bluuebunny/crossref_metadata_2025 huggingface dataset:
Value of Community Pharmacists' Interventions to Correct Prescribing Errors
Authors: Rupp Michael T.
Published: January 2017

OBJECTIVE:

The purpose of this analysis was to estimate the economic value created by community pharmacists who routinely screen for and correct prescribing-related problems during the course of their dispensing activities.

DESIGN:

Three expert judges evaluated the documented interventions of community pharmacists practicing in five states.

RESULTS:

The judges agreed that 28.3 percent of the identified problems could have resulted in patient harm had the pharmacist not intervened to correct the problem. The direct cost of medical care that was avoided as a result of pharmacists' intervention activities was estimated to be $122.98 per problematic prescription, or $2.32 per each new prescription order that was screened during the study.

CONCLUSIONS:

Clinical pharmacy services can and do create significant value by enhancing the achievement of positive patient outcomes and by avoiding negative outcomes. Research to develop reliable methods for measuring and monitoring the value of clinical pharmacy services must continue. Mechanisms must be created to encourage and reward pharmacists who consistently provide services that add measurable value to patient care.
Pain Management with Intravenous Ketorolac
Authors: Miller Lisa J. , Kramer Mark A.
Published: January 2017

OBJECTIVE:

To report a case in which intravenous ketorolac was used successfully on a chronic basis to treat cancer pain.

DATA SOURCES:

Clinical and compatibility studies obtained through a computer literature search.

STUDY SELECTION:

We identified five reports that specifically addressed intravenous dosing of ketorolac.

DATA SYNTHESIS:

A 41-year-old man received pain relief from intravenous injections of ketorolac for 11 months. As far as we know, there are no other reports in the literature in which intravenous ketorolac has been used on a chronic basis.

CONCLUSIONS:

Experience at our institution indicates that intravenous ketorolac is a useful, well-tolerated nonsteroidal antiinflammatory drug that should be investigated further for use in selected pain models.
Ciprofloxacin-Resistant Haemophilus Influenzae Infection in a Patient with Chronic Lung Disease
Authors: Barriere Steven L. , Hindler Janet A.
Published: January 2017

OBJECTIVE:

To report a case of ciprofloxacin-resistant Haemophilus influenzae infection in a patient with chronic lung disease who was exposed to multiple courses of antimicrobial therapy.

CASE SUMMARY:

The patient suffered recurrent pulmonary infections and developed bronchiectasis as a consequence of longstanding, severe, combined immunodeficiency disease. He had received ciprofloxacin on several occasions for treatment and prophylaxis of recurrent pulmonary infections. On a recent admission his usual H. influenzae isolate, which had been highly susceptible to ciprofloxacin (minimum inhibitory concentration [MIC] ≤0.06 mg/L) on previous admissions, was resistant to ciprofloxacin and ofloxacin (MIC 8 and 16 mg/L, respectively). The patient responded to treatment with ceftizoxime and was discharged with oral cefixime, which was to be taken for a total of two weeks.

DISCUSSION:

Rare isolates of H. influenzae resistant to ofloxacin and lomefloxacin have been noted in Europe and Asia; however, none resistant to the fluoroquinolones have been previously reported in the US, and no resistance has been reported to ciprofloxacin. We believe that repetitive, cycling exposure to ciprofloxacin may have induced the resistance that developed in this patient's flora.

CONCLUSIONS:

Fluoroquinolones may be added to the list of drugs to which H. influenzae have become resistant. Only judicious use of these drugs will preserve their activity against important pathogens in community-acquired infections.
Pharmacotherapy of Sexual Offenders
Authors: Richer Monique , Crismon M. Lynn
Published: January 2017

OBJECTIVE:

To review the definition, sociology, pathogenesis, diagnosis, medicolegal aspects, and pharmacologic treatment of sexual offenders, with emphasis on the antiandrogens, the luteinizing hormone-releasing hormone (LHRH) antagonists, and the serotonergics.

