the minimum inhibitory concentration, a 2‐ to 3‐log reduction in colony counts was seen against Streptococcus pneumoniae, Neisseria gonorrhoeae, Haemophilus influenzae, Escherichia coli, and Staphylococcus aureus. GAR‐936 is active against the antibiotic‐resistant gram‐positive bacteria methicillin‐resistant Staphylococcus aureus, penicillin‐resistant S. pneumoniae, and vancomycin‐resistant enterococci. It is most significant that GAR‐936 and other glycylcyclines are active against bacterial strains carrying either or both of the two major forms of tetracycline resistance: efflux and ribosomal protection. Using isogenic panels of bacteria carrying various tetracycline‐resistance determinants, a series of more than 300 analogs was tested for antibacterial activity, which allowed for structure‐activity relationships to be determined. Results indicated that certain substituents at the 9 position of the tetracycline molecule restored activity against bacteria harboring genes encoding either or both efflux and ribosomal protection. A single chemical modification overcame the two molecularly distinct forms of resistance while maintaining activity against susceptible gram‐positive, gram‐negative, aerobic, and anaerobic bacteria. Although mutants can be generated that are less susceptible to previously studied glycylcyclines, only marginal differences in susceptibility to GAR‐936 were noted. Therefore, whereas emergence of resistance to any widely administered antibiotic is a foregone conclusion, resistance to GAR‐936 will not readily arise by trivial mutations in existing resistance genes.
Methods to Assess the Economic Outcomes of Clinical Pharmacy Services
Authors: Schumock Glen T.
Published: June 2004

Studies that demonstrate the clinical and economic burden of drug misadventures have been published. The economic burden of drug misadventures likely exceeds $100 billion annually in the United States alone. Clinical pharmacy services (CPS) have been shown to reduce negative clinical outcomes and costs of drug therapy. Pharmacy practitioners and pharmacy managers need to demonstrate the impact of CPS at the local level and present the value to financial decision‐makers to gain support for implementation, continuation, and/or expansion of those services. The basic model of an economic evaluation includes measurement of both costs and consequences of a service and of an alternative for comparison. Strategies for economic assessments include the generalization from previously published literature, use of modeling techniques, and measurement of actual costs and consequences of an existing service. Guidelines for conducting an economic assessment are widely available. Pharmacy practitioners and managers should use these methods of assessing economic outcomes of CPS and, at the same time, develop relationships and skills to effectively communicate the value of those services so as to ensure long‐term success.
Technology for Patient Care Assessment, Documentation, and Education
Authors: Cataldo Renato
Published: June 2004

Computer technology plays a big role in health care systems and information management. As technology continues to evolve, its role will become even more prevalent and important. Among the trends seen in technology products are better integration and compatibility of systems and accessories, enhanced performance and speed, smaller size and portability, improved user‐friendliness, and affordability. All of these trends favor increased use in the health care environment. Selection of a product requires consideration of the desired goals and needs. An assessment should be made of existing technologies, particularly if interfacing will be required. Furthermore, most products have a life of only 10–18 months due to the rapid development of newer and better technologies.
Clinical Pharmacy in Inpatient Care
Authors: Bonal Joaquim F.
Published: June 2004

The aim of this paper is to describe how interventions by clinical pharmacists can provide quality pharmaceutical care to inpatients. Evidence‐based pharmacotherapy is necessary for the practice of clinical pharmacy. The use of published data, patient‐specific data, and data generated by conducted research are discussed with respect to unit dose computer systems, nutrition teams, and pharmacokinetic services, based on the experience of an European hospital pharmacy. Incorporating evidence into clinical pharmacy activities results in added value to these services. The implementation of evidence‐based pharmacotherapy is not an easy task for three reasons: a lack of scientific evidence in many medical areas, a lack of authority of pharmacists in Europe to take an active part in decision‐making for drug prescribing, and reluctance of some physicians to accept pharmacists within the health care team. Also, efforts are required to change education programs at the universities in Europe to better prepare clinical pharmacists in pharmacotherapy and pharmaceutical care.
Clinical Pharmacy in Disease‐Specific Clinics
Authors: Carter Barry L.
Published: June 2004

