bluuebunny/crossref_metadata_2025 huggingface dataset:
Quality of the Measurement of the Infrarenal Aortic Diameter by Ultrasound
Authors: Wilmink ABM , Hubbard C S F F , Quick C R G , Wilmink A B M
Published: January 2017

Objectives—

To assess quality and variability in measurements of the infrarenal aortic diameter by ultrasound, and to recommend quality control measures to improve consistency in measurements of the infrarenal aortic diameter (IAD) in a long running screening programme.

Setting—

An aneurysm screening programme in Huntingdon.

Methods—

Quality of the ultrasound image was subjectively assessed by each ultrasonographer. Quality of the measurements was assessed by analysing the frequency of measurements that were outside the normal variability of the estimated true diameter. The interobserver variability was measured by analysing repeated measurements of the IAD in the same patient by two ultrasonographers, using the same scanner. The variability between different scanners was measured by analysing repeat measurements of the IAD in the same patient by the same ultrasonographer, using two scanners. The intraobserver variability was estimated by analysing all patients with three consecutive measurements of the IAD, carried out by the same ultrasonographer.

Results—

Although the subjective assessment of the quality of the ultrasound image of the aorta varied, there were no statistically significant differences in the likelihood of obtaining measurements outside the limits of agreement between the ultrasonographers. The interobserver, intraobserver, and between scanner variability of ultrasound measurements of the IAD were all around 6 mm.

Conclusion—

The variability in ultrasound measurements of aortic diameters is acceptable for clinical decision making, and the interobserver variability is very similar to the long term intraobserver variability. Quality control measures are suggested to maintain long term consistency of ultrasound measurements of the IAD.
Bhojpuri Consolidations in the Hindi Territory: Infrastructure, Aesthetics, and Competing Masculinities in North India
Authors: Kumar Akshaya
Published: January 2017

The soaring emergence of Bhojpuri cinema in 2004 took over the B/C segments of Hindi film distribution in most of north India. The success of the film industry had followed from a vibrant music industry; in a few subsequent years, however, the success of the Bhojpuri film industry turned against itself, on account of the shifting balance between production and exhibition sectors. This paper explores how the Bhojpuri industry negotiated this challenge, particularly with the reconsolidation of the Hindi film industry. I argue that the Bhojpuri stars benefitted most from the enforced reconfigurations as the film-texts became further subservient to stardom and the new aesthetic grammar was organized around the figure of the action-star. Through Jaan Tere Naam (Prasad, 2013)—one among a series of successful films featuring Khesari Lal Yadav—I assess Yadav’s popularity, earned via his performances as a launda (female impersonator). Bhojpuri cinema survives by projecting the male star as its primary text and arranging a plethora of pleasures around his figure, including the bawdy registers that proudly claim the insignia of nativity. The rebellious and native masculinity thus not only anchors the switch between bawdy irreverence and moral exactitude, it also vanquishes the “othered” urban values often resident in the female body.
Book Review: Rosie Thomas, Bombay before Bollywood: Film City Fantasies
Authors: Creekmur Corey K.
Published: January 2017

Rosie Thomas, Bombay before Bollywood: Film City Fantasies. Albany: State University of New York Press, 2015, 346 pp., US$29.95, ISBN 978-1-4384-5676-8
Book Review: Aarti Wani, The Fantasy of Modernity: Romantic Love in Bombay Cinema in the 1950s
Authors: Gopal Sangita
Published: January 2017

Aarti Wani, The Fantasy of Modernity: Romantic Love in Bombay Cinema in the 1950s. Delhi: Cambridge University Press, 2016, US$99.99 (Hardback), ISBN 978-1-107-11721-1.
Globalisation and Trade Policy Reform: Whither the Automobile Components Sector in South Africa?
Authors: Barnes Justin , Kaplinsky Raphael
Published: January 2017

As in the case of many formerly inward oriented economies, South African industry is facing a new competitive environment as trade barriers fall. The initial result of this reform in trade policy has been a sharp increase in the trade deficit in the automobile and components sector. A survey of the major auto assemblers and a comparative review of the automobile sector in Brazil and India suggests that the prognosis for the future of the South African components industry is not good unless corrective action is taken. This will involve responses from a variety of stakeholders. A number of policy responses are discussed identifying both the relevant stakeholders and the policy instruments which might be utilised.
The Role of Transnational Corporations: Theory and Evidence
Authors: Kapler J.K.
Published: January 2017

U.S.-based transnational corporations (TNCs) and single-nation corporations (SNCs) are shown to occupy two distinct competitive regimes in a dual economy. TNCs are located predominantly in the technologically advanced industries, and invest more intensively in research and development, selling effort, and new plant and equipment. Intra-group asset-intensive TNC competition produces-higher and more homogeneous inter-industry rates of return for the group. One source of this result is significantly greater returns to capital strategies (capital and investment intensities) that suggests a greater ability to target investment to highly lucrative industrial sub-sectors.
An Overview of New Zealand Career Development Services
Authors: Furbish Dale
Published: January 2017

Career development services have existed in New Zealand since the early part of the 20th century. In many aspects, the profession has developed in New Zealand parallel to the development of career guidance and counselling in other Western countries but New Zealand also represents a unique context. In acknowledgement of the distinctive characteristics of New Zealand career services, this article will provide an overview by reviewing the history of New Zealand career services, discussing theoretical influences over time, providing the context for career development in New Zealand, examining some of the unique influences on career services and identifying current challenges for the delivery of career services in New Zealand.
Mental health in pregnancy: the sleeping giant
Authors: Buist Anne
Published: January 2017

Objectives:

This paper examines the difficulties of identifying depression in the perinatal period and proposes a way forward through a ‘beyondblue’ funded program, the National Postnatal Depression Program.