DATA SOURCES:

An English-language literature search using MEDLINE (1966–1991) yielded clinical trials, case reports, editorials, and review articles.

STUDY SELECTION:

Emphasis was placed on comparative trials and case reports discussing pedophilia, rape, and exhibitionism.

DATA EXTRACTION:

Data from controlled human studies were evaluated. The trials were assessed for sample size, duration of therapy, therapeutic response, and incidence of recidivism.

CONCLUSIONS:

The pharmacologic management of sexual offenders is controversial, and treatment is presently focused on psychotherapy and the use of antiandrogenic medications. Few well-controlled, blinded, efficacy trials with adequate sample sizes have been conducted. The populations studied are heterogeneous, and the subjects enrolled present with different sexually coercive behaviors. Consequently, the results of these studies are difficult to extrapolate to the treatment of other sexual offenders. No convincing evidence exists that pharmacologic treatment decreases the recidivism rate. Case reports describing the use of serotonergic drugs and LHRH antagonists hopefully will promote controlled clinical trials. A social consensus must be reached concerning the ethics of using these agents as a part of the treatment of sexual offenders.
Selection of Activated Charcoal Products for the Treatment of Poisonings
Authors: McFarland Arthur Karl , Chyka Peter A.
Published: January 2017

OBJECTIVE:

To determine if differences exist among currently available activated charcoal products, and if an evaluation of risk versus benefit provides a guide to product selection.

DESIGN:

National survey by mail.

PARTICIPANTS:

US manufacturers of activated charcoal products.

RESULTS:

Six companies market activated charcoal products in ready-to-use containers. The products differ in surface area of charcoal, sorbitol content, and packaging (aqueous or powdered form). No significant differences were noted in the cost of 25- to 30-g units or efficacy based on surface area of activated charcoal. The addition of sorbitol to activated charcoal, particularly at high concentrations, increases the incidence of adverse effects, especially in children.

CONCLUSIONS:

Although differences do exist among currently marketed activated charcoal products, the clinical significance of these variations is unknown. Based on an evaluation of risks and benefits, any activated charcoal product that does not contain sorbitol appears to be a suitable choice for treating poisoning victims.
Single-Dose Effect of Enteric-Coated Aspirin on Platelet Function and Thromboxane Generation in Middle-Aged Men
Authors: Mohri Hiroshi , Ohkubo Takao
Published: January 2017

OBJECTIVE:

To evaluate the effect of a single dose of enteric-coated aspirin (ECA) in three different dosages on platelet function and thromboxane generation in middle-aged men.

DESIGN AND METHODS:

In a nonblind, nonplacebo-controlled, crossover study, a single dose of ECA (50, 250, or 1000 mg) was given in a tablet form to a group of healthy, middle-aged men. Ten subjects, aged 50–67 years, volunteered to participate in this study. Platelet functions including bleeding time, platelet aggregation, adenine nucleotides, beta-thromboglobulin, platelet factor 4, thromboxane generation, and aspirin measurement were determined.

RESULTS:

Before ECA ingestion, the intracellular adenine nucleotides (adenosine triphosphate, adenosine diphosphate) were decreased, and both beta-thromboglobulin and platelet factor 4 were increased. These observations suggested that platelets were activated in vivo in middle-aged men. These findings returned to normal within 8 hours after the ingestion of ECA, and maintained normal for at least two days. Bleeding time was significantly prolonged at 8 and 24 hours compared with that before ingestion of ECA 1000 mg (p<0.05). The generation of platelet thromboxane was maximally inhibited by approximately 40 percent in the samples 8 hours after ECA ingestion. Abnormal values of adenine nucleotides, beta-thromboglobulin, and platelet factor 4 returned to normal within 8 hours. Arachidonic acid-induced platelet aggregation was inhibited compared with that before treatment (p<0.01) and the inhibitory effect was maintained for at least three days. Adenosine diphosphate- and epinephrine-induced aggregations were less inhibited than those induced by arachidonic acid. Inhibitory effects of ECA on platelet aggregation were dose dependent.

