bluuebunny/crossref_metadata_2025 huggingface dataset:
Effect of Filtering Amphotericin B Infusions on the Incidence and Severity of Phlebitis and Selected Adverse Reactions
Authors: Gotz Vincent P. , Rand Kenneth H. , Kramer Barnett S.
Published: May 2016

This study evaluated the effectiveness of filtering amphotericin B (ampho B) on the incidence and severity of drug-related complications. Fifteen males receiving ampho B via peripheral vein infusion participated in this randomized, double-blind study. Each patient had his dose of ampho B diluted in 500 ml of dextrose 5% in water, to which hydrocortisone 25 mg was admixed and infused over four to six hours. Eight patients had their ampho B infusions filtered through a 1 μm filter after preparation, while seven patients did not have their ampho B infusions filtered. Patients were evaluated daily for phlebitis and selected adverse effects. The two groups were comparable with regard to diagnosis, concomitant drugs, cannula type and size, vein selection, and frequency of iv site change. Four patients in each group developed phlebitis. Statistical testing using the Mann-Whitney U test revealed no difference between groups with regard to patient age, dose of ampho B, frequency and severity of phlebitis, time to onset of initial phlebitis, and frequency of adverse effects (fever, chills, headache, nausea, vomiting, and anorexia). Filtration of ampho B infusions using a 1 μm filter does not appear to decrease the incidence or severity of phlebitis and associated adverse effects.
Inservice Teaching and Adverse Drug Reactions in a Nursing Home
Authors: Lamy Peter P. , Jue Sandra G. , Clark Beverly G. , Araki Mark A.
Published: May 2016

A prospective study was carried out in two skilled nursing facilities (SNFs) to determine: (1) the feasibility of identifying potential adverse drug reactions (ADRs) by monitoring drug order changes; (2) the ADR rate in the elderly in SNFs; (3) the ease of using an algorithm to assess the probability that an adverse event is drug-related; and (4) whether a one-hour inservice lecture could alter the number of drug order changes or the number of ADRs detected. Over three months, 27 of 248 order changes (10.8 percent) were identified as possible ADRs. Fifteen of 248 (six percent) of the orders were probable or definite ADRs. The ADR rates were 9.5 percent and 14.8 percent, for the study and control SNFs, respectively (p > 0.05).

This method of detecting ADRs depends on recognition of a clinically observable adverse event by the nurse, nurse practitioner, or physician. Therefore, the hypothesis that an inservice lecture on ADRs could increase the recognition of ADRs was tested. More drug order changes were initiated in the control facility that retained a full-time nurse practitioner, but no change in the number of drug order changes or ADR rates was seen after the inservice lecture in the study facility. This method is the first to identify, prospectively, clinically manifest ADRs and to test a method to influence their rate in nursing home elderly.
Evaluation of Oral Acyclovir Therapy
Authors: Fletcher Courtney , Bean Bonnie , McLeod Donald C.
Published: May 2016

Acyclovir is a specific antiviral agent. The triphosphate form inhibits viral DNA replication by competing for incorporation into the replicating DNA chain or by inhibiting viral DNA polymerase. Cells not infected with herpesvirus are generally unaffected. Oral acyclovir inhibits most herpes simplex virus types 1 and 2, and varicellazoster virus at concentrations used clinically. Oral acyclovir has an average plasma half-life of three hours and is eliminated primarily by renal mechanisms. Peak plasma concentrations occur 1.5 to 2.5 hours after administration and the oral bioavailability is 15 to 30 percent. Acyclovir distributes into most body tissues, including vesicular fluid and the central nervous system. Oral acyclovir is effective treatment of initial and recurrent genital herpes and can suppress frequently recurring genital herpes in both immunocompetent and immunocompromised patients. It is also effective for acute herpes zoster in the immunocompetent and possibly immunocompromised patient. No role is established in either Epstein-Barr virus or cytomegalovirus infections. Oral acyclovir appears to be effective and relatively safe, nontoxic therapy when administered in doses of 1–4 g/d. Oral acyclovir represents a major therapeutic advance in the treatment of herpesvirus infections.
Nitrofurantoin
Authors: D'Arcy P.F.
Published: May 2016

For more than 30 years nitrofurantoin has been a widely prescribed and effective agent in the treatment of urinary tract infections. During this time, it has withstood the rigors of constant clinical evaluation and has competed successfully with more recent antibacterial agents. As with many widely used drugs, some serious and potentially hazardous reactions to therapy have been documented. This article reviews and analyzes major reported reactions and interactions from both published and unpublished sources. Incidence rates have been calculated for pulmonary, hepatic, neurological, and hematological responses. Calculated rates of occurrence were very low, and ranged from 0.001 percent of courses of therapy (all types of pulmonary reactions combined) to 0.0007 percent (neurological reactions).