The literature that describes and evaluates clinical pharmacy services in disease‐specific clinics is briefly reviewed. Various evaluation techniques are discussed, highlighting examples of sites using these techniques in published studies. The evaluation of clinical pharmacy services has evolved from examining a single parameter such as disease outcome to examining the broader perspective of the value of clinical pharmacists in the health care system, taking into account structure and process as well as outcomes. Assessment tools should consider all of these aspects to satisfactorily evaluate the value of clinical pharmacists in clinics.
Clinical Pharmacy in Primary Care and Community Pharmacy
Authors: De Gier Johan J.
Published: June 2004

The role of the community pharmacist involved in primary care has been undergoing change. In the late 1970s and early 1980s, developments in computerized medication surveillance within the Netherlands enabled pharmacists to react to prescriptions and detect inappropriate pharmaco‐therapy in community pharmacy sites. This activity became more clinically or patient‐oriented in the late 1980s. In the early 1990s, pharmaceutical care was introduced in community pharmacy practice, and emphasis was given to providing patient‐centered care and documenting cognitive services. The key features of pharmaceutical care provided in the primary care setting are described based on a review of the literature and on experiences in the Netherlands. Patient outcomes have yet to be shown to be improved by community pharmacy practice; methods for measuring performance are still lacking. Methods to evaluate the extent of integration of community pharmacy services into the clinical team are also lacking but are needed in order to define the future role of community pharmacists in the primary care setting. Integrated care needs to be developed in the Netherlands in order to present the next phase in the process of the “pharmaceutical evolution.”
Formulary Management
Authors: Scroccaro Giovanna
Published: June 2004

The hospital formulary is not only a list of drugs, but also a policy that involves several complex processes and activities. Formularies are developed based on cost‐effectiveness evaluation, but maintaining cost‐effectiveness requires educational strategies. The clinical pharmacist plays an active role in formulary processes. These processes are discussed in this paper. There is a need for studies on the cost‐effectiveness of clinical pharmacy services in support of the hospital formulary.
Target Drug Programs and Medication Use Evaluation
Authors: Hekster Yechiel A.
Published: June 2004

Target drug programs and medication use evaluations are activities that are undertaken to improve the correct use of drugs. These programs should focus on inappropriate drug use, drug use problems, optimizing use of drugs, and improving the level of patient care. To monitor the effects of the programs, several types of outcomes have been evaluated, such as economic and financial, clinical quality, quality of life, patient satisfaction, and collaborative practice. The methodology to classify and monitor drug use incorporates the classification system developed by the World Health Organization, which takes into account each drug's anatomic, therapeutic, and chemical classification. In order to avoid focusing only on drugs and drug costs in these programs, and to allow for monitoring the impact of the programs on clinical practice, linking drug data to patient data is stressed. Target drug programs improve the appropriate use of drugs, and by doing so, contribute to safe and rational use of drugs in society.
Assessing the Value of Pharmacists' Health‐Systemwide Services: Clinical Pathways and Treatment Guidelines
Authors: Petitta Antonio
Published: June 2004

Practice guidelines and clinical pathways are increasingly being used as tools to enhance the quality of health care services and to manage costs better. This article reviews the role of guidelines and clinical pathways in health care as defined within the broader concept of practice policies. The factors that increase the effectiveness of practice policies are examined. These include the origin of development, dissemination technique, and implementation strategy. Policies that are internally developed and implemented with concurrent reminder systems are the most effective. Clinical pathways fit these criteria and are therefore highly effective policy types. The roles that pharmacists within health systems can undertake in policy development are described. These include writing the policy document, providing expert review, providing education, and most important, facilitating the desired outcomes by implementing pharmacy services that promote compliance with the guidelines. Examples of pharmacy‐based guideline and pathway implementation from the Henry Ford Health System are described for inpatient anticoagulation, outpatient preferred drug formulary policy, and outpatient lipid therapy management.
How to Develop and Implement a Program to Continuously Demonstrate the Value of Clinical Pharmacy Services
Authors: Helling Dennis K. , Nelson Kent M.
Published: June 2004