CONCLUSIONS:

Our study indicates that platelets are activated in middle-aged men and that a single dose of ECA 50 mg is safe and can inhibit thromboxane synthesis and platelet aggregation. These results suggest that a daily dose of ECA 50 mg may be useful for blocking platelet activation and preventing thrombosis.
Subcutaneous Absorption Kinetics of Two Highly Concentrated Preparations of Recombinant Human Growth Hormone
Authors: Laursen Torben , Jørgensen Jens O.L. , Susgaard Søren , Møller Jens , Christiansen Jens S.
Published: January 2017

OBJECTIVE:

The relative bioavailability of two highly concentrated (12 IU/mL) formulations of biosynthetic human growth hormone (GH) administered subcutaneously was compared.

DESIGN:

A randomized, crossover study. Conventional GH therapy was withdrawn 72 hours before each study period. There was a washout period of at least four weeks between the study periods.

SETTING:

Participants were recruited from an outpatient clinic and were hospitalized during the two study periods.

PATIENTS:

Fourteen GH-deficient patients (mean age 25.2 y, range 14–54). One patient was excluded from data analysis because of signs of endogenous GH secretion. INTERVENTIONS: At the start of each study period, GH 3 IU/m2 was injected subcutaneously. The two formulations, PenFill and PenSet, differ in the buffers used and in the relative content of mannitol and glycine. Serum profiles of GH were monitored frequently for 24 hours. Samples were taken every 30 minutes for 6 hours and then hourly.

MAIN OUTCOME MEASURES:

Bioavailability (F) and absorption dynamics of human GH were measured. The relative absorption fractions estimated from the areas under the individual serum concentration curves from 0 to 24 hours, and the observed time (Tmax) to reach the maximum concentration (Cmax) were determined. Short-term metabolic effects of GH on insulin-like growth factor (IGF-I), glucose, and insulin were determined.

RESULTS:

The geometric mean (SD) of F was 0.910 (1.236). The 90 percent confidence interval was 0.819–1.010. Mean (± SD) of Cmax was 12.65 ± 5.89 and 12.58 ± 4.40 ng/mL for PenFill and PenSet, respectively. Corresponding values for Tmax were 5.49 ± 1.55 and 5.89 ± 1.79 hours for PenFill and PenSet, respectively. There was a considerable interindividual variation, but the relative absorption fraction did not significantly differ from 1 (p=0.13). Neither Cmax (p=0.74) nor Tmax (p=0.58) of the two formulations was significantly different. Injection of the two formulations induced similar increments in serum IFG-I (p=0.48). Serum insulin and blood glucose concentrations were not significantly different.

CONCLUSIONS:

There is no significant difference between the absorption kinetics and short-term metabolic effects of these two highly concentrated formulations of biosynthetic GH. The two formulations are bioequivalent.
Prevalence and Descriptors of Aspirin Use as an Antiplatelet Agent in Two New England Communities
Authors: Hume Anne L. , Barbour Marilyn M. , Lapane Kate L. , Assaf Annlouise R. , Carleton Richard A.
Published: January 2017

OBJECTIVE:

To determine the overall prevalence of aspirin use as an antiplatelet agent in a population-based sample of respondents between the ages of 18 and 64 years, and to describe their sociodemographic characteristics.

DESIGN:

Data were derived from five biennial cross-sectional household surveys conducted between 1981 and 1990 in two southeastern New England communities by the Pawtucket Heart Health Program. Individuals reporting aspirin use as an antiplatelet agent were identified using data from a structured medication interview.