Reports on interactions of nitrofurantoin with alcohol, antacids, and oral contraceptives are unfounded and anecdotal. Interactions with nalidixic and oxolinic acids are not clinically significant, and only one case of interaction has been reported with phenytoin. Bioavailability is enhanced by food or propantheline. False positives occur with Benedict's test for urine glucose estimations.
A Warfarin-Piroxicam Drug Interaction
Authors: Rhodes Richard S. , Rhodes Pamela J. , Klein Catherine , Sintek Charles D.
Published: May 2016

A piroxicam-warfarin interaction is presented with a discussion of the possible mechanism of action. A 60-year-old white male on warfarin therapy for recurrent pulmonary embolism and deep venous thrombophlebitis showed a decrease in his previously therapeutic and stable prothrombin time when piroxicam was discontinued from his drug regimen. On two rechallenges over a ten-month period, his prothrombin times showed consistent and clinically significant fluctuations as piroxicam was added and deleted from his drug regimen.
Verapamil-Rifampin Interaction
Authors: Barbarash Rick A.
Published: May 2016

A case of verapamil-rifampin interaction is presented in a patient receiving verapamil for supraventricular tachycardia (SVT) and rifampin for pulmonary tuberculosis. The patient experienced recurrent symptomatic SVT, despite receiving verapamil 480 mg po q6h. Serum verapamil concentrations were determined to be extremely low. Discontinuation of rifampin and substitution of ethambutol resulted in an almost four-fold increase in verapamil levels with concurrent control of SVT. Rifampin may have increased the metabolism of verapamil by inducing hepatic microsomal enzymes resulting in low verapamil levels and failure to control SVT.
A Comparative Study of Laboratory Parameters in Head-Injured Patients Receiving Either Phenytoin or Placebo for 24 Months
Authors: Bertch Karen E. , Norton Jane A. , Young A. Byron , Rapp Robert P. , Tibbs Phillip A.
Published: May 2016

The effects of chronic phenytoin therapy on serum calcium, phosphorus, folate, and various hematological indices were assessed. One hundred and fifty-one patients, ages 18 months to 81 years, received phenytoin in a previously-conducted, double-blind, placebo-controlled study. Of the patients receiving phenytoin, initially 127 were evaluable while for control patients receiving placebo, 116 were evaluable. All patients had various laboratory parameters monitored at one day post-loading dose, one week, 1,3,6,9,12,15,18,21, and 24 months. Laboratory values examined were serum calcium, phosphorus, folate, white blood cell count with differential, hemoglobin, hematocrit, and red blood cell and platelet counts.

A statistical analysis using the t-test method was employed to evaluate data. Data are reported as mean values ± standard deviation. Patients suffering early hypersensitivity, manifested by a morbilliform skin rash, were removed from the drug by day 30 and were not included in the chronic therapy review. Results indicate that the various laboratory values examined were not significantly affected by phenytoin administration in the patient population. Therefore, chronic phenytoin therapy following the initial hypersensitivity period does not cause abnormal laboratory values as followed in this study.
Monooctanoin Use for Gallstone Dissolution
Authors: Abate Marie A. , Moore Terri L.
Published: May 2016

Monooctanoin (Capmul 8210), a digestion product of medium chain triglycerides, is a cholesterol solvent that has been used for the dissolution of retained cholesterol gallstones following cholecystectomy. Bile duct infusion of monooctanoin is associated with little toxicity, although potentially serious problems can result from absorption of the drug or tissue infiltration. Gastrointestinal side effects such as anorexia, nausea, vomiting, diarrhea, and abdominal pain have been reported most commonly. Complete gallstone dissolution has occurred in ∼50–75 percent of patients receiving monooctanoin. Although mechanical stone removal is still considered to be the treatment of choice for retained gallstones, monooctanoin use appears promising for stone dissolution in patients in whom mechanical removal has been unsuccessful or is impossible.
Routine Pertussis Immunization
Authors: True Bev Lorraine , Burns Elizabeth A.
Published: May 2016

The benefits and risks of both the vaccine for pertussis and the disease itself are reviewed in this article. Unlike with the smallpox vaccine, it seems unlikely that a vaccine will be developed to eradicate pertussis completely, since most confer only a short-term immunity.

A longitudinal study was undertaken to compare the mortality and morbidity rates of pertussis with the adverse reaction rate of the vaccination program. Risks of the vaccination, such as erythema, drowsiness, and vomiting are well known. However, the issue of neurologic difficulties has surfaced and disagreement exists. Some association does seem to exist between the vaccine and neurologic problems; however, the morbidity and mortality of whooping cough is of a greater health consequence than these rare neurologic reactions.
Early Use of Oral Theophylline in Hospitalized Chronic Obstructive Pulmonary Disease Patients: Cost-Containment through Medical Education
Authors: Self Timothy H. , Ellis Robert F. , Davis Harry L. , Lee Marilyn D.
Published: May 2016

This study measured the impact of an education program conducted by a clinical pharmacist on early conversion from intravenous to oral theophylline in hospitalized chronic obstructive pulmonary disease patients. Two separate two-month audit periods were conducted on the pulmonary medicine service (PMS) of a teaching hospital. During the first audit period (pre-ed), no education was provided. Prior to each month of the second two-month audit period (post-ed), an education program and handout outlining the rationale for early conversion from intravenous to oral theophylline was presented to medicine residents rotating onto the PMS.

