bluuebunny/crossref_metadata_2025 huggingface dataset:
Improving Patient Care and Pharmacy Management: The Effect of Hospital Formularies
Authors: Plumridge Richard J. , Stoelwinder Johannes U. , Berbatis Con G.
Published: May 2016

A study of the organizational features and implementation procedures associated with formulary use in major acute-care hospitals throughout Australia was undertaken. Data were collected via a questionnaire mailed to 57 directors of pharmacy. An 86-percent response was obtained.

A high proportion of formularies was found to rate poorly in terms of organizational features (e.g., content, compilation methods, format) and process variables (e.g., effectiveness as a communication document, prescribing aid, or management tool). Methods of improving formulary effectiveness are outlined in the context of practical and normative research, including improving the quality of drug therapy, use of formularies in cost control, and improving user acceptance.

The results confirm previous research showing that methods of improving organizational features and implementation procedures associated with formulary compilation and use are neither widely applied nor widely known. There is an urgent need to reassess the usefulness of formularies and improve their effectiveness by adopting recommendations resulting from past research.
Clinical Pharmacokinetics of Chlorpheniramine
Authors: Rumore Martha M.
Published: May 2016

The clinical pharmacokinetics of chlorpheniramine are reviewed. Recent studies have established that the half-life of chlorpheniramine is longer than previously reported. Chlorpheniramine has a serum half-life of ∼20 hours in adults, and elimination from the body is primarily by metabolism to monodesmethyl and didesmethyl compounds. The half-life is increased in the presence of renal dysfunction and decreased in children. The exact mechanism of the presystemic first-pass elimination and the effects of dose levels on the process presently are unclear. Biopharmaceutical and pharmacokinetic studies after single or multiple doses in humans reveal wide interindividual variations in pharmacokinetics. Age, dialysis, urinary pH and flow influence the elimination kinetics of chlorpheniramine. Attention is brought to major issues that need further clarification to optimize drug therapy with this antihistamine. The use of pharmacokinetic parameters of chlorpheniramine for clinical application is discussed.
Some Pitfalls in Selecting Descriptive Pharmacokinetic Models
Authors: Vree Tom B. , Hekster Yechiel A. , Oosterbaan Marijn J.M. , Termond Emiel F.S.
Published: May 2016

Some pitfalls in selecting pharmacokinetic models are enumerated. To calculate the pharmacokinetic parameters of a drug that exhibits a biphasic convex plasma concentration-time curve, a two-compartment model does not automatically have to be applied. When only the parent drug in plasma is considered, a two-compartment model seems to be most appropriate. However, when the kinetic behavior of the metabolite has to be taken into account, and when a metabolic equilibrium underlies the metabolic elimination, the two-compartment model may not be appropriate. Also, when calculating the kinetic parameters of a drug with a concave biphasic plasma concentration-time curve, a capacity-limited metabolic conversion is not the automatic explanation for this observation. Limitations in renal excretion and bioavailability may be the reasons for this behavior. Convex and concave biphasic plasma concentration-time curves are illustrated, using sulfonamides as test compounds.
Moxalactam Therapy of Serious; Pediatric Infections
Authors: Reed Michael D. , Aronoff Stephen C. , Blumer Jeffrey L.
Published: May 2016

Forty children with documented or suspected bacterial infections arising outside the central nervous system (CNS) were studied. Fifteen different pathogens for a total of 30 isolates were obtained from multiple sources. Staphylococcus aureus (minimum inhibitory concentrations 4–8 μg/ml) was the most common pathogen isolated, involving seven patients. Each patient received moxalactam 50 mg/kg iv over 15 minutes q8h and responded favorably to therapy, exhibiting bacteriologic and/or clinical cures. Toxicity associated with moxalactam occurred in only two patients and necessitated discontinuation of drug therapy. Moxalactam 50 mg/kg iv q8h is effective therapy for non-CNS infections occurring in infants and children.
Bacterial Contamination of Pressurized Inhalers
Authors: Levesque Katherine A. , Johnson Cary E.
Published: May 2016

The objective of this project was to determine the incidence, location, and potential transmission of bacteria from pressurized inhalers contaminated during normal use by pediatric patients. Patients' inhaler usage and cleaning patterns also were evaluated.

Fifteen inhalers from 12 children were cultured at three separate sites: the mouthpiece, spray portal, and the spray itself. The patient and/or parent were interviewed to determine usage and cleaning patterns.

No bacterial growth was found from any of the cultured sites or aerosol of the control inhalers. All of the mouthpieces and portals of the patient-used inhalers were positive for growth, which is significant (p < 0.01). One patient-used inhaler was positive for bacterial growth from the aerosol, which is not significant (p > 0.05). These results demonstrate that despite inhaler contamination, bacteria are not significantly transmitted by the aerosol. Routine cleaning of inhalers to remove accumulated debris is recommended to prevent disruption of drug delivery.
Counseling the Oncology Patient
Authors: Vall Emily Du , Lash Stephen D.
Published: May 2016

The clinical pharmacist of today has developed a broad knowledge base in the areas of cancer chemotherapy and the associated ancillary therapies. In spite of this expertise, most are ill-prepared for a face-to-face interaction with the cancer patient. Difficult situations may tempt the pharmacist to avoid contact with the cancer patient and confine his talents to areas in which he feels more comfortable. However, the pharmacist is in a unique situation in that he is accessible, informed, and respected by the patient. Pharmacists must assume the responsibility of ensuring that the cancer patient receives the full benefit of this expertise, which can only be accomplished through appropriate communication skills.