Conclusions:

The perinatal period offers an excellent opportunity to identify mental illness and to intervene early to prevent transgenerational problems, particularly given increased links between mental health services, general practitioners and obstetric services. Barriers to doing so include attitudes, anxiety and - most importantly - resource implications, but it is argued that without attempting to address this, identify and remedy the deficiencies, change will not occur. General pactitioners have a crucial role, as do psychiatrists, in supporting them.
Interpersonal psychotherapy for postnatal depression: a quality improvement approach
Authors: Reay Rebecca , Robertson Michael , Owen Cathy
Published: January 2017

Objective:

To outline the processes involved in establishing an integrated perinatal mental health service in a public mental health setting.

Conclusions:

The Australian Capital Territory (ACT) Mental Health Services established a perinatal mental health service based on coordinated, evidence-based treatments. One of the treatment approaches introduced into the service was Interpersonal Psychotherapy, a time-limited, empirically validated therapy for postnatal depression.
Why ĘMOPSę should become ĘCPDę (continuing professional development)
Authors: Lancaster Jeanette
Published: January 2017

Objective:

To consider the principles underlying the Maintenance of Professional Standards (MOPS) program, in light of current developments in continuing medical education (CME).

Conclusions:

MOPS is a quality assurance (QA) project that is now outdated and needs review. Current thinking about how doctors learn suggests that what is needed in its place is an educational program based on continuous quality improvement (CQI) and adult learning principles. Such a program would be practice-based, self-directed, peer-supervised and locally managed. This would provide flexibility in meeting the ongoing educational needs of individual Fellows in a way that the current system does not.
Monitoring of mood stabilizing drugs for bipolar disorder in Australian general practice
Authors: Schrader Geoffrey , Dhillon Rohan , Bastiampillai Tarun , Atrash-Najar Rima Al
Published: January 2017

Objective:

To determine adherence to guidelines by general practitioners for monitoring mood stabilizing drugs in patients with bipolar disorder.

Method:

A postal survey of general practitioners was conducted in a metropolitan division of general practitioners.

Results:

Substantial numbers of general practitioners appear to not be following established guidelines for the monitoring of mood stabilising drugs.

Conclusion:

Greater educational input is required to enable general practitioners to optimise care for patients with chronic psychiatric disorder.
The development and pilot testing of a Focused Education and Psychotherapy Program (FEPP) for treatment of depression in general practice
Authors: Cockram Alexandra , Mccall Louise , Judd Fiona , Piterman Leon , Weissman Myrna , Gronn Peter , Davis Julian , Liaw Teng
Published: January 2017

Background:

Studies demonstrating efficacy of psychological therapies have predominantly been conducted in specialist psychiatric settings. Investigation of the effectiveness of these therapies when provided by general practitioners (GPs) in their specific work setting is lacking and much needed.

Objectives:

To develop and pilot test a new education and treatment program to assist GPs manage patients with a depressive illness. The Focused Education and Psychotherapy Program (FEPP) is intended to provide GPs and patients with a treatment and education program for the management of depressive illness using a psychological intervention within the cost and time constraints of general practice.

Methods:

Following consultation, we developed a draft program. This program incorporates established psychological therapies, Interpersonal Counselling (IPC) and Cognitive Behavioural strategies with patient education in a general practitioner manual and accompanying patient handbook. FEPP was reviewed by focus groups and was pilot tested using a simulated depressed patient who Mailed the program with four GPs.

Results:

Consultation and pilot testing of the program identified important issues for both GPs and their patients. These were incorporated into the final version of the program, which includes a 12-week acute phase of treatment followed by a maintenance program and is based on IPC and cognitive behavioural strategies, and patient and GP education utilising a manualised format.

Conclusions:

A practical and accessible form of psychological treatment for the general practice setting has been developed. Effectiveness of this program now needs to be established.
Follow-up Observations on 24-Hour Pharmacotherapy Services in the Emergency Department
Authors: Berry Nada S. , Folstad Jon E. , Bauman Jerry L. , Leikin Jerrold B.
Published: January 2017

OBJECTIVE:

To analyze the impact of 24-hour clinical pharmacy (CP) services in the emergency department (ED).

DESIGN:

A review of the “on-call report forms” and written consultations provided by CP between July 1985 and December 1987.

SETTING:

The University of Illinois Hospital.

MAIN OUTCOME MEASURES:

Patient-related versus non—patient-related cases; solicitor, type of and time per consultation; drug concentration determinations by CP; and comparison with other ED consultation services.

RESULTS:

Of 3787 consultations 3650 (96 percent) were patient-related, 137 (4 percent) were non—patient-related. Consultations were solicited from another individual in 2774 cases (73 percent); they were initiated by the clinical pharmacists in 831 cases (22 percent). Of the patient-related consultations, 1215 (33.3 percent) involved pulmonary disease, 796 (21.8 percent) toxicology, 635 (17.4 percent) seizures, 411 (11.3 percent) cardiac cases, 268 (7.3 percent) pharmacokinetics, and 325 (8.9 percent) miscellaneous. Consultations were solicited by physicians (1806, 65 percent), nurses (652, 23.5 percent), cardiac arrest page (237, 8.5 percent), patients (45, 2 percent), or pharmacists (34, 1 percent). They averaged 100 minutes each. Of 2197 drug concentrations, 1939 (88 percent) were completed by the clinical pharmacist. Concentrations were obtained for theophylline (1055, 54.4 percent), phenytoin (511, 26.4 percent), phenobarbital (324, 16.7 percent), and acetaminophen (49, 2.5 percent). Compared with other consultation services, CP ranked first in regard to frequency of use.