The results of this preliminary study suggest that the education program was responsible for a statistically significant decrease in intravenous aminophylline therapy from three days (pre-ed) to one day (post-ed). As a result of the reduction in length of intravenous therapy, both drug costs and patient charges were reduced by a statistically significant amount.
Potential Medication-Related Problems in Noninstitutionalized Elderly
Authors: Shimp Leslie A. , Ascione Frank J. , Glazer Howard M. , Atwood Beverly F.
Published: May 2016

The extent of potential medication-related problems was examined using a thorough review of drug therapy for 53 elderly patients who averaged five chronic illnesses and who used a mean of 11 drugs. An average of 11 specific potential medication-related problems was identified for each patient. These problems fell into three broad categories: Drug toxicity, physician prescribing, and patient medication behaviors. The strongest predictor of the total number of potential problems was the number of prescription medications. The type of drug therapy review used in this study can help health professionals identify and prevent the types of medication-related problems occurring in multiple medication users.
Desensitization with Human (Recombinant Dna) Insulin
Authors: Bodendorfer Thomas W. , Brown Morris E. , Frankel Eric H. , Palay Bernard H. , Fulp Sam R.
Published: May 2016

A 34-year-old woman developed gestational diabetes and was treated with insulin (beef-pork and beef) and oral therapy at various periods. She developed an insulin allergy; however, attempts at desensitization with the commercially available purified pork insulin desensitization kit (Eli Lilly Co.) were not successful. Reactivity to human (recombinant DNA) insulin as well as elevated IgE levels and eosinophilia were also demonstrated. A second desensitization attempt with human (recombinant DNA) insulin using a protocol developed by the authors was successful. This report discusses a desensitization procedure using human insulin in an insulin-allergic patient.
Accelerated Hypertension Associated with the Central Nervous System Toxicity of Metrizamide
Authors: Rodman Michael D. , White William B.
Published: May 2016

A 68-year-old woman with a history of mild hypertension developed a toxic encephalopathy following myelography with metrizamide. Concomitant with the symptoms of vomiting, headache, muscle twitching, and hallucinations was a sudden and marked increase in arterial pressure. Treatment with parenteral vasodilators caused a partial, but transient lowering of the blood pressure. The mental status abnormalities were resolved by treatment with parenteral lorazempam and, subsequently, the blood pressure returned to the premyelography levels. This report demonstrates that metrizamide can induce a severe, accelerated form of hypertension.
Experience with Intrainstitutional Clinical Evaluations of Newly Marketed Preparations as a Basis for Drug-Product Selection to Hospital Formularies
Authors: Green Jeffrey A. , Clementi William A. , Bufton Marilyn G. , Farringer John A. , Moiser Ronald , Durst Nancy L. , Gonzalez Lydia , Lalumiere Ann
Published: May 2016

The decision to admit a new drug-product formulation (NDPF) to a hospital pharmacy formulary is a difficult task, particularly when minimal pharmacokinetic or clinical efficacy data are available. To provide objective information to the Pharmacy and Therapeutics (P&T) Committee, we implemented a procedure to evaluate these NDPFs at our institution.

This procedure, termed clinical evaluation, was initiated at our institution in 1981. The clinical evaluations of two NDPFs were performed. The two NDPFs studied were a transdermal nitroglycerin preparation and a sustained-release procainamide preparation. The clinical assessment of the therapeutic and the pharmacokinetic performance of each preparation was made by clinical pharmacists. Following completion of the clinical evaluation, the data were presented at a regular meeting of the P&T committee. The presentation of clinical data derived from our patient population facilitated objective assessment by the P&T committee regarding formulary status. We conclude that the clinical evaluation represents a novel approach to acquire data necessary for objective decisions on NDPFs by the P&T committee.
Mitoxantrone
Authors: Poirier Therese I.
Published: May 2016

Mitoxantrone is an anthraquinone antineoplastic agent with structural similarities to doxorubicin. It has a mechanism of action similar to the anthracyclines. Its primary elimination route is hepatic metabolism (only seven percent renal excretion) and it has a terminal half-life of −40 hours. Mitoxantrone has significant activity in the treatment of metastatic breast cancer, acute leukemias, and non-Hodgkin's lymphoma. Some activity is reported in head and neck cancer, Hodgkin's, myeloma, bladder cancer, prostate cancer, non-small-cell lung cancer, and liver cancer. There is a suggestion of incomplete cross-resistance between mitoxantrone and the anthracyclines in certain neoplasms. Some activity is reported with mitoxantrone in patients refractory to the anthracyclines in breast cancer, acute leukemias, and non-Hodgkin's lymphomas. The usual doses used in solid tumors and in lymphomas are mitoxantrone 12–14 mg/m2 iv q3–4wk and in leukemias is mitoxantrone 12 mg/m2/d × 5 d iv for initial induction.
Evaluation of the Ames Seralyzer for Therapeutic Drug Monitoring of Theophylline
Authors: Vaughan Leigh M. , Weinberger Miles M. , Milavetz Gary
Published: May 2016

Dry reagent technology and reflectance photometry are combined in the Ames Seralyzer to offer a solid-phase plastic strip assay methodology. Light reflected from serum placed on the antibody-impregnated strip is quantitated with a two-point standard curve to display a theophylline result in 90 seconds. The accuracy and precision of the Seralyzer for serum theophylline are compared to the enzyme-multiplied immunoassay technique (Emit) which is commonly used to determine drug concentrations. Liquid calibrators (5 and 25 μg/ml) and liquid-spiked sera (10, 15, and 20 μg/ml) were measured six times daily simultaneously by both methods for twenty days.