RESULTS:

The prevalence of aspirin use per 1000 population was 2.5 (95 percent confidence interval [CI] 0.5,4.4), 5.0 (95 percent CI 2.4, 7.6), 7.8 (95 percent CI 4.6, 11.0), 7.5 (95 percent CI 4.3, 10.6), and 11.8 (95 percent CI 7.1, 16.5) in the first through the fifth survey periods, respectively (p=0.0002). The prevalence of aspirin use per 1000 men increased from 4.9 (95 percent CI 0.6, 9.1), 8.7 (95 percent CI 3.3, 14.1), 12.3 (95 percent CI 6.1, 18.5), 8.5 (95 percent CI 3.5, 13.5) to 23.2 (95 percent CI 13.4, 32.9) for the first through the fifth survey periods, respectively. The corresponding prevalence rates of aspirin use per 1000 women were 0.7 (95 percent CI 0, 2.1), 2.43 (95 percent CI 0.05, 4.80), 4.6 (95 percent CI 1.4, 7.8), 6.6 (95 percent CI 2.7, 10.6), and 2.7 (95 percent CI 0, 5.7). Both a gender trend (p=0.0002) and a survey trend (p=0.0001) were detected. A gender-survey interaction was not found.

CONCLUSIONS:

In this population, aspirin use was reported primarily by middle-aged men who had coexisting cardiovascular disease as indicated by concurrent medications. Aspirin use as antiplatelet therapy increased in the population-based samples of two New England communities over the past nine years, with slightly more than one percent of the respondents reporting its use in the fifth cross-sectional survey conducted in 1989–1990. This finding may reflect the publication of important clinical trials near the time the survey was performed and subsequent dissemination of the findings both in the professional and lay press.
Cetirizine: A New, Nonsedating Antihistamine
Authors: Lee Barnes Connie , McKenzie Constance A. , Webster Kathy D. , Poinsett-Holmes Kim
Published: January 2017

OBJECTIVE:

To introduce cetirizine, a nonsedating antihistamine, and discuss its mechanism of action, chemistry, clinical and comparative trials, and adverse effects.

DATA SOURCES:

An English-language literature search of MEDLINE was conducted.

STUDY SELECTION:

Human clinical trials were selected for evaluation.

DATA SYNTHESIS:

Cetirizine, an investigational agent and a potent histamine1-antagonist is a piperazine derivative and carboxylated metabolite of hydroxyzine. As a second-generation, nonsedating antihistamine, cetirizine is associated with fewer adverse effects compared with first-generation antihistamines. It appears to be at least as effective as the other nonsedating antihistamines in the treatment of allergic rhinitis, chronic idiopathic urticaria, and pollen-induced asthma. The recommended adult dosage of this agent is 5 or 10 mg/d.

CONCLUSIONS:

Clinical studies indicate that cetirizine may be more beneficial in some ways than other available agents. Two of these advantages are a rapid onset of action and a once-daily dosing regimen. Future postmarketing surveillance is warranted to further document these findings.
Zalcitabine
Authors: Goodwin S. Diane , Fletcher Courtney V. , Shelton Mark J. , O'Donnell Alice M. , Morse Gene D.
Published: January 2017

OBJECTIVE:

To review the chemistry, intracellular metabolism, pharmacokinetics, and clinical trials of zalcitabine (2',3'-dideoxycytidine, ddC).

DATA SOURCES:

English-language articles and conference proceedings. The indexing terms used were zalcitabine, 2',3'-dideoxycytidine, and ddC.

STUDY SELECTION:

In addition to the manufacturer's package insert, available Phase I and Phase I/II studies were reviewed.

DATA EXTRACTION:

Clinical experience with ddC has been limited to uncontrolled studies and an expanded-access program. Efficacy was evaluated solely on surrogate markers of HIV disease: CD4+ lymphocyte counts and p24 antigen determinations. Clinical endpoints, such as disease progression and survival rates, must be provided to the Food and Drug Administration (FDA) for continued approval.