CONCLUSIONS:

The CP consultation service in the ED was as well used as most physician consultation services and tended to involve specific therapeutic areas that have implications for the training of emergency department clinical pharmacists.
Effect of Cisplatin-Containing Chemotherapy on Lithium Serum Concentrations
Authors: Beijnen Jos H. , Vlasveld L. Thomas , Wanders Jantien , ten Bokkel Huinink Wim W. , Rodenhuis Sjoerd
Published: January 2017

OBJECTIVE:

A case in which a possible cisplatin interference with lithium pharmacokinetics is evaluated.

DATA SYNTHESIS:

A 36–year-old woman with disseminated cervical cancer and multiple metastatic lesions in both kidneys was being treated with five courses of bleomycin, vindesine, mitomycin C, and cisplatin. The patient had also been taking lithium carbonate for the management of a manic-depressive disorder. Serum and urinary lithium concentrations were measured daily during the first course of chemotherapy and on a periodic basis during and between the consecutive courses. Lithium concentrations remained within the therapeutic range during the first course and increased later in association with deterioration of the patient's renal function secondary to progressive disease in both kidneys. This required dose adjustments of lithium.

CONCLUSIONS:

Lithium therapy should be guided by serial serum concentrations in such patients.
Continuous Ambulatory Peritoneal Dialysis: A Review of its Mechanics, Advantages, Complications, and Areas of Controversy
Authors: Bailie George R. , Eisele George
Published: January 2017

OBJECTIVE:

The primary objective of this article is to review the mechanics, advantages, complications, pharmacokinetics, and future trends of continuous ambulatory peritoneal dialysis (CAPD) as they pertain to pharmacotherapy.

DATA SOURCES:

Pertinent articles were obtained from an English-language literature search using MEDLINE (1980–1991), Index Medicus (1987–1990), and bibliographic reviews of review articles. Indexing terms included peritoneal dialysis, pharmacokinetics, peritonitis, vancomycin, and fluoroquinolones.

DATA SYNTHESIS:

All clinical studies comparing organism recovery methods and treatment of peritonitis have methodologic limitations (e.g., comparison of disparate patient groups, different definitions of peritonitis, lack of follow-up, lack of control for sterile cultures) that may affect the reported results.

CONCLUSIONS:

CAPD is an alternative to hemodialysis for the treatment of endstage renal disease and has many complications, leading to significant morbidity. This indicates that CAPD is not appropriate for all patients. Using blood-culturing techniques to culture for dialysate is most productive, but also the most costly. There are few data to indicate exactly the drugs, doses, and durations of choice for peritonitis. Both intraperitoneal and oral administration appear to be appropriate.
Outcomes of Cefazolin versus Ceftriaxone Therapy in Treating Lower Respiratory Tract Infections in Adults
Authors: Thompson David , Huse Daniel M. , Oster Gerry
Published: January 2017

OBJECTIVE:

To determine whether choice of a first- versus third-generation cephalosporin as initial therapy for lower respiratory tract infections in hospitalized adults affects the course and duration of care, both of which may influence antimicrobial treatment cost.

DESIGN:

Retrospective analysis of discharge abstracts and hospital pharmacy records.

SETTING:

Forty-eight US acute-care hospitals.

PATIENTS:

One thousand ninety-two hospitalized adults (aged >17 y) with principal diagnoses of lower respiratory tract infections (DRGs 79–80, 89–90).

INTERVENTIONS:

Cefazolin or ceftriaxone, given as sole antimicrobial therapy for at least one day.

MAIN OUTCOME MEASURES:

(1) The number of patients who received another parenteral antibiotic anytime prior to hospital discharge; (2) the number of days during which patients received any parenteral antibiotic while in the hospital; and (3) the number of days patients remained hospitalized following the start of antibiotic therapy.

RESULTS:

Patients treated with cefazolin (n=763) were more likely to receive another parenteral antibiotic while in the hospital (30.3 vs. 20.7 percent; p<0.001) and received more total days of therapy (7.2 vs. 6.7 d; p<0.05) than those treated with ceftriaxone (n=329). Although the time to hospital discharge did not differ in the full sample (9.2 d for both groups), it was greater among those receiving cefazolin (8.6 vs. 8.0 d; p<0.05) when patients with lengths of stay exceeding 24 days were excluded from both groups.

CONCLUSIONS:

In addition to acquisition cost, differences in course and duration of care should be considered when determining the most cost-effective choice for antimicrobial therapy.
Incidence and Cost of Hospital Admissions Secondary to Drug Interactions Involving Theophylline
Authors: Hamilton Robert A. , Gordon Tammy
Published: January 2017

OBJECTIVE:

To determine the incidence and cost of hospital admissions for theophylline toxicity, which occurred as a result of the concurrent use of one of the following medications: cimetidine, erythromycin, or ciprofloxacin.

DESIGN:

Retrospective chart review (18 months, between June 1989 and November 1990).

SETTING:

A Department of Veterans Affairs Medical Center.

PARTICIPANTS:

All patients who were receiving theophylline chronically (913 patients) and also had a prescription for cimetidine (124 patients with 140 treatment courses), erythromycin (66 patients with 93 treatment courses), or ciprofloxacin (39 patients with 59 treatment courses) dispensed.