This editorial explores some of the techniques and common pitfalls that await the pharmacist in his day-to-day practice.
A Key to the Literature of Total Enteral Nutrition
Authors: Worthen Dennis B. , Lorimer Joan R.
Published: May 2016

Proper nutrition is a prerequisite for good health. Nutritional support of stressed patients hospitalized for surgery, trauma, or medical treatment is a rapidly evolving science. This bibliography provides an access to the literature on enteral nutrition with chemically defined elemental diets.
Tobramycin Blood Levels from an Indwelling Right Atrial Catheter
Authors: Umstead Greg S.
Published: May 2016

Indwelling right atrial catheters provide continuous access to the venous circulation for the purpose of long-term alimentation and blood collection. Two types of central venous systems are the Broviac and Hickman catheters. In general, the Hickman is more versatile, allowing easy blood sample collection, in addition to continuous intravenous fluid and drug administration. Two cases are presented where apparent erroneous tobramycin blood samples were collected through one of these catheter systems. One case compares Hickman tobramycin blood levels with standard peripheral venicollection. Possible ramifications and solutions to the problem are discussed.
The Adult Respiratory Distress Syndrome
Authors: Boucher Bradley A. , Foster Thomas S.
Published: May 2016

The adult respiratory distress syndrome (ARDS) is a common form of acute respiratory failure that has been increasingly reported as associated with a wide variety of medical conditions. Unlike other identifiable pathological events causing severe lung injury, it is now recognized that ARDS is not a single disease, but a complex interaction of pathophysiological events that result in diffuse injury to lung parenchyma.

Only through a thorough understanding of ARDS pathophysiology, pathogenesis, and clinical course can medical intervention be instituted in a judicious and timely manner.

This review article is intended to provide an overview of the suspected precipitating causes, discrete pathophysiologic changes, and monitorable clinical events associated with ARDS.

With mortality from ARDS high, significant attention is being given to improving therapeutic intervention with such conventional measures as mechanical ventilation, positive end-expiratory pressure, and fluid management, along with corticosteroids and several new experimental pharmacologic approaches.
Dipyridamole: A Critical Evaluation
Authors: Rivey Michael P. , Alexander Michael R. , Taylor Jerry W.
Published: May 2016

Dipyridamole is a vasodilator that is used primarily in clinical practice as an antiplatelet agent. It increases coronary blood flow and was originally introduced as an antianginal agent. An ability to prolong a shortened platelet survival has been used to justify its value in preventing thromboembolic complications. Conditions characterized by a reduction in platelet survival and where dipyridamole has been used include heart valve replacement, arterial grafting, cerebrovascular disorders, and disorders of peripheral circulation. The in vivo effect of dipyridamole on platelet aggregation has not been well defined and may depend on additional factors. Prostaglandins appear to have important roles in platelet homeostasis; their relationships to the action of dipyridamole are discussed. Dipyridamole usually is combined with aspirin for synergistic anti-aggregatory purposes. However, the nature of the interaction has not been elucidated and benefit from the addition of dipyridamole has not been demonstrated in clinical studies. A review of clinical studies using dipyridamole indicates that it currently has limited value.
2′Fluoro-5-Iodo-Arabinosyl-Cytosine: A New Agent for Herpes Infections in the Immunosuppressed Patient
Authors: Donner Alvin L. , Leyland-Jones Brian
Published: May 2016

Concurrent with our increased understanding of mechanisms of viral replication, new antiviral agents were developed with greater selectivity and sensitivity. Acyclovir was the first of these. We now present the initial compound of a series of 2′-Fluoro pyrimidine nucleosides with potent antiviral activity. This agent demonstrates both potency and sensitivity in vitro and in vivo against herpes simplex virus types I and II, and varicella zoster virus and is selective in vitro against cytomegalovirus. Initial clinical trials show the drug to be well tolerated and to be more effective than adenine arabinoside against varicella zoster in the immunosuppressed patient. Future developmental plans with the drug are outlined. FIAC (2′-Fluoro-5-iodo-aracytosine) is still at an early stage of clinical development and any comparison with acyclovir is premature; rather, therapy of severe viral infections in the future should consider combinations of such agents that show differential selectivity at multiple sites of action.
Acalculous Cholecystitis and Fever Related to Total Parenteral Nutrition
Authors: Tucker Robert A. , Jenkins Henry L.
Published: May 2016

Over the past several years, clinicians have become aware of the importance of maintaining a positive nitrogen balance in hospitalized patients. This has led to the widespread use of total parenteral nutrition (TPN). However, with increased experience with this form of nutrition, numerous potential complications have been uncovered. One of the complications demonstrated with increased frequency is that of abnormal liver function, manifested by elevated serum liver enzymes. This report describes a 44-year-old woman with rectal abscesses and possible inflammatory bowel disease who developed severe right upper quadrant pain, abnormally elevated liver enzymes, and elevated body temperature during her course of TPN therapy. These problems possibly were related to the TPN regimen. Once TPN therapy was discontinued, the patient's liver enzyme values and elevated body temperature began to return to baseline. She subsequently was discharged from the hospital. A follow-up visit to the physician's office revealed that all liver enzyme values had returned to normal, the pain had resolved, and she was recovering well.
Warfarin Dosage following Prosthetic Valve Replacement: Effect of Smoking History
Authors: Weiner Bruce , Faraci Philip A. , Fayad Rene , Swanson Larry
Published: May 2016