DATA SYNTHESIS:

The FDA has approved use of ddC in combination with zidovudine (ZDV) as therapy of HIV infection for patients with CD4+ lymphocyte counts ≤300 cells/mm3 who have experienced significant clinical or immunologic deterioration. Although ddC has the same mechanism of action as other nucleoside analogs, it is more potent on a molar basis. The drug is stable in gastric pH and has good bioavailability (∼70–90 percent), but it is rapidly cleared from plasma (half life ∼1–3 h). Intracellular concentrations of ddC triphosphate, the active form, are probably related to plasma concentrations, yet may persist in cells longer than the parent drug persists in plasma. When used as primary therapy in patients with CD4+ ≤300 cells/mm3, ddC/ZDV increased CD4+ lymphocyte counts and reduced plasma p24 antigen concentrations. In comparison to ZDV monotherapy data taken from other studies, ddC/ZDV appeared to demonstrate a more pronounced and sustained increase in CD4+ cell counts; however, this observation cannot be confirmed until the results of ZDV-controlled comparisons are available. Overall, 17–31 percent of the patients receiving the currently recommended initial dosage of ddC experience peripheral neuropathy.

CONCLUSIONS:

In combination with ZDV, ddC appears to augment the CD4+ cell response of ZDV monotherapy in the treatment of HIV infection for ZDV-naive patients, although controlled studies and rigorous statistical analyses are lacking at present. The efficacy of ddC/ZDV in patients who received prior treatment with ZDV monotherapy is unclear at the present.
Patient Counseling in Community Pharmacy and its Relationship with Prescription Payment Methods and Practice Settings
Authors: Raisch Dennis W.
Published: January 2017

OBJECTIVE:

To determine whether patient counseling activities in community pharmacies are related to payment method and practice setting.

DESIGN:

Randomly selected pharmacists voluntarily performed self-data collection (39 percent participation rate) of counseling activities for 40 hours. Observational data were also collected by trained observers.

SETTING:

Community pharmacies.

RESULTS:

Forty-seven pharmacists in national chain pharmacies and 26 in independent pharmacies collected data on 3766 counseling events. Patient counseling rates, defined as percentage of patients counseled per prescription per pharmacist, were significantly higher (p<0.05) for self-pay (median 12.9 percent) and Medicaid (median 13.0 percent) than for capitation patients (median 7.9 percent). Rates were somewhat higher (p=0.06) for chain (median 17.7 percent) than for independent pharmacists (10.7 percent). Although there was no difference in terms of pharmacist-initiated counseling, chain pharmacists had higher rates of patient-initiated counseling per prescription (median 4.3 percent) than independent pharmacists (median 2.7 percent) (p<0.01). Counseling information was related to payment method and practice setting. A significantly higher percentage (p<0.01) of counseling events for capitation patients pertained to chronic therapies (33.6 percent) compared with counseling events involving patients using other payment methods (21.8–24.8 percent). A strong correlation between observational data and self-reported data was found (Pearson r=0.696, p<0.001).

CONCLUSIONS:

The finding that pharmacists counsel capitation patients less frequently may be attributable to financial incentives or to pharmacists' perception that these patients do not need to be counseled. Independent pharmacists' higher number of capitation patients and increased workloads may have affected their counseling activities. These findings have implications for pharmacy service reimbursement programs, practice conditions, and continuing education programs.
Inadvertent Intravenous Administration of an Elemental Enteral Nutrition Formula
Authors: Malone Margaret , Aftahi Shahab , Howard Lyn
Published: January 2017

OBJECTIVE:

To report a case of intravenous infusion of an elemental enteral nutrition formula.

CASE SUMMARY:

A 65-year-old woman with a high-output jejunostomy required fluid and electrolyte replacement via a central line and enteral nutrition support via a gastrostomy tube. She inadvertently received 160 mL of half-strength elemental enteral nutrition formula (Vivonex TEN) via her central venous catheter. After four hours of the infusion, the patient felt ill and was found to be hypotensive and pyrexic. Over the next 24 hours she developed severe back pain and diffuse muscle tenderness. Her creatine kinase concentration was mildly elevated and there were no electrocardiographic changes. There was no rise in serum amylase concentration. Her renal function deteriorated markedly over the following three hours but responded to hydration and diuretic therapy. Liver enzymes, slightly elevated prior to this event, remained unchanged. Blood cultures were negative, but prophylactic therapy with vancomycin and ceftazidime was instituted. The patient recovered and was discharged eight days later.