INTERVENTIONS:

Each patient's medical record was reviewed to identify hospital admissions within 30 days following the dispensing of the interacting drug.

MAIN OUTCOME MEASURES:

Admissions were considered to be related to theophylline toxicity if appropriate signs and symptoms were present and the theophylline concentration was above 20 μg/mL or had increased significantly from the concentration obtained prior to introduction of the interacting drug.

RESULTS:

One patient who received cimetidine and one who received ciprofloxacin were admitted for theophylline toxicity (2 of 292 potential interactions, 0.81 percent). Admissions were for 16 and 13 days, respectively, and total costs for the two admissions were $12 864.22 or $44.00, respectively, per potential interaction. The entire admission was not for theophylline toxicity; it appeared that iatrogenic factors contributed to the duration.

CONCLUSIONS:

The incidence of hospital admissions secondary to theophylline drug interactions with cimetidine, ciprofloxacin, or erythromycin is low, but the admissions represent considerable expense, even when distributed among all patients at risk for the interactions.
Stevens-Johnson-Type Reaction with Vancomycin Treatment
Authors: Laurencin Cato T. , Horan Richard F. , Senatus Patrick B. , Wheeler Clara B. , Lipson Stephen J.
Published: January 2017

OBJECTIVE:

To report a case of Stevens-Johnson syndrome caused by vancomycin.

CASE SUMMARY:

Stevens-Johnson syndrome is an acute mucocutaneous process characterized by epidermal and mucosal desquamation. Its pathogenesis is poorly understood. Mortality rates have ranged from 30 to 100 percent. We describe a case of Stevens-Johnson syndrome related to the use of vancomycin in a 71-year-old woman with rheumatoid arthritis receiving treatment for an infected cervical fusion site. Classic “target” lesions distributed throughout the trunk and extremities along with erosive lesions involving the oral and vaginal mucosae were observed in this patient.

DISCUSSION:

A number of agents have been implicated in the etiology of Stevens-Johnson syndrome. Serious cutaneous reactions to vancomycin, however, have been uncommon. Cessation of vancomycin treatment in our patient led to eventual resolution of her symptoms.

CONCLUSIONS:

Vancomycin is a potential causative agent of Stevens-Johnson syndrome.
Contamination Study of Multiple-Dose Vials
Authors: Melnyk Paul S. , Shevchuk Yvonne M. , Conly John M. , Richardson C. Jane
Published: January 2017

OBJECTIVE:

To document the number of opened, dated, and expired multiple-dose vials (MDVs) in patient-care areas and to determine what proportion of MDVs were contaminated with bacteria or cellular debris.

DESIGN:

Every tenth opened MDV (69/656) identified on the wards was collected, ensuring representation from each nursing unit. Contents were examined for contamination.

SETTING:

Medical-school-affiliated, tertiary care center.

MAIN OUTCOME MEASURES:

(1) Visual inspection for debris, medication type, location, lot number, manufacturer's expiration date, and date of opening; (2) culture in solid and broth media for bacterial growth; and (3) staining and microscopic examination for cellular constituents.

RESULTS:

No vials had been dated after opening and 4.6 percent were expired according to the manufacturer's expiration date. No bacterial contamination was evident; however, one vial was contaminated with red blood cells.

CONCLUSIONS:

Transmission of infection via contaminated MDVs has been well documented and contamination with red blood cells raises concerns about potential for transmission of bloodborne pathogens. Recommendations include dating MDVs after opening, emphasizing the need for proper aseptic technique, and discarding MDVs on the manufacturer's date of expiration.
Arthropathy Secondary to Ciprofloxacin in an Adult Cystic Fibrosis Patient
Authors: Samuelson Wayne M. , Pleasants Roy A. , Whitaker Martha S.
Published: January 2017

OBJECTIVE:

To report a case of possible ciprofloxacin-induced arthropathy in an adult patient with cystic fibrosis (CF).

CASE SUMMARY:

A 25-year-old man with CF received three separate courses of ciprofloxacin therapy at usual doses for acute pulmonary exacerbations of his disease. During the second and third courses, the patient experienced bilateral swelling of his knees between two to three weeks after initiation of each course. Both times symptoms markedly decreased after discontinuation of the drug. The patient had no prior history of arthropathy. Furthermore, during the last two acute exacerbations of his CF, he did not receive ciprofloxacin and did not experience any symptoms of arthropathy.

DISCUSSION:

Prior cases of quinolone-induced arthropathy involving pediatric CF patients or adult patients without CF have been reported in the literature. We report the first case of such an arthropathy in an adult patient with CF. The findings are supported by a rechallenge with the drug.

CONCLUSIONS:

It is likely that ciprofloxacin may produce arthropathy in adult as well as pediatric patients with CF. Quinolones should be considered as a possible cause of arthropathy in adult CF patients.
Aminoglycoside Dosing Considerations in Intensive Care Unit Patients
Authors: Watling Sharon M. , Dasta Joseph F.
Published: January 2017

OBJECTIVE:

Factors affecting aminoglycoside dosing requirements in critically ill adult patients were reviewed.

DATA SOURCES:

A literature search was performed from 1979 to 1992 and articles pertaining to aminoglycoside dosing were obtained.

STUDY SELECTION:

Only studies appearing in peer-reviewed journals were selected. Topics selected included: Bactericidal kill kinetics, once-daily dosing regimens, critical illness, toxicity, aminoglycosides, intensive care unit, and lung penetration.