Warfarin currently is the most widely used agent in the prevention of thrombosis and embolism after prosthetic cardiac valve replacement. Since smoking has been shown to increase the requirement for medications undergoing hepatic metabolism, this study was designed to determine if a correlation exists between smoking history and warfarin daily maintenance dose (DMD) in patients undergoing cardiac valve replacement. Of 200 charts retrospectively reviewed at the New England Medical Center, 174 satisfied the criteria for inclusion in the study (normal hepatic, renal, and hematologic function, and absence of complicating medications). The study population included aortic, mitral, and combined valve replacement. Study groups consisted of 117 nonsmokers (Group A), 23 light smokers (Group B), and 34 heavy smokers (Group C). Thirty-three percent of patients required a low DMD of warfarin (≤2.5 mg), 43 percent required a moderate DMD (>2.5–7.5 mg), and 24 percent required a high DMD (>7.5 mg). Each of the subgroups followed a similar pattern. In Group A, there were 31 percent low, 44 percent moderate, and 25 percent high-dose requiring patients. In Group B, there were 48 percent low, 39 percent moderate, and 13 percent high-dose requiring patients and in Group C there were 29.5 percent low, 41 percent moderate, and 29.5 percent high-dose requiring patients.

Chi-square analysis did not demonstrate any statistically significant difference between smokers and nonsmokers in regard to daily maintencance warfarin dose (p = 0.5). The study population followed a normal pattern of distribution in regard to warfarin dosage. On the basis of these data we conclude that smoking history does not affect warfarin dose requirement.
A Utilization Review of Theophylline Assays: Sampling Patterns and use
Authors: Guernsey Brock G. , Ingrim Naomi B. , Hokanson James A. , Fuchs John E. , Prohaska Christine , Doutre' William H. , Bryant Stephen G. , Sigler Katherine A.
Published: May 2016

Use of the theophylline assay was reviewed for two months in 121 hospital inpatients who received 426 evaluations at a university medical center. Clinicians adapted published audit criteria for the collection and use of theophylline assays. The charts of all patients receiving theophylline were examined daily, and the following data, among others, were collected: pulmonary function tests, arterial blood gases, liver function tests, vital signs, and physician assessments. Only 29.8 percent of the evaluations complied with all criteria. When the audit categories of rational indication, correct performance, and appropriate dosage adjustment were evaluated independently, compliance rates were 69.1, 72.3, and 67.2 percent, respectively. In 171 cases (48.6 percent), the physicians' instructions for the assay were inadequate to ensure proper collection time by the phlebotomist. Hospital laboratory charges for unnecessary, incorrectly performed, or inappropriately used theophylline assays were estimated to exceed $77000 annually. This audit demonstrates the need for a collaborative pharmacokinetics service with reimbursement through the physician billing charge.
Clinical Pharmaceutical Services in Retail Practice. I. Pharmacists' Willingness and Abilities to Provide Services
Authors: Zelnio Robert N. , Nelson Arthur A. , Beno Carolyn E.
Published: May 2016

The expansion of service levels in traditional community pharmacies in the face of structural and process impediments as well as the lack of reinforcement that would be provided by demand and reimbursement for such services requires a highly dedicated professional. As a result, this research had the goals of (1) investigating the relationship between service provision and pharmacist willingness and competency, and (2) characterizing pharmacists who presently do or do not provide expanded levels of service. A census of South Carolina community pharmacists was carried out using a self-administered, mail questionnaire. Analysis of the 890 responses representing 63.4 percent of the sample revealed that there is a significant relationship between pharmacists' willingness and ability and the extent to which they provide expanded levels of service. Pharmacists providing services were not only more willing and able to do so, but worked longer hours, tended to work in apothecary or independent pharmacies, held advanced degrees, and were more involved in continuing education. The results generally support the hypothesis that both willingness and competency may serve as barriers to the extension of clinical services into traditional community pharmacy settings.
Prolonged Hypnotic Response to Triazolam-Cimetidine Combination in an Elderly Patient
Authors: Parker William A. , MacLachlan Richard A.
Published: May 2016

An 82-year-old white female developed a 36-hour episode of unresponsiveness/drowsiness after a single dose of triazolam 0.5 mg in combination with cimetidine. This case illustrates the need for careful dose-titration of drug therapy in the elderly, particularly when a drug with the potential to impair drug metabolism is coadministered. Cimetidine, when coadministered with triazolam, may increase the intensity and duration of action of single doses of triazolam.
Inadequacy of FDA Dosing Guidelines for Intravenous Theophylline
Authors: Lopez Larry M. , Russell Wayne L. , Hemmes Robert J. , Ryerson Eugene G.
Published: May 2016