This paper summarizes key elements that support the success of clinical pharmacy services to continuously improve the quality of drug therapy. Five drivers identify a successful model for continuously demonstrating the value of clinical pharmacy services: knowing the organizational culture; providing leadership; recruiting pharmacy sponsors; showing tenacity; and acting with management courage. Difficulties encountered when communicating the value of clinical pharmacy services within a health care organization usually arise because of failure to include one of these drivers.
The Psychosocial Aspects of Complementary and Alternative Medicine
Authors: Cauffield Jacintha S.
Published: June 2004

Approximately one in four persons in the United States uses complementary and alternative medicine (CAM). Out‐of‐pocket costs of CAM rival medical treatment at $21.2–32.7 billion versus $29.3 billion, respectively. Users of CAM tend to have high incomes and high levels of education. They also have medical conditions not easily treated by modern medicine such as chronic pain, poor mental health, human immunodeficiency virus infection, and cancer. The most common therapies are noninvasive (acupuncture, chiropractic, massage), however, consumption of dietary supplements has grown dramatically. Patients often use CAM in addition to modern medicine and are reluctant to discuss CAM with their physicians. Pharmacists' professional approach to science may bias them against CAM therapies. Complementary and alternative medicine use should be included in visit histories and discussed in an objective, nonjudgmental manner to encourage patient disclosure.
Effect of Intravenous Metoprolol or Intravenous Metoprolol plus Glucagon on Dobutamine‐Induced Myocardial Ischemia
Authors: Murthy Dakshina R. , White C. Michael , Katten Deborah , Ahlberg Alan W. , Salloum Ahmad , Heller Gary V.
Published: June 2004

Study Objective. To determine the effect of metoprolol on dobutamine stress testing with technetium‐99m sestamibi single‐photon emission computed tomography imaging and ST‐segment monitoring, and to assess the impact of intravenous glucagon on metoprolol's effects.

Design. Randomized, double‐blind, placebo‐controlled trial.

Setting. Community hospital.

Patients. Twenty‐two patients with known reversible perfusion defects.

Intervention. Patients underwent dobutamine stress tests per standard protocol. Before dobutamine was begun, no therapy was given during the first visit, and patients were randomized on subsequent visits to receive metoprolol or metoprolol plus glucagon 1 mg. Metoprolol was dosed to achieve a resting predobutamine heart rate below 65 beats/minute or a total intravenous dose of 20 mg.

Measurements and Main Results. Metoprolol reduced maximum heart rate 31%, summed stress scores 29%, and summed difference scores 43% versus control. Metoprolol plus glucagon also reduced the maximum heart rate 29% versus control. Summed stress and summed difference scores were not significantly reduced, although they were 18% and 30% lower, respectively, than control. No significant differences were found in any parameter between metoprolol and metoprolol‐glucagon.

Conclusion. During dobutamine stress testing, metoprolol attenuates or eliminates evidence of myocardial ischemia. Glucagon 1 mg, although somewhat effective, does not correct this effect to the extent that it can be administered clinically.
Gender Differences in Metered‐Dose Inhaler‐Spacer Device Technique
Authors: Chafin Carol C. , Tolley Elizabeth A. , George Christa M. , Demirkan Kutay , Kuhl David A. , Pugazhenthi Muthiah , Self Timothy H.
Published: June 2004

Study Objective. To determine whether gender affects the correct use of a metered‐dose inhaler (MDI)‐spacer device.

Design. Prospective, observational study.

Setting. University classrooms.

Patients. Eighty‐three students in their third year of a Doctor of Pharmacy program.

Intervention. Students were given the device and received 20 minutes of education on its use. They then were asked to perform the technique. Assessment and retraining were done, as necessary, by clinicians who were experienced with the device. Students returned 1 week later to perform the technique again.