CONCLUSIONS:

Studies suggest that larger initial aminoglycoside doses are necessary in critically ill patients (tobramycin/gentamicin 3 mg/kg or amikacin 9 mg/kg) to achieve adequate peak serum concentrations. Current studies have not shown an increase in the incidence of aminoglycoside toxicity when using these larger initial doses. Follow-up monitoring is dependent upon the patient's physiology and risk factors for aminoglycoside-induced toxicity.
Stability of Famotidine in Polyvinyl Chloride Minibags and Polypropylene Syringes and Compatibility of Famotidine with Selected Drugs
Authors: Keyi Xu , Gagnon Nancy , Bisson Chantal , Desmarais Marc , LeBel Marc
Published: January 2017

OBJECTIVE:

(1) To determine the stability of famotidine 200 μg/mL in admixtures with dextrose 5% injection (D5W) and NaCl 0.9% injection (NS) in polyvinyl chloride (PVC) minibags and polypropylene syringes, at room temperature (22 °C), protected and unprotected from light for 15 days; and (2) to evaluate the visual compatibility of famotidine with 34 selected drugs for four hours at room temperature.

DESIGN:

Concentration of famotidine samples was determined on day 0 and again on days 3, 6, 9, 12, and 15 by a stability-indicating HPLC. Inspection for visual and pH changes was also performed at these time intervals.

RESULTS:

More than 95 percent of the day 0 famotidine concentration remained in all samples over the 15-day study period. During this period, all samples remained clear and colorless and no change in absorbance at 450 and 540 nm was observed. The pH of the samples also remained unchanged. Famotidine 2000 μg/mL was found to be compatible with 33 selected drugs; only furosemide was found to be incompatible. A white precipitate was observed when an equal volume of famotidine 2000 μg/mL in NS was mixed with furosemide 3000 μg/mL in D5W. The concentration of famotidine in the supernatant gradually decreased during the 4-hour study period. At 0.5, 1.0, 2.0, and 4.0 hours after mixture of famotidine with furosemide, famotidine concentrations were 97.5, 23.6, 21.7, and 17.2 percent of the initial famotidine concentration, respectively.

CONCLUSIONS:

Our results show that famotidine 200 μg/mL was stable in admixture with D5W and NS in PVC minibags and polypropylene syringes when these solutions were stored at room temperature, protected and unprotected from light for 15 days. Famotidine 2000 μg/mL in NS was compatible with 33 of the drugs, and was incompatible with furosemide.
Fluconazole-Cyclosporine Interaction: A Dose-Dependent Effect?
Authors: López-Gil J. Arturo
Published: January 2017

OBJECTIVE:

To present cases supporting the hypothesis that fluconazole inhibition of cyclosporine metabolism is dose-dependent.

DESIGN:

Case reports.

PATIENTS AND INTERVENTIONS:

One renal-pancreatic transplant patient taking fluconazole 100 and 300 mg/d for 37 and 17 days, respectively; four bone marrow transplant recipients taking fluconazole 100 mg/d as antifungal prophylaxis and five other concurrent nonmatched recipients whose antifungal prophylactic agent is nystatin mouthwash. All of these patients underwent transplantation during the same period.

RESULTS:

There was a sharp rise in cyclosporine trough concentration (ng/mL), concentration: dose ratio (ng·mL−1/mg·kg−1), and serum creatinine concentration (μmol/L) in the renal-pancreatic transplantation patient taking fluconazole 300 mg/d. No such increase occurred at 100 mg/d. No significant alterations in cyclosporine concentration:dose ratio were seen in the patients undergoing bone marrow transplantation and receiving fluconazole 100 mg/d.

CONCLUSIONS:

The case of the renal-pancreatic transplantation patient shows a characteristic interaction profile, and it supports the hypothesis of a dose-dependent interaction between cyclosporine and fluconazole. Given the nephrotoxic potential of the immunosuppressant drug, dosage reduction and closer monitoring of cyclosporine concentrations and/or renal function in patients receiving fluconazole dosages greater than 200 mg/d must be considered.
Surrogate Markers for Assessing Treatment Response in HIV Disease
Authors: Thompson Dennis F. , Raebel Marsha A. , Rathbun R. Chris
Published: January 2017

OBJECTIVE:

To provide an awareness of the issues surrounding the selection and utility of surrogate markers to evaluate treatment response for new antiretroviral therapies for HIV infection.

DATA SOURCES:

A MEDLINE search of applicable articles published between 1987 to the present, including clinical trials, commentaries, and editorials, was performed.

DATA SYNTHESIS:

Surrogate markers are proximal indicators that are predictive of rare or distant outcomes and can be used in clinical trials to decrease sample size and study duration, Characteristics of potential surrogate endpoints include relevance to disease state, face validity, ability to be detected in the majority of patients, and correlation between treatment-induced changes and terminal endpoints. Potential surrogate markers for assessing treatment response in HIV infection can be categorized as either virologic (p24 antigen, plasma viremia, proviral DNA) or immunologic (CD4+ lymphocytes, neopterin, beta2-microglobulin, soluble interleukin-2 receptors, immunoglobulin A [IgA]). The CD4+ lymphocyte count and the p24 antigen have been evaluated in most of the clinical trials examining antiretroviral agents and have the greatest documentation supporting their use. Neopterin and beta2-microglobulin are nonspecific markers, but may improve the predictive value of the CD4+ count when used in combination. Other markers (i.e., soluble interleukin-2 receptors, IgA) remain relatively unstudied at this point.