The ability of a dosing regimen of intravenous theophylline to achieve therapeutic serum theophylline concentrations was evaluated. Intravenous theophylline was administered to 25 adult patients with acute bronchospasm using dosing guidelines 20 percent higher than FDA recommendations. The dose of theophylline was determined by assignment to one of four clinical categories. Blood samples for determination of serum theophylline concentrations were collected 12 and 24 hours after initiation of a constant infusion. Differences between mean observed and target theophylline concentrations did not achieve statistical significance. All patients in categories 1 and 2 achieved therapeutic concentrations of theophylline. Most of those with subtherapeutic levels were smokers suffering from multiple diseases. We conclude that current FDA recommendations for dosing intravenous theophylline are unreliable for routine use in category 3 and 4 patients. Further work is necessary to evaluate these recommendations in pediatric and category 1 and 2 patients.
The Intensive Care Unit Syndrome: Causes, Treatment, and Prevention
Authors: Dasta Joseph F. , Weber Robert J. , Oszko Michael A. , Bolender Barbara J. , Grysiak Deborah L.
Published: May 2016

The psychological assessment and management of the critically ill patient is often overlooked as a part of the patient care plan. The intensive care unit (ICU) syndrome is a type of organic brain syndrome manifested by a variety of psychological reactions, including fear, anxiety, depression, hallucinations, and delirium. Causes, treatment modalities, and a multidisciplinary approach to preventing the ICU syndrome are presented.

Causative factors that should be assessed in the psychological evaluation of ICU patients include: (1) preadmission history; (2) past ability to adapt to stress; (3) past and current medications; (4) current clinical status; and (5) environmental factors. The treatment of the ICU syndrome includes: (1) the correction or elimination of causative factors; (2) the appropriate choice, dose, and route of administration of anxiolytic and antipsychotic agents; (3) reduction or elimination of sources of environmental stress; and (4) frequent patient and family communication.

Finally, the prevention of the ICU syndrome through the involvement of physicians, nurses, and pharmacists is stressed.
Combination Antiemetic Therapy in the Control of Chemotherapy-Induced Emesis
Authors: Fortner Clarence L. , Finley Rebecca S. , Grove William R.
Published: May 2016

Severe nausea and vomiting are frequent complications of cancer chemotherapy. Historically, single-agent antiemetic therapy frequently has been less than optimal. Because multiple sites of emetogenic activity may be involved in chemotherapy-induced nausea and vomiting, many investigators are now using combinations of antiemetics in an effort to block multiple receptor sites. Several preliminary studies using combinations of antiemetic agents that have shown encouraging results are summarized.
Guanabenz Therapy for Opiate Withdrawal
Authors: Mulry James T.
Published: May 2016

A 29-year-old man used codeine ∼1000 mg/d for seven years prior to detoxification. He developed dose-related clonidine side effects of dizziness, sedation, and dysphoria during standard clonidine detoxification; however, opiate withdrawal symptoms persisted. Conversion to guanabenz, a clonidine-like α2 agonist, promptly relieved the opiate withdrawal symptoms without side effect recurrence. Guanabenz shows promise as an opiate withdrawal agent.
Psychotropic Drug use by Women: Demographic, Lifestyle, and Personality Correlates
Authors: Marinier Raymonde L. , Pihl Robert O. , Wilford Colleen , Lapp Janet E.
Published: May 2016

From initial telephone interviews with a random population of 1187 francophone women, 179 women participated in a further three-hour person-to-person interview focusing on the use of psychotropic medications. Psychotrope users typically were older, in poorer health, and had a lower level of education than abstainers. They showed an increased prevalence of nervousness, anxiety, depression, and restlessness. Initial contact with psychotrope use was through their general practitioners after presentation of vague and ill-defined symptoms. Psychotropic drug use was found among housewives, especially those with children, and among those unemployed but desiring work. Personality profiles of psychotrope users showed that they think of themselves as failures and are more distressed, with significantly greater life changes. Users scored higher on “femininity” subscales, apparently reflecting dependent and nondefensive personality types. In addition, personality measures defined psychotrope users as precise, methodical, cautious, serious, unassertive, and modest.

The incompleteness of present unidirectional models of psychotropic drug use are discussed. Suggestions for future research include encompassing the cognitive organization of the psychotrope user within the context of social, affective, and physician influences on this form of coping style.
Evaluation of a Digoxin Pharmacokinetic Monitoring Service in a Community Hospital
Authors: Horn John R. , Christensen Dale B. , deBlaquiere Patricia A.
Published: May 2016

This study was done to determine the effects of a pharmacokinetic service (PKS) on digoxin concentration monitoring and patient outcomes, including length of stay and toxicity measures. Two-hundred and eighteen consecutive patients with digoxin concentrations outside a target range were studied using a prospective before and after design. Demographic, diagnostic, and digoxin monitoring data were collected. The after group received PKS intervention by a clinical pharmacist. Results showed that the number of digoxin sample obtained was reduced by 22 percent in the after group and plasma concentrations were less often in the toxic range. The after group had significantly shorter lengths of stay (15.3 vs. 11.6 d) and fewer incidences of in-hospital digoxin toxicity (11.1 vs. 2.2 percent). Clinical pharmacist intervention was found to be associated with significant changes in patient outcomes, including length of stay and morbidity. The cost of the PKS was offset by savings resulting from the reduction in digoxin assays alone.
Amoxicillin-Potassium Clavulanate: A Novel β-Lactamase Inhibitor
Authors: McLeod Donald C. , Smith Bruce R. , LeFrock Jack L.
Published: May 2016