Measurements and Main Results. The performance of men versus women was analyzed with X2 tests and the Student's t test. Power analysis indicated that 30 students were needed in each group.

Conclusion. There were no significant differences between men and women in proper MDI‐spacer technique.
Oxandrolone in Trauma Patients
Authors: Gervasio Jane M. , Dickerson Roland N. , Swearingen Jessica , Yates Mary E. D. , Yuen Ceaminia , Fabian Timothy C. , Croce Martin A. , Brown Rex O.
Published: June 2004

Study Objective. To determine the effect of oxandrolone administration on nutritional and clinical outcomes after multiple trauma.

Design. Prospective, randomized, double‐blind, placebo‐controlled study.

Setting. Level 1 trauma center in a university teaching hospital.

Patients. Sixty‐two patients requiring enteral nutrition, 60 of whom completed the study.

Intervention. Patients were randomized to receive either oxandrolone 10 mg or placebo twice/day for a maximum of 28 days.

Measurements and Main Results. Total urinary nitrogen, prealbumin, nitrogen balance, total body water, and body cell mass were measured on day 1 of enteral nutrition and then at day 7, day 10, and study exit. Patients were assessed daily for metabolic and infectious complications. The two groups were similar for demographics and dosage of enteral nutrition. Measurement of total urinary nitrogen at study entry showed both groups to be highly catabolic (oxandrolone 17.2 ± 4.9, placebo 19.1 ± 10.8 g/day, NS). On days 7 and 10, total urinary nitrogen increased in both groups; however, there was no significant difference between groups. Nitrogen balance was negative throughout the study in each group. Body cell mass decreased slightly in both groups over the study period. Prealbumin serum concentrations increased significantly in both groups at day 10 and study exit compared with study entry. The groups did not differ significantly for length of hospital stay (oxandrolone 30.8 ± 17.9, placebo 27.0 ± 25.7 days), length of intensive care unit stay (oxandrolone 17.1 ± 7.8, placebo 15.5 ± 9.7 days), and frequency of pneumonia or sepsis (oxandrolone 48, placebo 43 episodes).

Conclusion. Oxandrolone 20 mg/day does not have obvious benefit in nutritional and clinical outcomes during the first month after multiple trauma.
Antifungal Pharmacodynamics: Review of the Literature and Clinical Applications
Authors: Dodds Elizabeth S. , Drew Richard H. , Perfect John R.
Published: June 2004

Invasive fungal infections are seen with growing frequency, likely due to increases in numbers of patients at risk of infection. Optimal selection and dosing of antifungal agents are important, as these infections are often refractory to available therapy. In contrast to antibacterials, studies examining the pharmacodynamic properties of antifungals and their application in treating invasive disease often are lacking. Agents administered for invasive infections are amphotericin B, flucytosine, and azole antifungals. Several drugs are under investigation, such as posiconazole, voriconazole, and the echinocandins, and preliminary pharmacodynamic data likely will help shape dosing regimens. Clinical trials that investigated dosage and administration, as well as the potential benefits of combination and sequential therapy, are addressed. In addition, antifungal susceptibility and animal models of infection are discussed.
Cost‐Benefit Analysis of Sumatriptan Tablets versus Usual Therapy for Treatment of Migraine
Authors: Biddle Andrea K. , Shih Ya‐Chen Tina , Kwong W. Jacqueline
Published: June 2004