CONCLUSIONS:

There is no current consensus regarding the selection of surrogate markers for HIV disease. On the basis of the present literature, the CD4+ lymphocyte count has the greatest endorsement; however, combination with several surrogate markers may prove to be useful in clinical trials. Studies are needed to verify the reliability of surrogate markers used alone and in combination to predict therapeutic response from antiretro viral therapy.
Triazolam and Nitrazepam Use in Elderly Outpatients
Authors: Takami Naoko , Okada Akira
Published: January 2017

OBJECTIVE:

To determine adverse reactions and effects on sleep among three groups of patients: those taking triazolam, those taking nitrazepam, and a control group.

DESIGN:

Telephone interviews.

PATIENTS:

Forty-seven patients taking triazolam, 36 taking nitrazepam, and 40 control patients. All study participants were outpatients over 60 years of age.

RESULTS:

The rate of awakening in the middle of sleep was not significantly different among patients taking triazolam (61.7 percent) and those taking nitrazepam (69.4 percent). Incidence of nocturia, the primary reason for awakening, was not significantly different between triazolam- (36.2 percent) and nitrazepam-taking patients (41.7 percent). The rate of having difficulty falling back to sleep was significantly different among triazolam (62.1 percent) and nitrazepam (8 percent), and triazolam and control (11.1 percent) groups (p<0.01). No difference was evident, however, between nitrazepam and control groups.

CONCLUSIONS:

Patients taking nitrazepam have less difficulty returning to sleep compared with those who take triazolam. Thus, for elderly patients who awaken because of nocturia, nitrazepam may be more appropriate therapy.
Phenformin-Induced Lactic Acidosis: A Forgotten Adverse Drug Reaction
Authors: McGuinness Margaret E. , Talbert Robert L.
Published: January 2017

OBJECTIVE:

To document a case of severe metabolic and lactic acidosis secondary to phenformin. This adverse effect has almost been forgotten as 15 years have passed since its withdrawal from the US market.

CASE SUMMARY:

A 64-year-old man presented with a four-day history of left upper abdominal pain and a one-week history of constipation and diarrhea. His arterial blood gases were pH 6.7, pCO2 2.80 kPa, and pO2 12.00 kPa with 90% oxygen saturation on room air. Serum chemistries indicated an unmeasurable serum bicarbonate concentration, anion gap 52 mmol/L, lactate concentration 29.5 mmol/L, blood urea nitrogen 6.63 mmol/L, creatinine 229.84 μmol/L, and blood glucose 4.35 mmol/L. There were low levels of urine and serum ketones. In the emergency department, he required resuscitation for hypotension and bradycardia. His diagnosis was lactic and ketoacidosis secondary to phenformin. The patient was treated with NaCl 0.9%, sodium bicarbonate, insulin, and hemodialysis. Although he survived the initial insult of lactic and ketoacidosis, his hospital course was complicated and he died on hospital day 105.

CONCLUSIONS:

Treatment of lactic acidosis is difficult and challenging. The continued availability of phenformin in neighboring countries, and the renewed interest in biguanide therapy for treating diabetes mellitus make it an important diagnosis of exclusion in diabetic patients who present with severe acidosis. Metformin, another biguanide under investigation for the treatment of diabetes mellitus, is associated with a much lower incidence of lactic acidosis than is phenformin.
Pharmacodynamic Interpretation of Adrenocorticotropin Stimulation Tests
Authors: Milad Mark A. , Jusko William J.
Published: January 2017

OBJECTIVE:

To report a pharmacodynamic model that describes increases in Cortisol concentrations during administration of an adrenocorticotropin (ACTH) infusion, taking into account both steroid secretion and elimination.

DATA SOURCES:

Previously published data.

DATA SYNTHESIS:

Using a population estimate of the elimination rate constant for Cortisol and equations describing changes in Cortisol concentration versus time, a value for the rate of Cortisol secretion (Rcort) was derived. The Rcort value more directly represents the capacity for adrenal secretion of cortisol.

CONCLUSIONS:

Pharmacodynamic modeling techniques were used to successfully describe the rate of cortisol secretion during an ACTH infusion. This model can be applied to assess the extent of adrenal suppression after long-term corticosteroid therapy or in the presence of disease states.
Paclitaxel Stability and Compatibility in Polyolefin Containers
Authors: Chin Alfred , Ramakrishnan Radha R. , Yoshimura Norman N. , Jeong Erwin W.S. , Nii Leslie J. , DiMeglio Lourdes S.
Published: January 2017

OBJECTIVE:

To determine the compatibility and stability of paclitaxel in polyolefin containers.

DESIGN:

The following paclitaxel concentrations were determined by a stability-indicating HPLC method: 0.3 and 1.2 mg/mL diluted in dextrose 5% for injection, USP (D5W) or sodium chloride 0.9% for injection, USP (NS). The solutions were prepared in polyolefin containers and the stability and compatibility were monitored for 48 hours when stored at ambient temperature (20–23 °C)and normal fluorescent lighting. A mixture of the drug carrier consisting of approximately 10% polyoxyethylated castor oil (Cremophor EL) and 10% ethanol in D5W and NS, without paclitaxel, was studied to differentiate the effect of paclitaxel from the effect of the drug carrier on the container. Paclitaxel concentrations, pH changes, and visual clarity were used as stability and compatibility indicators.

RESULTS:

Paclitaxel concentrations remained at 96–99 percent of the initial concentration for up to 48 hours when placed in the polyolefin containers. No changes in color or visual clarity were noted. Only minor changes in the pH of the admixtures were observed.