Potassium clavulanate is a novel β-lactamase inhibitor, which, in combination, expands the spectrum of amoxicillin to include many amoxicillin-resistant organisms. Potassium clavulanate is excreted 30–50 percent unchanged renally and its plasma time-course parallels that of amoxicillin. Several studies suggest that an increased incidence of gastrointestinal side effects may occur with this combination. In the current oral formulation, its greatest utility may be in pediatric infections due to β-lactamase-producing Haemophilus influenzae and B. cattarhalis. In adults, the combination has not been adequately studied against other effective antibiotics.
Phenytoin Clearance by Continuous Ambulatory Peritoneal Dialysis
Authors: Hays Dennis P. , Primack William A. , Abroms Israel F.
Published: May 2016

Phenytoin clearance by continuous ambulatory peritoneal dialysis (CAPD) was studied in a three-year, 8-month-old child. This dialysis resulted in a clearance rate < 1 ml/min. This is different from that reported in the literature for regular peritoneal dialysis for phenytoin overdose. Unlike regular peritoneal dialysis, CAPD may not require phenytoin adjustment.
Analgesic Effect of Ceruletide Compared with Pentazocine in Biliary and Renal Colic: A Prospective, Controlled, Double-Blind Study
Authors: Lishner Michael , Lang Ruth , Jutrin Itzhak , De-Paolis Chiara , Ravid Mordchai
Published: May 2016

The analgesic effect of ceruletide in biliary and renal colic was evaluated by a randomized, double-blind study in 82 patients. Ceruletide was compared with pentazocine, a well-established analgetic agent. Rapid and effective analgesia was obtained by intramuscular injection of ceruletide 0.5 μg/kg in 56 patients with biliary colic. The analgesic effect of ceruletide compared well with pentazocine 0.5 mg/kg im, and was associated with remarkably fewer side effects. In 26 patients with renal colic, ceruletide was significantly inferior to pentazocine. These data support the recommendation of ceruletide as a first-choice analgetic agent for biliary colic.
Impact of Clinical Pharmacy Services on Prescribing on a Cardiothoracic/Vascular Surgical Unit
Authors: Herfindal Eric T. , Bernstein Linda R. , Kishi Donald T.
Published: May 2016

A multi-faceted approach was used to study the impact of clinical pharmacy services on the cost of drug therapy on a cardiothoracic and vascular surgical service. Physician and nursing attitudes about the usefulness and likely effect of clinical pharmacist recommendations were also assessed.

A cross-sectional design with a temporal factor was used to study physician prescribing of all pharmacologic classes, and particularly of antibiotics. Measurements were taken for nine months before the institution of clinical pharmacy services, 12 months during a clinical pharmacy service period, and for six months after the cessation of the services.

A trend toward reduction in drug costs per patient day was observed on both services. This was observed for all pharmacologic classes, and when antibiotics were analyzed alone. The difference was significant when antibiotics were specifically analyzed on the vascular surgical service. The pharmacist's log and a survey of physicians' and nurses' attitudes toward clinical pharmacy services supported the above results.
Ceftazidime Review
Authors: Yost Richard L. , Ramphal Reuben , McLeod Donald C.
Published: May 2016

The chemistry, in vitro activity, adverse effects, and clinical indications for the new third-generation cephalosporin, ceftazidime, are reviewed. Ceftazidime appears to have a unique place among the third-generation agents in the treatment of some infectious processes caused by Pseudomonas aeruginosa. It does not demonstrate superiority to other third-generation drugs against Enterobacteriaceae, aerobic gram-positive cocci, or anaerobes. It is eliminated renally and is similar to ceftizoxime, cefoperazone, and moxalactam in half-life. Ceftazidime shares the safety profile of most of the cephalosporins, and has not been shown to have an effect on prothrombin or produce the disulfuram reaction seen with moxalactam and cefoperazone. Specific indications for its use are discussed.
Recurrent Dystonic Reactions Induced by Thiethylperazine
Authors: Khanderia Ujjaini
Published: May 2016

Three attacks of acute dystonia occurred in a 19-year-old male following the initiation and discontinuation of thiethylperazine administered rectally in therapeutic doses. The time course of onset of the attacks and the proposed mechanisms by which dystonia develops are discussed.
Subcutaneous Epinephrine Vs. Nebulized Metaproterenol in Acute Asthma
Authors: Elenbaas Robert M. , Frost Gary L. , Robinson William A. , Collier Robert E. , McNabney W. Kendall , Ryan Joseph L. , Singsank Mark J.
Published: May 2016

The efficacy and side effects of subcutaneous epinephrine (E) and aerosolized metaproterenol (M) were compared in acute asthma. Adults randomly received E 0.3 mg sub-Q q20min (max 0.9 mg; n = 20) or M 15 mg in 3.0 ml NaCl 0.9% nebulized over 10 minutes (n = 20) in a double-blind fashion. Vital signs and peak expiratory flow rate (PEFR) were measured every ten minutes for one hour. The two groups were comparable in age, weight, baseline theophylline concentration, PEFR, heart rate, and systolic and diastolic blood pressure. PEFR improved in both groups within ten minutes (p < 0.01; analysis of variance). There was no difference in PEFR between the groups over the one-hour observation period following treatment. Heart rate decreased following treatment in M patients (p < 0.05), but remained unchanged in E patients. Systolic blood pressure rose slightly in E patients (p < 0.01), but remained unchanged in M patients. Subcutaneous E and nebulized M are equally effective as initial therapy in acute asthma.
Nitroglycerin Adsorption to a Combination Polyvinyl Chloride, Polyethylene Intravenous Administration Set
Authors: Schaber Daniel E. , Uden Donald L. , McCoy Harry G.
Published: May 2016

Loss of nitroglycerin (NTG) from intravenous solutions to intravenous bags and administration sets has been well documented. This study was designed to examine a commercially available low adsorption administration set that was compatible with a volumetric infusion pump. A solution of NTG 100 μg/ml in dextrose 5% in glass bottles was used. Six study administration sets were tested. The infusion sets were connected to the NTG-containing glass bottles, filled as rapidly as possible, placed in the infusion pump, and set at the appropriate rate. Effluent was collected for NTG assay initially, and at 20 and 40 minutes, and 1, 1.5, 2, 3, 6, and 24 hours. The effects of flow rate were studied at 0.2 and 1.0 ml/min.