We performed a systematic assessment of the costs and benefits of sumatriptan and usual therapy for migraine from society's perspective. A decision tree was constructed with probability estimates based on data from an open‐label clinical trial assessing the economic and human impacts of sumatriptan and usual therapy on nursing personnel. Direct medical care costs including costs for drug, physician, and emergency room visits were considered. Benefits were estimated using the human capital approach based on the national average of weekly earnings and productivity loss estimated from a migraine clinical trial. The net benefits of sumatriptan and usual therapy for the treatment of a single migraine attack were estimated to be $50 and $20, respectively. The annual incremental net benefit of sumatriptan over usual therapy was estimated to be $114–540/patient. The price difference was offset by benefits of sumatriptan in reducing use of health care resources and productivity loss.
Pharmaceutical Care of Postoperative Nausea and Vomiting: Balanced Scorecard for Outcomes
Authors: Graumlich James F. , Belknap Steven M. , Bullard Sue A. , Storm Gerald A. , Brunsman Kathleen S. , Howerton John A.
Published: June 2004

Using the balanced scorecard to measure outcomes, a multidisciplinary team worked to improve antiemetic therapy and decrease postoperative nausea and vomiting. Patient satisfaction measures were nausea and pain scales (10 cm, nonnumbered, visual analog). The quality measure was number of vomiting episodes. Cost measures were length of postoperative stay and antiemetic requirement. Institutional learning was assessed by spread of prescribing changes beyond the first cohort of patients. Intervention subjects were providers of general anesthesia in two cohorts of patients (60 and 346) undergoing laparoscopic cholecystectomy. Outcome assessment revealed low nausea and vomiting scores throughout the study, and antiemetic use decreased 50%. There were no deteriorations in pain scores or length of stay. Balanced scorecard measurements suggest no adverse unintended outcomes consequent to changes in prescribing behavior. Balanced scorecard processes assisted consensus among pharmacists, nurses, and physicians that may have accelerated behavioral changes.
Effect of a Clinical Pharmacist‐Managed Lipid Clinic on Achieving National Cholesterol Education Program Low‐Density Lipoprotein Goals
Authors: Bozovich Michelle , Rubino Christopher M. , Edmunds John
Published: June 2004

Despite national guidelines for treatment of hyperlipidemia, significant numbers of individuals with coronary artery disease are not treated to their National Cholesterol Education Program (NCEP) low‐density lipoprotein (LDL) goals. The potential benefits of a clinical pharmacist‐managed lipid clinic would be to improve rates of success in achieving these goals, improve drug adherence and compliance with therapy, and reduce cardiovascular events. All patients who had a documented history of coronary artery disease and were under the care of one cardiologist were treated in the pharmacist‐managed lipid clinic. A second cardiologist provided usual care to a group of patients with coronary artery disease who served as controls. Patients in each arm were followed for a minimum of 6 months. A protocol for therapy changes in clinic patients was developed by the clinical pharmacist and approved by the cardiologist. At the end of 6 months, 69% of patients in the pharmacist‐managed clinic achieved their LDL goal, compared with 50% of controls. Compliance with laboratory tests and drug regimens also improved in clinic patients. Compliance with lipid panels went from 8% 2 months before to 89% 2 months after the start of the study. At the end of 6 months compliance with laboratory work and refills was 80%. Thus the clinical pharmacist‐managed clinic was highly successful in achieving NCEP goals for secondary prevention.
Effect of Pharmacist Intervention and Initiation of Home Blood Pressure Monitoring in Patients with Uncontrolled Hypertension
Authors: Mehos Brenda M. , Saseen Joseph J. , MacLaughlin Eric J.
Published: June 2004

This prospective, randomized, controlled study evaluated the impact of pharmacist‐initiated home blood pressure monitoring and intervention on blood pressure control, therapy compliance, and quality of life (QOL). Subjects were 36 patients with uncontrolled stage 1 or 2 hypertension. Eighteen subjects received home blood pressure monitors, a diary, and instructions to measure blood pressure twice every morning. Home measurements were evaluated by a clinical pharmacist by telephone, and the patient's family physician was contacted with recommendations if mean monthly values were 140/90 mm Hg or higher. Eighteen control patients did not receive home monitors or pharmacist intervention. Office blood pressure measurements and QOL surveys (SF‐36) were obtained at baseline and after 6 months. Mean absolute reductions in systolic and diastolic pressures were significantly reduced from baseline in intervention subjects (17.0 and 10.5 mm Hg, both p<0.0001) but not in controls (7.0 and 3.8 mm Hg, p=0.12 and p=0.09). More intervention subjects (8) had blood pressure values below 140/90 at 6 months compared with controls (4). During the study 83.3% (15) of intervention subjects had drug therapy changes versus 33% (6) of controls (p<0.01). Compliance and QOL were not significantly affected. Our data suggest that the combination of pharmacist intervention with home monitoring can improve blood pressure control in patients with uncontrolled hypertension. This may be related to increased modifications of drug regimens.
Corticosteroids and Serious Cytarabine‐Induced Pulmonary Edema
Authors: Larouche Geneviève , Denault André , Prénovault Julie
Published: June 2004