CONCLUSIONS:

Paclitaxel diluted in D5W or NS at concentrations of 0.3 and 1.2 mg/mL is stable and compatible in flexible, polyolefin containers for up to 48 hours.
Heparin-Induced Thrombotic Thrombocytopenia
Authors: Phillips David E. , Payne D. Keith , Mills Glenn M.
Published: January 2017

OBJECTIVE:

To report a case of heparin-induced thrombotic thrombocytopenia (HITTS) and discuss the incidence, possible mechanisms, complications, and treatment for this syndrome.

DATA SOURCES:

Case reports and review articles identified by MEDLINE from 1980 through 1991. Older articles located by manual searches.

DATA EXTRACTION:

Data were extracted and reviewed from published sources. Cases were selected on the basis of case presentation, time of disease onset, pathophysiology of disease, and therapeutic options.

SETTING:

A 600-bed university teaching hospital and an affiliated community hospital.

PATIENT:

A 36-year-old woman with insulin-dependent diabetes mellitus, sepsis, adult respiratory distress syndrome, diabetic ketoacidosis, oliguric renal failure developed HITTS and subsequent gangrene of her right arm.

INTERVENTION:

Immediate cessation of all heparin use and amputation of the patient's right arm.

RESULTS:

The patient's condition improved progressively over the following 60 days and she was discharged to outpatient care.

CONCLUSIONS:

Heparin has been associated with thrombocytopenia and thrombotic events. Laboratory tests for HITTS are unreliable and the diagnosis is usually suspected by the clinical presentation of the patient. Platelet counts should be monitored closely during heparin use. In the event of a marked decrease in platelet count associated with venous or arterial thrombosis, heparin therapy should be stopped immediately. If further anticoagulation is necessary, oral anticoagulants such as warfarin may be used instead. As the onset of warfarin may take several days to become therapeutic, aspirin, dipyridamole, or both may be used effectively. Healthcare workers should be aware that in these patients, the use of even small amounts of heparin can produce catastrophic results.
Probable Pentamidine-Induced Acute Pancreatitis
Authors: Sauleda Jaume , Gea Joaquim G. , Aguar M Carmen , Aran Xavier , Pastó Meritxell , Broquetas Joan M
Published: January 2017

OBJECTIVE:

To report a case of probable pentamidine-induced acute pancreatitis.

CASE SUMMARY:

A patient was hospitalized because of fever, dyspnea, and productive cough. Chest X-ray revealed diffuse alveolar infiltrates, and the examination of bronchoalveolar lavage demonstrated the presence of Pneumocystis carinii. Intravenous cotrimoxazole was administered but the patient's condition did not improve. As secondary leukopenia appeared, the treatment was changed to pentamidine isethionate 4 mg/kg/d iv. On day 5 of this new therapy, the patient experienced abdominal pain, and both blood and urine amylase concentrations raised to 330 U/L and 3960 U/L, respectively. The patient died 48 hours later, and signs of acute pancreatitis were observed in necropsy.

DISCUSSION:

With reference to a classical method for estimating the probability of adverse drug reactions, a probable relationship between pentamidine therapy and acute pancreatitis was found in this patient. Furthermore, no alternative causes of pancreatitis were present.

CONCLUSIONS:

It is likely that pentamidine administration in our patient resulted in an acute episode of pancreatitis. Serum and urine amylase concentrations should be monitored in patients receiving this drug.
Reassessment of Measuring Total Iron Binding Capacity in Acute Iron Overdose
Authors: Raebel Marsha A.
Published: January 2017

OBJECTIVE:

To evaluate recent data that suggest that total iron binding capacity (TIBC) is not a reliable laboratory parameter in assessing acute iron overdose.

DATA SOURCES:

A MEDLINE search of the literature with a fan search of relevant articles.

STUDY SELECTION AND DATA EXTRACTION:

Laboratory, human, and animal studies on the measurement and relevance of TIBC in acute iron poisoning were reviewed. These data were analyzed in light of the current guidelines for use of TIBC in assessing iron poisoning.

DATA SYNTHESIS:

There are significant data to suggest that the sensitivity of TIBC in acute iron poisoning is unacceptable. This lack of sensitivity is also reflected in the poor positive predictive value of TIBC. The specificity and negative predictive value are higher but not without error. One survey of 500 laboratories reported a coefficient of variation for TIBC of 16 percent (95 percent confidence interval), suggesting unacceptable accuracy.

CONCLUSIONS:

These data suggest that TIBC may not be a reliable laboratory parameter in assessing acute iron poisoning. Studies are needed to develop a reliable analytical procedure for TIBC and to correlate TIBC with clinical outcomes in acute iron poisonings.
Doesciprofloxacin Interact with Cyclosporine?
Authors: Hoey Lori L. , Lake Kathleen D.
Published: January 2017

OBJECTIVE:

To provide the reader with a review of the literature that evaluates whether a pharmacokinetic or pharmacodynamic drug interaction exists between ciprofloxacin and cyclosporine.

DATA SOURCES:

A MEDLINE search was used to identify pertinent review articles, pharmacokinetic studies, and case reports.

STUDY SELECTION:

As both pharmacokinetic trials and case reports were few in number, all available sources were reviewed.

DATA EXTRACTION:

A few case reports were reviewed; however, data were extracted primarily from prospective human studies involving cyclosporine pharmacokinetic profiles.