The tubing performed similarly to other polyvinyl chloride (PVC)-containing sets at 0.2 ml/min and similar to non-PVC sets at 1.0 ml/min. The effect of an initial flush with 20–100 ml of 100 μg/ml NTG was also examined. An initial flush of 20 ml of 100 μg/ml NTG solution was found to enhance delivery of NTG immediately. NTG aliquots were stored frozen in glass vials prior to assay by high performance liquid chromatography.
Cost-Justification of a Clinical Pharmacist-Managed Anticoagulation Clinic
Authors: Gray David R. , Garabedian-Ruffalo Susan M. , Chretien Steven D.
Published: May 2016

A cost-benefit evaluation of a clinical pharmacist-managed anticoagulation clinic (AC) was performed. Outpatient and hospital records were examined for 26 patients in the treatment group with an AC clinic and 26 patients in the control group. Therapeutic prothrombin times were maintained within the treatment group to a significantly greater extent than within the control group (p < 0.001).

The AC was successful in preventing hospitalizations resulting from hemorrhage or thromboembolism (p < 0.01). The abnormal prothrombin times on admission in the control group correlated with hemorrhagic and thromboembolic admissions (p < 0.05, p < 0.005, respectively).

Patients were hospitalized 3.22 days and .048 days per patient-treatment-year in the control and treatment groups, respectively. The net savings in reduced hospitalization costs per year in the treatment group was $211776. The benefit:cost ratio (B:C) was 6.55, suggesting the program is socially valuable.

This clinical pharmacist-managed AC was effective in maintaining therapeutic prothrombin times, and reducing the incidence of hospitalizations resulting from anticoagulation complications, and can be cost-justified based on a cost-benefit analysis.
Review of the Etiology and Treatment of Premenstrual Syndrome
Authors: True Bev Lorraine , Goodner Susan M. , Burns Elizabeth A.
Published: May 2016

Premenstrual syndrome (PMS) is a diagnostic enigma that causes significant morbidity in many woman. Numerous theories have been proposed in an attempt to explain the varied symptoms that occur cyclically in women with PMS.

Suggested etiologic theories of PMS include psychological abnormalities, nutritional deficiencies, aberrations in the renin-angiotensin-aldosterone axis, altered prostaglandin activity, hormonal imbalances, and changes in endogenous opioid peptide activity.

Because of the lack of standardized diagnostic criteria, clinical drug trials for PMS have been severely compromised. For every proposed cause of PMS, there exists a drug or drug class that has been investigated for treatment of the associated symptoms. Many clinical studies are uncontrolled, a significant deficiency in study design for a disorder that is associated with a high placebo response rate. At the present time, no definitive treatment for PMS exists and therapy must be individualized according to clinical response.

This review article defines PMS, describes one of the current approaches to the diagnostic work-up, discusses the proposed etiologies of PMS, and reviews the various proposed treatment modalities.
Severe Withdrawal Syndrome after Substitution of a Short-Acting Benzodiazepine for a Long-Acting Benzodiazepine
Authors: Bond William S. , Berwish Neil J. , Swift Brian
Published: May 2016

A severe withdrawal syndrome occurred in a patient after oxazepam 10 mg bid was substituted for diazepam 5 mg bid. The onset of symptoms was consistent with the rate of decline of diazepam and its active metabolite, desmethyldiazepam. Reintroduction of diazepam produced prompt symptom remission.

This report and others suggest the need for caution when substituting a short-acting drug for a long-acting one, even when usual doses of each are used. The chronic use of benzodiazepines for eight months or longer prior to substitution or withdrawal appears to place the patient at a higher risk of incurring withdrawal phenomena. Slow and careful tapering of drug is required in such patients to reduce the risk of withdrawal symptoms.
Hallucinations after Preoperative Baclofen Discontinuation in Spinal Cord Injury Patients
Authors: Harrison Sandra A. , Wood Charles A.
Published: May 2016

Baclofen is a muscle relaxant approved in this country for the treatment of muscle spasms secondary to multiple sclerosis, spinal cord injury, and other spinal diseases. Although baclofen is considered to have fewer side effects than alternative drugs, problems can occur when the dosage is changed abruptly. Two patients are presented who developed hallucinations after discontinuing baclofen as part of routine preoperative procedures. Both patients responded at 23 and 31 hours after reinstituting baclofen. If possible, patients should be withdrawn slowly from baclofen before surgery. Any patient withdrawn abruptly from baclofen should be restarted as soon as possible.
A Survey of Prophylactic Antibiotic Use for Total Joint Replacements in a Community Hospital
Authors: Armstrong Edward P. , Kopp Daniel L.
Published: May 2016