A woman with acute leukemia receiving induction chemotherapy with conventional doses of cytarabine (ARA‐C) 200 mg/m2/day and daunorubicin 45 mg/m2/day developed acute respiratory distress syndrome. Respiratory failure was attributed to ARA‐C primarily by exclusion and radiographic findings. She was weaned rapidly from the ventilator after receiving steroid therapy.
Position Paper on Critical Care Pharmacy Services
Authors:   Society of Critical Care Medicine and the American College of Clinical Pharmacy, Rudis Maria I. , Cohen Henry , Cooper Bradley E. , Gonzalez Luis S. , Hassan Erkan , Klem Christian , Kluth‐Land Vanessa L. , Kramer Katherine M. , Swerlein Ala M. , Whipple Julie Ann
Published: June 2004

Objective. To identify and describe the scope of practice that characterizes the critical care pharmacist and critical care pharmacy services. Specifically, the goals were to define the level of clinical practice and specialized skills characterizing the critical care pharmacist as clinician, educator, researcher, and manager; and to recommend fundamental, desirable, and optimal pharmacy services and personnel requirements for the provision of pharmaceutical care to critically ill patients. Hospitals having comprehensive resources as well as those with more limited resources were considered.

Data Sources. Consensus of critical care pharmacists from institutions of various sizes providing critical care services within several types of pharmacy practice models was obtained, including community‐based and academic practice settings. Existing guidelines and literature describing pharmacy practice and drug use processes were reviewed and adapted for the critical care setting.

Conclusions. By combining the strengths and expertise of critical care pharmacy specialists with existing supporting literature, these recommendations define the level of clinical practice and specialized skills that characterize the critical care pharmacist as clinician, educator, researcher, and administrator. This position paper recommends fundamental, desirable, and optimal pharmacy services as well as personnel requirements for the provision of pharmaceutical care to critically ill patients.
Peak Expiratory Flow Rate and Premenstrual Symptoms in Healthy Nonasthmatic Women
Authors: Chong Elaine , Ensom Mary H. H.
Published: June 2004

Study Objectives. To characterize intrasubject, intersubject, and diurnal variability in peak expiratory flow rates (PEFR) of healthy nonasthmatic women over at least one complete menstrual cycle; to determine whether a relationship exists between PEFR and premenstrual symptoms in these women; and to provide a forum to educate women pharmacy students by interactive study participation.

Design. Longitudinal, investigator‐blinded study.

Setting. University of British Columbia and Children's and Women's Health Centre.

Patients. Forty healthy nonasthmatic female pharmacy students were enrolled, and 31 (aged 22.1 ± 1.5 yrs) completed the study.

Intervention. Women were followed for at least one menstrual cycle during which they recorded premenstrual symptom questionnaire scores daily (15 mood and physical symptoms, graded 0–3 in severity). They also measured and recorded PEFR (3 consecutive attempts) every morning and every evening. A feedback survey was later administered by electronic mail.