Eighty patient samples (theophylline range: 0–33 μg/ml) were measured twice each during the twenty days. Acceptable assay limits were established and maintained by measuring 15 μg/ml spiked sera prior to and during the evaluation period. All within-run and between-run means for the Seralyzer and Emit were within ± 1 μg/ml of the spiked value. All ranges of within-run and between-run means were within ± 2 μg/ml of the spiked value. Mean between-run coefficients of variation for the Seralyzer at the 5, 10, 15, 20, and 25 μg/ml values were 11.5, 6.7, 4.9, 4.6, and 4.9 percent, respectively. Linear regression on the 80 patient samples gave a slope of 1.02, intercept of −0.28, and correlation of 0.984. The Seralyzer's accuracy and precision compare favorably with Emit for theophylline determinations greater than 7.5 μg/ml.
Moxalactam Myoclonus, Seizures, and Encephalopathy
Authors: Cho Inwha , Bertoni John M. , Hopkins Leigh
Published: May 2016

Severe myoclonus, generalized seizures, and marked stupor occurred in a 39-year-old woman with chronic renal insufficiency after one week of moxalactam 2 g iv q8h. Moxalactam serum levels far exceeded the recommended therapeutic range. The drug half-life was 17 hours (normal 1.9). Excessively high levels of moxalactam, which penetrates the blood-brain-barrier relatively easily, may provoke seizures and encephalopathy.
Behavioral Side Effects of Triazolam in Psychiatric Inpatients: Report of Five Cases
Authors: Soldatos Constantin R. , Sakkas Paul N. , Bergiannaki Joanne D. , Stefanis Costas N.
Published: May 2016

Triazolam was administered to five psychiatric inpatients for a two-week period. This period was preceded by a one-week placebo baseline and followed by another week of placebo administration. All conditions were double blind. By the second week of active drug administration, psychopathology greatly intensified across all of the patients with the emergence of anxiety, memory impairment, confusion, paranoid ideation, and hallucinations. The drug-induced behavioral changes persisted during the initial withdrawal period, but then gradually subsided. Also following drug withdrawal, four patients showed a marked worsening of their sleeplessness for several nights.
Patient-Controlled Analgesia in the Terminally Ill Cancer Patient
Authors: Baumann Terry J. , Batenhorst Randal L. , Graves David A. , Foster Thomas S. , Bennett Richard L.
Published: May 2016

Patient-controlled analgesia (PCA) is a relatively new therapeutic modality which has allowed postsurgical patients to safely and effectively self-administer doses of intravenous narcotics via a syringe pump and sequencing device. A pilot study was designed to evaluate PCA's safety and effectiveness in the terminally ill cancer patient. Eight patients whose chronic pain was not adequately controlled by oral narcotics were permitted to use PCA for a minimum of 48 hours. Respiratory rates, sedation rankings, and pain rankings indicated these patients achieved satisfactory analgesia with a minimum of sedation and experienced no respiratory depression. Three patients were switched to oral regimens using PCA dosing as a guide. Pain and sedation rankings were similar to those registered while exclusively on PCA. This self-dosing technique was judged to be safe, effective, and able to accommodate wide fluctuations in analgesic need when treating pain in the terminally ill cancer patient. The results obtained in these patients support further trials using PCA to individualize oral analgesic regimens.
Alfentanil in Anesthesia and Analgesia
Authors: Reitz Jeffrey A.
Published: May 2016

Alfentanil is a tetrazole derivative of fentanyl. Many of the pharmacologic effects of alfentanil are similar to those of fentanyl and sufentanil, but of quicker onset than those of fentanyl and of shorter duration than those of fentanyl and sufentanil. Alfentanil may cause less intense respiratory depression than equianalgesic doses of fentanyl. Alfentanil has a lower total body clearance, smaller volume of distribution, and shorter half-life than fentanyl and sufentanil.

Clinical trials indicate alfentanil can be used effectively as an analgesic, an analgesic supplement to anesthesia, an anesthetic induction agent, and as the major component of a general anesthetic. Its short duration of effect makes it attractive as an analgesic supplement for short ambulatory surgical procedures. Alfentanil is recommended for addition to drug formularies, but its use should be restricted to anesthesia personnel.
The Hepatic and Renal Mechanisms of Drug Interactions with Cimetidine
Authors: Nazario Mitchell
Published: May 2016

Cimetidine is one of the most frequently prescribed drugs with a known potential to interfere with the metabolic disposition of numerous other medications. Some of these drug interactions may be hazardous to patients. The hepatic and renal mechanisms of drug interactions with cimetidine are discussed in this article. The interactive processes include inhibition of hepatic microsomal enzyme activity, reduction of liver blood flow, and competition for renal tubular secretory sites. The clinical significance and proposed mechanisms of interaction for individual drugs are also presented.
Compatibility of Intravenous Drugs in a Coronary Intensive Care Unit
Authors: Dasta Joseph F. , Zeller Frederick P. , Anders Robert J.
Published: May 2016