This study was conducted in a nonteaching community hospital to characterize the use of prophylactic antibiotics in patients undergoing total joint replacements by orthopedic surgeons in private practice. Of the 101 patients studied, 43 were started on antibiotics too early, 32 were left on the drugs for too long a period, and 33 received subsequent oral antibiotics without identifiable reason. Seventy-nine (78.2 percent) received 8 g/d of a first- or second-generation cephalosporin for prophylaxis. None of the patients received cefazolin 1 g q8h.
Evaluation of High-Dose Tobramycin-Carbenicillin Therapy in Pseudomonal Infections in Cystic Fibrosis
Authors: Fraser Gilles L. , Valenti August J. , Grimes Gilbert R. , Corbin Richard P.
Published: May 2016

Fourteen episodes of acute pseudomonal pulmonary exacerbations of cystic fibrosis were treated with high-dose tobramycin (10.1–17.1 mg/kg/d) and carbenicillin (600 mg/kg/d). The Sawchuck-Zaske method of dosing tobramycin was used and resulted in good agreement between the desired and measured peak (8.1 ± 0.5 vs. 8.2 ± 1.5 μg/ml) and trough (0.5 ± 0.2 vs. 1.0 ± 0.4 μg/ml) concentrations. Ninety-three percent of cases improved clinically. Forced expiratory volume in one second and forced vital capacity increased significantly (39.3 ± 24.8, p < 0.001 and 24.1 ± 22.8 percent, p < 0.05, respectively) after treatment. Pseudomonas aeruginosa was eradicated from the sputa of 69 percent of the cases, with recolonization occurring within three months. Significant nephrotoxicity and ototoxicity were not seen. Liver enzymes, however, were elevated in 29 percent of those treated. Combination high-dose carbenicillin and tobramycin satisfies the treatment goals of bacteriological and clinical cure with a minimal degree of toxicity.
Prophylaxis of Stress Ulcers: Antacid Titration vs. Histamine2-Receptor Blockade
Authors: Gonzalez Edgar R. , Morkunas Anthony R.
Published: May 2016

The near universal occurrence of stress ulcers in critically ill patients emphasizes the need for early and effective prophylaxis. Intraluminal gastric acidity, ischemic insult to the bowel, and the presence of stress factors are the major precipitants of stress ulcers. The use of H2-receptor antagonists vs. antacid titration for stress ulcer prophylaxis is reviewed. The goals of preventive therapy are to eliminate the stress factors and to maintain intragastric pH >5. Hourly gastric pH monitoring and antacid titration are the mainstay of stress ulcer prophylaxis, with high potency antacids being the preferred agents. H2-receptor antagonists may serve as adjuncts in patients requiring large doses of antacids or having acid-base abnormalities from high gastric output states.
Terfenadine, a Nonsedating Antihistamine
Authors: Carter Charles A. , Wojciechowski Norbert J. , Hayes J. Michael , Skoutakis Vasilios A. , Rickman Lucy A.
Published: May 2016

Terfenadine is an antihistamine recently approved for use in the U.S. Terfenadine possesses a unique chemical structure when compared with other antihistamines. It is a selective inhibitor of H1-receptors with little or no anticholinergic, antiserotoninergic, or antiadrenergic effects. Comparative studies have shown that terfenadine is as effective as other antihistamines in the treatment of allergic rhinitis and other hypersensitivity conditions. This drug produces a minimal amount of central nervous system (CNS) depression, which is documented by studies demonstrating that terfenadine and its metabolites do not readily pass into the CNS and have little affinity for central H1-receptors. The lack of CNS depression and anticholinergic effects, and the long duration of action that allows twice-a-day dosing make terfenadine an attractive alternative to other antihistamines.
Quinidine-Nifedipine Interaction
Authors: Van Lith Richard M. , Appleby Daryl H.
Published: May 2016

Quinidine pharmacokinetics are known to be altered by a number of drugs. We present a case where dose-related increases in quinidine serum concentrations were significantly suppressed by concurrent nifedipine therapy. Clinicians should be alert to the possibility of an alteration in quinidine serum concentrations when instituting or discontinuing nifedipine in patients receiving quinidine.
Variation in Prophylactic Antibiotic Use in Pediatric Orthopedic Surgery
Authors: Nahata Milap C. , Winters Cora B. , Powell Dwight A.
Published: May 2016

Fifty-two pediatric patients undergoing orthopedic surgery were evaluated to determine the pattern of prophylactic antibiotic use. Of the 50 patients receiving antibiotics, 43 patients were given the antibiotic prior to surgery; 38 patients received the drug within two hours prior to surgery. All patients received the postoperative antibiotic for a duration ranging from 2 to 14 days. Thirty-one patients received the postoperative antibiotic for longer than 48 hours without documentation of infection.