DATA SYNTHESIS:

Ciprofloxacin has been reported to interact with cyclosporine during concomitant use through an interaction with the cytochrome P-450 system or by additive nephrotoxicity. Because ciprofloxacin may be used to treat a variety of infections in transplant recipients who receive cyclosporine, it is important to determine whether an interaction exists. Although cyclosporine is known to cause nephrotoxicity, only a few reports of ciprofloxacin-induced acute renal failure exist, all involving an immune-mediated interstitial nephritis. Four case reports have suggested a possible pharmacokinetic or pharmacodynamic drug interaction between cyclosporine and ciprofloxacin; however, many pharmacokinetic studies have refuted these reports. Several studies performing cyclosporine pharmacokinetic profiles have documented no increased cyclosporine concentrations, thus supporting the premise that ciprofloxacin does not interact with cyclosporine.

CONCLUSIONS:

Controlled studies involving cyclosporine pharmacokinetic profiles do not support a pharmacokinetic or pharmacodynamic drug interaction between ciprofloxacin and cyclosporine. Although anecdotal case reports have suggested synergistic nephrotoxicity, no clear correlation can be made. Based on our review of the literature, it can be concluded that cyclosporine and ciprofloxacin may be used together safely at the recommended dosages without increased cyclosporine monitoring.
Stability of Ceftazidime and Vancomycin Alone and in Combination in Heparinized and Nonheparinized Peritoneal Dialysis Solution
Authors: Vaughan Leigh M. , Poon Cathy Y.
Published: January 2017

OBJECTIVE:

To examine the stability of ceftazidime, vancomycin, and heparin, alone and in combination, in dialysis solution over six days at three temperatures.

DESIGN:

Nine 250-mL Dianeal PD-2 dextrose 1.5% bags were prepared with ceftazidime, vancomycin, and heparin alone and in combination at set concentrations of 100 μg/mL, 50 μg/mL, and 1 unit/mL, respectively. Three bags of each mixture were stored at 4, 25, and 37°C. Duplicate samples for analysis were removed from each bag at the following time points: premix, 0, 12, 24, 48, 72, 96, 120, and 144 hours.

MAIN OURCOME MEASURES:

Each sample was examined visually for signs of cloudiness and precipitation. Each sample was analyzed by stability-indicating HPLC assay for ceftazidime and vancomycin, with stability defined as less than 10 percent degradation of drug overtime.

RESULTS:

No color change or precipitation was observed in any bag. Vancomycin with or without heparin was stable for 5–6 days at 4, 25, and 37°C. Ceftazidime with and without heparin was stable for 6 days at 4°C, 4 days at 25°C, and less than 12 hours at 37 °C. Vancomycin plus ceftazidime with and without heparin was stable for 6 days at 4 °C and 25°C, and 4–5 days at 37 °C, Ceftazidime plus vancomycin with or without heparin was stable for 6 days at 4°C, 2–3 days at 25°C, and 12 hours at 37 °C.

CONCLUSIONS:

Bulk preparations of ceftazidime and vancomycin, alone and in combination and with or without heparin in Dianeal PD dextrose 1.5% solution, are sufficiently stable for use up to 6 days under refrigeration or 48 hours at room temperature.
Possible Red-Man Syndrome Associated with Systemic Absorption of Oral Vancomycin in a Child with Normal Renal Function
Authors: Bergeron Luc , Boucher François D.
Published: January 2017

OBJECTIVE:

To report possible red-man syndrome (RMS) associated with oral administration of vancomycin.

CASE SUMMARY:

A 23-month-old child with acute myeloblastic leukemia developed symptoms compatible with RMS while receiving oral vancomycin for suspected Clostridium difficile colitis. Serum concentrations of vancomycin, measured at the time of the clinical episode, demonstrated significant oral absorption of the drug. Serum concentrations of vancomycin decreased later, implying a possible decrease in absorption, after the patient's neutrophil count returned to normal. The child later experienced another clinical episode compatible with RMS while vancomycin was being administered intravenously for suspected sepsis.

DISCUSSION:

There is no published report of RMS following oral administration of vancomycin. The reaction described took place while the child was neutropenic. Because of the absence of any significant renal function alteration that could explain the importance of the serum concentrations observed, we assume that C. difficile, neutropenia-, and chemotherapy-associated colitis may have resulted in extensive intestinal lesions, leading to an increased amount of vancomycin being systemically absorbed. This increased absorption during profound neutropenia may have been sufficient to exceed a purported threshold, leading to RMS.

CONCLUSIONS:

This case demonstrates that significant absorption of vancomycin may occur in neutropenic patients with normal renal function, and that it may be accompanied by RMS, usually associated with rapid infusions or large parenteral doses of the drug.
Acyclovir Excretion in Human Breast Milk
Authors: Taddio Anna , Klein Julia , Koren Gideon
Published: January 2017

OBJECTIVE:

To measure acyclovir concentrations in the breast milk of a lactating woman using the drug for herpes zoster while nursing her 7-month-old infant.

METHODS:

The maternal dosage of acyclovir was 800 mg five times daily for seven days. Three random breast milk samples collected on the fifth and sixth days of therapy were analyzed for acyclovir concentrations with radioimmunoassay (RIA).

RESULTS:

Acyclovir concentrations in breast milk ranged from 18.5 μmol (4.16 μg/mL) to 25.8 μmol (5.81 μg/mL). An estimate of the infant's dosage ingested through nursing was 0.73 mg/kg/d, or approximately 1 percent of the maternal dose in milligrams/kilograms/day. The baby was nursed without any signs of adverse effects.

CONCLUSIONS:

Acyclovir was measured in clinically insignificant concentrations in the milk of a woman receiving large dosages for herpes zoster. Breast feeding continued without adverse effects to the nursing infant.