In a coronary intensive care unit (CCU) it is often necessary to utilize extensive pharmacologic interventions and multiple intravenous medications in order to stabilize a critically ill patient. However, the necessity of several intravenous infusions often presents the problem of compatibility of these medications when infused within a common line. The pharmacist must possess adequate skill to identify potential incompatibilities by retrieving information on the physical and chemical compatibilities of various intravenous medications. In a critical care setting, time is an important factor, and information that can be obtained rapidly and reliably is vital for the pharmacist to prevent the administration of an irritating substance or a medication that has undergone deterioration as a result of chemical inactivation. A compatibility table containing the most commonly used drugs in a CCU has been developed based on currently available literature, including standard reference texts, about these medications. The table outlines the potential for interactions, within a single intravenous line, when several drugs are infused concurrently. In addition, a review of the concepts of physical and chemical incompatibility is presented. The stability of an admixture is defined utilizing requirements established in the USP NF monographs and manufacturers' specifications. The resulting table concisely organizes vital information in a form that allows rapid, accessible information to the pharmacist in a critical care setting, where it is most needed.
Nifedipine-Induced Hypokalemia
Authors: Tishler Moshe , Armon Shoshana
Published: May 2016

Nifedipine, a calcium-channel blocking agent, has been reported to cause many side effects, particularly in the cardiovascular system. A case of nifedipine-induced hypokalemia is presented, with a discussion on the presumable mechanism involved in this phenomenon.
How Pharmacists are Rated as a Source of Drug Information by Physician Assistants
Authors: Fincham Jack E.
Published: May 2016

A study to examine physician assistants' (PAs) views of drug information sources was undertaken in a sample of practicing PAs in Georgia. Analysis of Kendall's coefficient of concordance statistic indicated Pharm.D.s were ranked highest as being good sources of drug information of the six categories listed. Next in descending order of classification as good sources of drug information were the categories of journal articles, physicians, non-Pharm.D. pharmacists, detail persons, and physician assistants. A significant correlation was found between PA contact with pharmacists and the classification of pharmacists as good sources of drug information. The difference in rating between Pharm.D.s and journal articles and physicians was not significantly different, but the rating differences between these categories and each of the other sources were statistically significant. Pharm.D. pharmacists were rated higher as a source of drug information than were non-Pharm.D. pharmacists.

Results indicate pharmacists are viewed positively as sources of drug information for PAs, and that view increases with contact with pharmacists.
Pharmacist Involvement in Norwegian Clinical Drug Trials: A Questionnaire Study
Authors: Eriksen Inger Lise , Andrew Erik
Published: May 2016

In order to survey the involvement of pharmacists in clinical drug trials (CDTs) in Norway, a questionnaire was submitted to all community pharmacies (288), pharmacy departments in hospitals (98), and pharmaceutical companies (52). The response rate was 81, 73, and 64 percent, respectively. Community pharmacies had minimal involvement, while 34 percent of the pharmacy departments had taken part in one or more CDTs annually 1980–1982. During the same three-year period, 393 trials had been started by the responding companies. Within the pharmaceutical industry 41 percent of the CDT staff were pharmacists. Pharmacists in 48 percent of community pharmacies and 96 percent of pharmacy departments in hospitals considered CDTs a pharmaceutical task. However, none of the community pharmacists and less than half of the hospital pharmacists said they had knowledge of CDT methodology. We recommend that pharmacists should be more extensively engaged in CDTs. Their participation should not be limited to traditional pharmaceutical work, but should include CDT planning and monitoring. This in turn requires education in CDT methodology, which should be included in the compulsary pharmaceutical curriculum.
Cyclosporine Monitoring
Authors: Burckart Gilbert J. , Canafax Daniel M. , Yee Gary C.
Published: May 2016

Cyclosporine is an important immunosuppressive agent in organ and bone marrow transplantation. The pharmacokinetics of cyclosporine are quite complex and are complicated by the availability of two assay systems that yield differing results. This article summarizes the views from two major solid organ transplant centers and one bone marrow transplant center on important cyclosporine monitoring questions. A general consensus exists in the four areas discussed that: (1) cyclosporine concentrations must be monitored due in part to the extreme variability in kinetics, (2) either blood or plasma can be used in monitoring programs, (3) the radioimmunoassay or high pressure liquid chromatography can be used in routine monitoring, and (4) the interpretation of cyclosporine concentrations must be performed in relation to patient variables that affect drug response and toxicity.
The Abdomen
Authors: Longe R. Leon , Calvert Jon C.
Published: May 2016

This article describes the normal anatomy and physiology of the abdomen. Physical examination techniques illustrate the evaluation of the abdominal structures. The text describes physical presentation of selected diseases and discusses their pathophysiology. The text material is applied through a case study.
Drug Utilization Research in Clinical Practice
Authors: Hekster Yechiel A. , Vree Thomas B.
Published: May 2016

This report describes the use of drug utilization studies in clinical practice, with special emphasis on future developments. It has been shown that pharmacy services affect prescribing patterns, have great potential for reducing health care costs, and are in a position to produce financial savings in drug therapy and drug use. However, it is essential to balance the drug utilization figures against the resulting outcome, and attention should be focused on the assessment of therapeutic results. To make therapeutic result assessment possible, end points need to be defined.