DISCUSSION:

Previous reports of inadvertent intravenous administration of enteral feedings have described such complications as osmolality, microembolism, hypersensitivity, and septicemia. This patient's nonfatal outcome may have been related to the infusion of the enteral formula via the central rather than the peripheral route, the infusion of an elemental rather than a whole protein formula, and the use of sterile water to reconstitute the formula.

CONCLUSIONS:

Particular care should be taken when a patient has more than one catheter implanted on the chest or abdomen (e.g., central venous or peritoneal dialysis catheter). It is important that inservice training is provided and written protocols are available for the safe infusion of enteral formulas.
Enoxaparin: The Low-Molecular-Weight Heparin for Prevention of Postoperative Thromboembolic Complications
Authors: Carter Charles A. , Skoutakis Vasilios A. , Spiro Theodore E. , West Mark E. , Tooms Robert E. , Joe Ronald H. , Knutson Troy J.
Published: January 2017

OBJECTIVE:

To introduce readers to a new low-molecular-weight heparin (LMWH) product, enoxaparin. The chemistry, pharmacology, pharmacodynamics, clinical efficacy in thromboembolic prophylaxis following surgery, and adverse effects are reviewed.

DATA SOURCES:

A MEDLINE search of the English-language literature was used to identify relevant literature.

STUDY SELECTION:

A focus was placed on human clinical studies with well-accepted measures of antithrombotic efficacy endpoints, i.e., venography and ultrasonography. Emphasis was on pharmacologic and pharmacokinetic studies conducted in humans.

DATA EXTRACTION:

Most data were extracted from double-blind, controlled clinical studies. Other study designs were accepted if the results were believed to be significant. Pharmacology and pharmacokinetic data were selected from studies with exceptional design conducted in humans.

DATA SYNTHESIS:

Enoxaparin is a polysaccharide chain produced by the depolymerization of heparin. In comparison with heparin, which has an average molecular weight of 12 000–15 000 daltons, the average molecular weight of enoxaparin is approximately 4500 daltons. Enoxaparin does not form a complex with antithrombin III and thrombin as extensively as does heparin; however, the anti-Xa activity of enoxaparin is similar. The significance of this fact is an enhancement of antithrombotic activity and clinical efficacy. Trials comparing enoxaparin with other thromboembolic prophylaxis techniques are ongoing.

CONCLUSIONS:

Thromboembolism remains one of the major complications of all surgical procedures. Attempts have been made throughout the last century to develop the most effective means to prevent this complication. Clinical studies performed throughout the world have shown that enoxaparin is superior or equivalent to other antithrombotic agents, including heparin, in preventing the formation of venous thromboembolism. In addition, enoxaparin appears to possess an equivalent or lower incidence of bleeding complications when compared with heparin prophylaxis. Enoxaparin is expected to be joined by other LMWH products in the future. As a result, the methods of providing effective prophylaxis against thromboembolic complications is expected to change in the coming years.
Meaningful Interpretation of Risk Reduction from Clinical Drug Trials
Authors: McCormack James P. , Levine Marc
Published: January 2017

OBJECTIVE:

To illustrate the concepts of relative and absolute risk reduction, and by example, present and discuss the results of prevention trials that have evaluated the impact of drug therapy on cardiovascular disease. Additional approaches to evaluating the results of prevention trials are also presented.

DATA SOURCES:

Data were gathered from eight frequently quoted major cardiovascular intervention trials.