Measurements and Main Results. Thirty‐one women, 28 of whom were of Asian descent, completed the study. Over half of them (58.1%) showed classic patterns of premenstrual symptoms, whereas PEFR fluctuated randomly over the course of the cycle. Average coefficients of variation (CVs) were 4.17 ± 2.09% for morning PEFR, 3.97 ± 2.25% for evening PEFR, and 3.72 ± 2.55% for mean daily PEFR. Average absolute diurnal variation was 17.13 ± 12.46 L/minute, and relative diurnal variation was 3.98 ± 2.52%. Intersubject variability for morning, evening, and mean daily PEFRs yielded low CVs of 13.7%, 14.3%, and 13.9%, respectively. Only 14 (11.3%) of 124 correlations between PEFR and premenstrual symptoms were significant (p<0.05). Most participants responded positively (mean score 3.87 on a 5‐point scale) to the survey on the impact of this study.

Conclusion. Intrasubject and diurnal variability in PEFR are minimal in nonasthmatic women; similarly, intersubject variability is relatively low. The menstrual cycle appears to have little effect on PEFR in healthy nonasthmatic Asian women. Pharmacy students who take part in serial PEFR monitoring gain new appreciation for asthma and asthmatic patients.
Effect of Antipyretic Therapy on the Duration of Illness in Experimental Influenza A, Shigella sonnei, and Rickettsia rickettsii Infections
Authors: Plaisance Karen I. , Kudaravalli Suneel , Wasserman Steven S. , Levine Myron M. , Mackowiak Philip A.
Published: June 2004

Study Objectives. To determine whether antipyretic therapy prolongs the course of experimental influenza A, Shigella sonnei, and Rickettsia rickettsii infections.

Design. Retrospective observational study.

Setting. University Center for Vaccine Development.

Subjects. Fifty‐four volunteers with experimentally induced influenza A, 45 with S. sonnei, and 21 with R. rickettsii infections participated.

Interventions. Subjects from the six influenza A studies were challenged intranasally. If they met certain criteria, they were offered aspirin or acetaminophen for symptomatic relief. Subjects from the three Shigella studies were challenged with the bacteria and then given trimethoprim‐sulfamethoxazole. Acetaminophen also could be administered. In the one R. rickettsii trial, subjects were inoculated intradermally and treated with tetracycline. Again, acetaminophen was administered for symptomatic relief.

Measurements and Main Results. Data, excerpted from subjects' study records, were evaluated using Wilcoxon tests, Spearman's correlation coefficients, and multiple regression analysis. Two‐tailed hypotheses with a value of 0.05 were used for all of the analyses. There was a striking correlation between antipyretic therapy and duration of illness in subjects infected with influenza A and S. sonnei, but not R. rickettsii.

Conclusions. Multivariate analysis suggested that antipyretic therapy prolonged illness in subjects infected with influenza A, but its use was the result of prolonged illness in those infected with S. sonnei. The precise nature of these relationships requires a prospective, randomized, placebo‐controlled trial.
Tramadol and Seizures: A Surveillance Study in a Managed Care Population
Authors: Gardner Jacqueline S. , Blough David , Drinkard Carol R. , Shatin Deborah , Anderson Gail , Graham David , Alderfer Raymond
Published: June 2004

Study Objective. To investigate the occurrence of tramadol‐associated seizures.

Design. Retrospective cohort and case‐control studies.

Setting. UnitedHealth Group‐affiliated independent practice model health plans, from different regions of the United States, contracting with large networks of physicians.

Intervention. Analysis of administrative data from a large U.S. managed care population.

Patients. A cohort of 9218 adult tramadol users and 37,232 concurrent nonusers.

Measurements and Main Results. Fewer than 1% of users (80) had a presumed incident seizure claim after the first tramadol prescription. Risk of seizure claim was increased 2‐ to 6‐fold among users adjusted for selected comorbidities and concomitant drugs. Risk was highest among those aged 25–54 years, those with more than four tramadol prescriptions, and those with history of alcohol abuse, stroke, or head injury. A case‐control study among users was conducted to validate incident seizure outcomes from medical records. Only eight cases were confirmed, and all had cofactors associated with increased seizure risk.

Conclusion. In a general population, risk of seizure may be associated with long‐term therapy with tramadol or the presence of cofactors, or confined to a small sensitive population subset.