Several examples of such end points are given and include incidence of nosocomial infections and postoperative wound infections. New parameters have been established to assess the severity of the illness and to follow the effect of drugs on the disease process in the form of an Index of Disease Activity (IDA). IDAs have been prepared for Crohn's disease, rheumatoid arthritis, and ankylosing spondylitis. It then becomes possible to link drug utilization data with a drug's influence on a disease, making drug utilization research a recognized discipline within the medical field.
The Mackerel was in Fact a Red Herring
Authors: Pan Henry Y. , Glazener Frederic S.
Published: May 2016

A case of misdiagnosis and therapeutic misadventure is presented. The misdiagnosis resulted from the coincidental intake of mackerel and poor history taking. The therapeutic misadventure resulted from treatment with allopurinol and thiazide, which may not have been indicated. Dietary regulations for the treatment of certain biochemical abnormalities may be more desirable than therapeutic interventions. Use of allopurinol for hyperuricemia, if indicated, should be reserved for overproducers and not undersecretors.
Parenteral Benzyl Alcohol-Induced Hypersensitivity Reaction
Authors: Wilson James P. , Solimando Dominic A. , Edwards Michael S.
Published: May 2016

An uncommon hypersensitivity reaction due to parenteral benzyl alcohol administration is reported. One patient treated with benzyl alcohol-preserved cytarabine, vincristine, and heparin solutions developed a systemic hypersensitivity reaction on three separate occasions. Hypersensitivity to benzyl alcohol was confirmed by skin testing. Clinically, the patient presented with a fever and a maculopapular rash on the chest and arms. None of the reactions were life-threatening or required hospitalization of the patient.
Compatibility of Cefazolin and Gentamicin in Peritoneal Dialysis Solutions
Authors: Walker Paul C. , Kaufmann Ralph E. , Massoud Neil
Published: May 2016

The compatibility of cefazolin and gentamicin in fluid commonly used for continuous ambulatory peritoneal dialysis (CAPD) was studied.

Five admixtures containing cefazolin (75 mg/L and 150 mg/L) and gentamicin (8 mg/L), alone and in combination, were prepared in 1.5% dextrose peritoneal dialysis solution. Solutions were stored for 48 hours at 4°C, 26°C, and 37°C; aliquots for drug assay were obained at 0, 4, 8, 24, and 48 hours. HPLC and immunofluorescent assays were used to determine cefazolin and gentamicin concentrations, respectively.

The cefazolin and gentamicin concentration changes over the study period did not reach statistical significance. Maximal cefazolin and gentamicin losses (12 and 7 percent of the initial concentrations, respectively) were observed at 48 hours in solutions stored at 37°C. No significant differences in concentration changes were observed between combination solutions and solutions containing either cefazolin or gentamicin alone.

Cefazolin and gentamicin, alone or in combination, are compatible for at least 48 hours in CAPD solutions.
Evaluation of Premixed Intravenous Theophylline Loading Doses
Authors: Zarowitz Barbara J.M. , Dubey Janice , Popovich John , Pancorbo Salvador
Published: May 2016

We evaluated the use of a standard protocol utilizing premixed theophylline containers in comparison to traditional intravenous aminophylline loading doses in 19 critically ill adults. Blood samples were obtained immediately before and after 30-minute infusions of aminophylline and theophylline bags. Aminophylline loading doses were calculated to the exact mg/kg and were delivered as such. Calculation of the theophylline loading dose used a simplified protocol that uses doses rounded to the nearest 100 mg. Comparison of the relative performance of the two loading dose methods was evaluated by computing mean squared prediction errors and root mean squared errors. The two methods were not statistically different when evaluated by a matched pair t-test. We conclude that use of a standard protocol that rounds theophylline doses to the nearest 100 mg results in peak theophylline concentrations not significantly different from those predicted.
Sudden Death Associated with Switching Monoamine Oxidase Inhibitors
Authors: Bazire Stephen R.
Published: May 2016

A drug-free interval is often recommended when switching monoamine oxidase inhibitors, although the evidence firmly supporting this caution has been minimal. A case is reported where an abrupt change in monoamine oxidase inhibitor was followed by the death of a patient.
Is There Cost Reduction Potential for Extended Half-Life Cephalosporins?
Authors: Scalley Robert D. , Stuart Clifford C.
Published: May 2016

Two new second-generation cephalosporin derivatives with extended half-lives, ceforanide and cefonicid, have recently entered the U.S. marketplace. Because longer dosing intervals require fewer daily doses, potential exists for overall cost reduction if pharmacy and nursing time can be effectively saved. Reduction in personnel costs, however, must be sufficient for these more expensive products to be truly cost effective.

We studied the impact of substituting these newer agents for older, less expensive products with formulary status at our 200-bed community hospital. Results show that no nursing expenses could be recovered, and there is little chance of consistently reducing pharmacy compounding expenses. Within the constraints of these studies, particularly physician prescribing habits, the GRASP (Grace Reynolds Application and Study of PETO) system of determining nurse staffing, and our drug acquisition costs, we find that the newer extended half-life products have very limited usefulness and may only increase the cost of antibiotic utilization.
A Clinical Pharmacy-Oriented Drug Surveillance Network: I. Program Description
Authors: Grasela Thaddeus H. , Schentag Jerome J.
Published: May 2016

The limitations of the new drug development process, particularly in regard to the evaluation of drug safety, have resulted in a need for monitoring drug experience in the postmarketing period. Although a number of systems have evolved to perform postmarketing surveillance, each has important limitations, suggesting the need for an alternative, innovative approach that would permit rapid identification of potential problems and support studies of multiple drugs and/or disease states in patient populations large enough to permit identification of uncommon, but significant adverse drug reactions. This has led to the organization of a nationwide network of clinical pharmacists with an active role in patient-care monitoring to collect information regarding the safety and effectiveness of drugs. At the present time there are 383 clinical pharmacists from all 50 states participating in the network. These individuals collectively monitor more than 150000 inpatient hospital beds, more than 40000 nursing home beds, and more than 800000 ambulatory care visits per year.