CONCLUSIONS:

Reference to large reductions in relative risk in review papers, newspapers, and at professional meetings can lead to false expectations among clinicians and patients regarding the potential impact of the treatment in individual patients. When making decisions about preventive drug therapy, clinicians are encouraged to examine measures other than relative risk reduction and to include the patient in the decision process. Educators should emphasize these other measures of outcome and not rely solely on relative risk reduction in discussing particular areas of therapeutics.
Peripheral Intravenous Line Survival and Phlebitis Prevention in Patients Receiving Intravenous Antibiotics: Heparin/Hydrocortisone versus In-Line Filters
Authors: Roberts Gregory W. , Holmes Mark D. , Staugas Rima E.M. , Day Rosemary A. , Finlay Christine F. , Pitcher Anne
Published: January 2017

OBJECTIVE:

To compare the use of in-line filtration with the addition of heparin/hydrocortisone (hep/hc) to the infusate for both phlebitis prevention and intravenous(iv) line survival in peripheral iv catheters. This study was specific for a patient group receiving prolonged courses of iv antibiotics. Analysis of the two endpoints for conventional short iv catheters (short lines) versus long (30 cm) iv catheters (long lines) was also performed.

METHODS:

Patients with cystic fibrosis receiving intermittent iv antibiotics were randomly allocated to receive their drugs either through an in-line filter using a drug-free infusate or with no filter and an infusate containing heparin 500 units and hydrocortisone 10 mg/L. Infusion sites were assessed daily.

RESULTS:

Both the hep/hc and filter groups were similar in terms of phlebitis incidence and iv line survival when analyzed separately for both short and long lines. Long lines displayed markedly prolonged survival times and reduced phlebitis compared with short lines.

CONCLUSIONS:

The effectiveness of iv filters in excluding the large particle load introduced by iv antibiotics and hence in reducing the subsequent phlebitis makes them a useful alternative to the use of hep/hc. The use of filters in this patient group may offer advantages in terms of ease of use and a possible decrease in hep/hc-related problems. Long lines offer practical advantages over short lines for patients requiring longer term iv access.
Evaluation of Recent Pharmacy Graduates' Practice Patterns, Professional Lifelong Learning, Pharmacy Organization Memberships, and Salary
Authors: Bond C.A. , Pitterle Michael E. , Raehl Cynthia L.
Published: January 2017

OBJECTIVES:

To document information on recent bachelor of science (B.S.) pharmacy graduates' practice patterns, professional lifelong learning (PLL) methods, pharmacy organization memberships, and salary. The association between advanced training and education on PLL methods, pharmacy organization membership, and salary are explored. DATA

SOURCES:

Pertinent literature was identified by MEDLINE searches (1966–1992).

STUDY DESIGN:

The results of a Fall 1991 survey of recent B.S. pharmacy graduates (n=371) of the University of Wisconsin School of Pharmacy are reported (55 percent response rate).

RESULTS:

Hospital pharmacists devoted more time to PLL outside of work (l8.00 ± 17.89 h/mo) than community pharmacists (9.93 ± 8.76 h/mo), t=5.02, degrees of freedom (df)=289, p <0.001. Graduates who had completed an advanced degree program, residency, or fellowship (advanced degree/training [ADT]) spent more time in PLL (17.76 ± 10.63 h/mo) compared with graduates who had only obtained a B.S. degree (10.63 ± 8.56 h/mo), t=3.80, df=311, p<0.001. Graduates who had ADT were more likely to belong to multiple pharmacy organizations (2.14 ± 1.38 organizations) than hospital pharmacists (1.61 ± 1.27 organizations) and community pharmacists (l.ll ± 1.06 organizations). Of the pharmacists who graduated in 1989 and 1990 (one to two years postgraduation), 55 percent belonged to the American Pharmaceutical Association. This declined to 19 percent of the graduates from 1984 and 1985 (six to seven years postgraduation), a 62 percent decline in membership. Membership in the American Society of Hospital Pharmacists (ASHP) was held by 19 percent of graduates one to two years after graduation; and 34 percent of graduates belonged to ASHP six to seven years after graduation, an 81 percent increase. Graduates with ADT (compared with graduates with the B.S. degree only) showed the strongest correlation of membership affiliation, which was about equal with ASHP (phi=0.32) and ACCP (phi=0.33). Although pharmacists changed their individual pharmacy organization memberships during the first seven years after graduation, there was no evidence of a decline in overall interest in pharmacy organization membership. Pharmacists who had completed ADT had an annual mean salary of $51 112 ± $10 012; those pharmacists who did not complete an ADT program had an annual mean salary of $46 440 ± $7802, a difference of $4672 per year. Hospital pharmacists who had obtained ADT had an annual mean salary of $51 840 ± $9765; B.S. pharmacists without ADT in hospital practice had an annual mean salary of $43 603 ± $8192, a difference of $8237 per year.