Cephapirin and/or cefazolin were the most common antibiotics used. Due to fixed postoperative doses (0.5–2 g), the dose/kg/d exceeded the maximum recommended therapeutic doses in one-third of the patients. The results of this study illustrate that the use of prophylactic antibiotics in pediatric orthopedic surgery can be improved to maximize benefits and minimize costs and the potential for adverse effects. Until data from controlled studies become available, it seems appropriate to follow the Centers for Disease Control guidelines in establishing hospital policy for surgical prophylaxis.
Estimation of the Steady-State Volume of Distribution for Digoxin: A Comparison of Model-Independent Methods with a Two-Compartment Model in Healthy Volunteers
Authors: De Vito Joseph M. , Crass Richard E. , Blum Robert A. , Pleasants Roy A. , Schentag Jerome J.
Published: May 2016

Digoxin serum concentration vs. time data have been described in the literature by a linear two-compartment model. When calculating the steady-state volume of distribution for digoxin after oral dosing, a computer fitting program is often used because of the complex first-order absorption, two-compartment model employed. Since computer programs are not always available, we computed and compared the steady-state volume of distribution/bioavailability for digoxin using both a model-independent (area) and compartmental approach. Six healthy subjects participated in the study; each received digoxin 0.2 mg in capsule form daily for ten days. The mean steady-state volume of distribution/bioavailability calculated by noncompartmental analysis was 785 L and the mean for compartmental analysis was 784 L. The small difference between methods suggests that area analysis offers a simpler alternative to computerized compartmental fitting to determine this parameter for digoxin.
Pharmaceutical Services at Sint Radboud Hospital
Authors: McLeod Donald C. , Van Der Kleijn Eppo
Published: May 2016

This article describes a contemporary pharmaceutical and clinical pharmacy program at a major university medical center in The Netherlands. The service components described illustrate practice concepts on an international basis. The number of professional personnel and their training vary considerably among the nations, and this requires imagination in adapting practice concepts in various countries.

Several types of technical persons are used to support the professional role of the pharmacist at Sint Radboud Hospital. Pharmaceutical research and international liaison are high priorities in the department of clinical pharmacy. Primary differences at Sint Radboud, as compared with U.S. hospitals, are the use of various supportive personnel and a continuing drug analysis/quality control program for commercial pharmaceuticals.
Individualized Adjustment of Vancomycin Dosage: Comparison with Two Dosage Nomograms
Authors: Rybak Michael J. , Boike Steven C.
Published: May 2016

An individualized method of vancomycin dosage adjustment using steady-state serum concentrations was assessed in 50 patients (86 sets of vancomycin serum concentrations). The predictive accuracy of this method was compared with that of two published nomograms (Moellering, Matzke). Peak and trough serum concentrations predicted from previously drawn vancomycin serum concentrations (individualized method) using a one-compartment pharmacokinetic model were compared with measured steady-state peak and trough serum concentrations. Predicted peak and trough serum concentrations were also generated for both the Moellering and Matzke nomograms by using the elimination rate constant derived from each of the respective nomograms and the fixed volume of distribution (0.9 L/kg) assumed by the nomograms, and the actual administered vancomycin dose and dosage interval. These predicted concentrations were also compared with the measured peak and trough concentrations.

Statistical measures of bias and precision indicated that the individualized method of dosage adjustment more closely predicted vancomycin serum concentrations following a dosage change than did either of the nomograms. Overall, the Moellering nomogram was the least accurate of the three methods in predicting vancomycin serum concentrations, and this nomogram should not be used to titrate vancomycin dosages in a clinical setting. Adjustment of vancomycin dosages should be individualized based on pharmacokinetic data derived from measured serum concentrations. In situations where quantitative analysis of vancomycin concentrations is not available, the Matzke nomogram appears to be a reasonable method of adjusting vancomycin dosages.
Reducing Prophylactic Antibiotic Costs in Cardiovascular Surgery: The Role of the Clinical Pharmacist
Authors: Peterson Charles D. , Lake Kathleen D.
Published: May 2016

A project was undertaken to demonstrate significant drug cost savings from clinical pharmacy services. The method of identifying and documenting the problem and the presentation and implementation of the project are discussed. The cost savings of the project are presented, including the economic impact on the patient and institution. The clinical pharmacist, the key figure in the success of the project, presented a complete pharmacological and financial analysis of the project to the medical staff. The project resulted in a financial savings of ∼$600000/yr to patients in decreased drug charges, $200000/yr in decreased drug purchases/inventory, and $105000/yr to the hospital in an improved revenue/expense statement. This project represents an example of the important role of the clinical pharmacist in helping a hospital identify areas to reduce drug therapy costs. A future role for clinical pharmacists will be to work closely with the director of pharmacy, hospital administration, and medical staff in identifying and implementing cost-effective drug therapy.
Aspirin and Reye's Syndrome: The Change in Prescribing Habits of Health Professionals
Authors: Rahwan Gary L. , Rahwan Ralf G.
Published: May 2016

Epidemiological studies demonstrate the possible increased risk of Reye's syndrome after aspirin ingestion in children suffering from viral influenza or chicken pox.

This study was conducted to determine whether the possible association between aspirin and Reye's syndrome in viral influenza and chicken pox deterred pediatricians and pharmacists in a large American city (Columbus, Ohio) from prescribing or recommending aspirin to their pediatric patients suffering from other causes of fever or pain.

The results indicate that 90.6 percent of pediatricians and 97.8 percent of pharmacists no longer recommend aspirin to their pediatric patients, and an almost identical percentage recommend acetaminophen instead of aspirin.

This change in prescribing habits of health professionals is reflected in a drop in sales of pediatric aspirin products with a simultaneous rise in sales of pediatric acetaminophen products reported by 93.3 percent of pharmacies.

However, only 69.8 percent of pediatricians and 86.7 percent of pharmacists noted that their abstention from prescribing or recommending aspirin to children was rooted in a belief in a possible association between aspirin and Reye's syndrome.