Participating clinical pharmacists, using standardized data collection forms, perform concurrent monitoring of drug-therapy outcome in targeted patient populations. Careful analysis and interpretation of this information will yield clinically relevant information regarding the outcome of drug therapy under actual clinical conditions.
Pentoxifylline in End-Stage Renal Disease
Authors: Silver Marcia R. , Kroboth Patricia D.
Published: May 2016

Little information is available about the clearance of pentoxifylline and its metabolites in renal failure. Consequently, when a dialysis patient required this drug, we started at a low dose and gradually increased the dosage while monitoring the patient for signs or symptoms of toxicity and following plasma concentrations of parent drug and its metabolites. Our patient appeared to develop evidence of drug toxicity after about six days on two-thirds of the usual recommended adult dose of the drug. The pentoxifylline half-life and apparent half-life of metabolite I were both substantially prolonged as compared with data from healthy volunteers. Both accumulated rapidly in plasma. Concentrations of metabolites IV and V were also very high.
Lithium Toxicity Presenting as Mania
Authors: El-Mallakh Rif S. , Kantesaria Atul N. , Chaikovsky Leo I.
Published: May 2016

Acute lithium toxicity generally presents with a change in mental status, usually seen as lethargy progressing to coma as poisoning becomes more severe. We discuss three patients who presented with mild lithium toxicity. In two patients the presentation mimicked mania, but the third presented with a more typical toxic confusion state. Improvement in all cases paralleled the drop in serum lithium levels. This uncommon presentation of lithium toxicity is not adequately stressed in the literature.
Concentration Guidelines for Parenteral Antibiotics in Fluid-Restricted Patients
Authors: Robinson Daniel C. , Cookson Thomas L. , Grisafe Joseph A.
Published: May 2016

A guideline for the preparation of peripherally administered antibiotics in fluid-restricted patients was developed. A maximum osmolality of 560 mOsmol/kg was selected since this corresponds to the theoretical osmolality of dextrose 5% in NaCl 0.9%, a solution commonly administered peripherally without significant incidence of phlebitis.

Percentage concentrations corresponding to 560 mOsmol/kg of 26 intravenous antibiotics were calculated using sodium chloride equivalents. The antibiotics were reconstituted using sterile water, dextrose 5%, and NaCl 0.9% to provide an osmolality of 560 mOsmol/kg. The resulting solutions were measured for osmolality using a freezing-point depression osmometer.

A total of 78 solutions were prepared and measured in triplicate. Of the 78 measured osmolalities, 67 (86 percent) were within 20 percent of the desired 560 mOsmol/kg. Only two osmolalities were more than 10 percent above the projected value.

The percentage concentrations of 26 antibiotics in three solutions corresponding to 560 mOsmol/kg are presented. A method is also provided for tailoring concentrations to achieve desired osmolalities other than 560 mOsmol/kg.
Clinical Research in the Elderly: Ethical and Methodological Considerations
Authors: Bell Julie Ann , May Franklin E. , Stewart Ronald B.
Published: May 2016

Clinically oriented research in the elderly is of growing interest because of increasing numbers of older persons, the relative lack of research data with this population, and recent Food and Drug Administration mandates to study drugs in the elderly. Studies of young, healthy persons cannot necessarily be extrapolated to the elderly due to changes associated with aging and the increased number of concomitant disease states and medications. Subject recruitment may be more time consuming in finding subjects with the appropriate inclusion criteria and lack of exclusion criteria who are willing to participate. Additional concern must be placed on protecting the subject's rights while allowing autonomous decision making. Likewise, protocols may need to be flexible enough to include persons with concomitant disease and medications.
Time Course of Gentamicin Serum Concentration Rebound following Hemodialysis
Authors: Catolico Marbel M. , Campbell Suzanne , Jones William N. , Logan Joy L.
Published: May 2016

The rebound in gentamicin serum concentration following hemodialysis was studied in six patients with chronic renal failure. The patients were not infected at the time of the study and received a single dose of gentamicin 2 mg/kg before hemodialysis. Serum samples were obtained immediately after dialysis and at 0.5, 1, 2, and 3 hours following hemodialysis. The average increases in gentamicin serum concentrations were 3.6 percent at 0.5 hour, 12.6 percent at 1 hour, and 6.6 percent at 2 hours. An average decline of 4.2 percent occurred at three hours. Only the increase seen at one hour was significantly different from the gentamicin serum concentration immediately following hemodialysis. This rebound was of small magnitude, though, and may not be clinically significant.
Drug Information Services in Quebec: Determination of Community and Hospital Pharmacists' Needs
Authors: Mailhot Claude , Giacona-Dahl Nicola S.
Published: May 2016

A survey of Quebec pharmacists was conducted to determine drug information resources currently available, obtain information on pharmacists' involvement as drug information providers, and determine their perceived drug information needs.

Responses were obtained from 665 of 3283 registered pharmacists for a response rate of 20.3 percent. Hospital and community pharmacists represented more than 90 percent of the respondents. The two reference texts most frequently found in community pharmacists' libraries were Compendium of Pharmaceutical Specialties and Goodman and Gilman's The Pharmacological Basis of Therapeutics, the latter being available to only 49 percent of the pharmacists. More than 60 percent of the hospital pharmacists had at least 10 of the reference texts listed on our survey instrument.

The majority of pharmacists were actively involved in a variety of clinical pharmacy services. Providing drug information to consumers or health professionals was one of the most common activities. Several pharmacists expressed their needs for drug information center (DIC) support in different drug information categories. Information on drug interactions and adverse drug reactions was rated as an important need by 68 and 59.9 percent of the community pharmacists, respectively. The institution of a regional DIC may provide the support system needed by the pharmacists of Quebec.
Comment: Therapeutic Decision Making
Authors: Billstein Stephan A. , Sudol Thaddeus E. , Polk Ronald E. , Barriere Steven L.
Published: May 2016

Comment: Therapeutic Decision Making
Consumer Preferences for Verbal and Written Medication Information
Authors: Culbertson Vaughn L. , Arthur Thomas G. , Rhodes Pamela J. , Rhodes Richard S.
Published: May 2016

The extent of medication use and drug information preferences was surveyed randomly from patients at six different pharmacy health care systems. Following verbal consultation, each patient was given one or more modified United States Pharmacopeia drug information leaflets corresponding to the verbal information and a self-addressed, stamped questionnaire to complete. Chi-square analysis was performed on 317 responses with overwhelming acceptance (96 percent) of the medication information provided. Although a majority of respondents (62 percent) preferred a combination of both written and oral information, specific information preferences (oral, written, or both) were significantly related to educational level, pharmacy attended, and prescription status. Nearly 45 percent of the respondents indicated the information was responsible for changing their medication use. Subjects who were elderly, taking cardiovascular medications, or getting refill prescriptions were significantly less likely to change as a result of the information provided. Although 65 percent of the respondents were unwilling to pay an additional fee for the service, females and those who were 45–54 years and over 65 years old were significantly more willing to pay for the information. In addition, the willingness to pay tended to increase as the number of daily medications taken increased. Consideration of socioeconomic and prescription variables may help define subgroups with specific information preferences and counseling activities that may be directly reimbursable.
Dyspnea Possibly Associated with Controlled-Release Morphine Sulfate Tablets
Authors: Kerr Harry D.
Published: May 2016

Morphine sulfate in controlled-release tablet form is a relatively new oral preparation being used for the relief of chronic severe pain, such as that related to cancer. A patient with adenocarcinoma of the prostate with bone metastases experienced dyspnea possibly related to the ingestion of these tablets. Discontinuing the drug quickly resulted in disappearance of the dyspnea. The respiratory effects of morphine and the particular risks posed to the elderly patient are discussed.
Sulbactam/Ampicillin, a New Beta-Lactamase Inhibitor/Beta-Lactam Antibiotic Combination
Authors: Benson John M. , Nahata Milap C.
Published: May 2016

Sulbactam/ampicillin is a combination of a beta-lactamase inhibitor with minimal intrinsic antibacterial activity (sulbactam sodium), and an aminopenicillin (ampicillin sodium). The addition of sulbactam to ampicillin has no effect on the chemical stability of ampicillin in aqueous solution, and the administration guidelines of the combination are the same as for ampicillin alone. Sulbactam acts primarily by irreversible inactivation of beta-lactamases from most beta-lactamase-producing organisms. The pharmacokinetics of sulbactam are similar to those of ampicillin with an elimination half-life of about one hour in most patients. One difference is that serum and tissue concentrations of sulbactam are usually twice those of ampicillin, at equivalent doses. The sulbactam/ampicillin combination has been approved for the treatment of adults with intraabdominal, skin and skin structure, and gynecological infections due to beta-lactamase-producing bacteria such as Staphylococcus aureus, Escherichia coli, and species of Klebsiella and Bacteroides. Clinical studies to date have also shown the combination to be effective for the treatment of meningitis, pneumonia, gonorrhea, epiglottitis, urinary tract infections, cervical adenitis, and as prophylaxis for abdominal and gynecological surgeries. Many of these studies, however, have included small numbers of patients and/or had design flaws. Adverse effects have been minor with most being attributed to the ampicillin component. Sulbactam/ampicillin compares favorably with other antibiotic regimens in terms of acquisition costs and ease of administration.
Inter- and Intrasubject Variation of Digoxin Renal Clearance in Normal Adult Males
Authors: Wagner John G.
Published: May 2016

Three methods of estimating inter- and intrasubject variances and coefficients of variation of digoxin renal clearance are discussed and illustrated. All three methods gave essentially the same values for intrasubject variation; two of the methods (II and III), based on two-factor and one-factor analyses of variance, respectively, gave the same estimates of intersubject variation. The preferred method I involves directly calculating variances from the rows and columns of the tabular data, where the rows are repetitive treatments in the same subject and the mean variance represents intrasubject variance; a column represents different subjects' results on a given treatment and the mean of the column variances represents intersubject variance. Problems in attempting to use components of variance are discussed. Intrasubject coefficients of variation of digoxin renal clearance averaged 23.8 percent by method I and ranged from 15.2 to 28.6 percent. Intersubject coefficients of variation averaged 30.5 percent with a range of 17.5–41.8 percent by method I and averaged 42.1 percent with a range of 19.2–49.7 percent by methods II and III.