CONCLUSIONS:

Pharmacists' PLL methods, organization memberships, and salaries varied significantly by their practice site and the completion of an ADT program.
Telephone Contacts Do Not Improve Adherence to Niacin or Bile Acid Sequestrant Therapy
Authors: Schectman Gordon , Hiatt Janet , Hartz Arthur
Published: January 2017

OBJECTIVE:

Noxious adverse effects frequently limit patient acceptance of niacin and bile acid sequestrants (BAS), first-line agents in the management of hypercholesterolemia. The purpose of this study was to determine whether telephone contacts from a healthcare professional could improve drug adherence and tolerance in patients prescribed these medications.

PATIENTS AND METHODS:

This was a randomized, single-blind trial of telephone contacts vs. no intervention in patients with hyperlipidemia who were prescribed either niacin or BAS in a large, Veterans Affairs, lipid clinic. Patients randomized to telephone contact (n=81) received weekly calls from a trained healthcare professional during the first month of drug therapy. Counseling regarding adverse effects, and prescriptions to overcome minor adverse effects, were provided as needed to patients during the telephone contact.

RESULTS:

Significant differences were not observed between groups in the drug discontinuance rate, adherence assessed by two independent methods, or in the final dosage of medication ingested.

CONCLUSIONS:

Telephone contacts do not improve either adherence or tolerance to niacin or BAS. Alternative approaches to enhance acceptance of these medications requires further evaluation.
Possible Drug Interaction between Warfarin and Combination of Levamisole and Fluorouracil
Authors: Scarfe Mary A. , Israel Marc K.
Published: January 2017

OBJECTIVE:

To report a possible drug interaction between the combination of fluorouracil (5-FU), levamisole, and warfarin.

CASE SUMMARY:

An elderly patient with chronic atrial fibrillation and prosthetic valve replacements had been taking warfarin 22.5 mg/wk. Following the diagnosis of colon cancer (Duke's classification D), a chemotherapy regimen of 5-FU and levamisole was started. Within four weeks after initiation of chemotherapy, the International Normalization Ratio (INR) increased from 3.04 to 39.56. Warfarin was discontinued and restarted at 7.5 mg/wk. Discontinuation of levamisole and 5-FU for a five-week period resulted in the INR falling to a subtherapeutic level. Reinstitution of the chemotherapeutic regimen once again led to an increase in INR.

DISCUSSION:

A literature search showed no reports of an interaction between warfarin and levamisole. However, prolongation of 5-FU half-life and an increase in INR have been reported with the concurrent use of 5-FU and warfarin. Inhibition of the hepatic metabolism of warfarin by 5-FU and levamisole is the postulated mechanism of this drug interaction.

CONCLUSIONS:

This case describes the clinically significant increase of INR in an elderly patient after adding a chemotherapy regimen of levamisole and 5-FU to a previous regimen of warfarin alone. The increasing incidence of both atrial fibrillation and colon cancer with age could potentially require the concomitant use of 5-FU, levamisole, and warfarin. Because of the potential severity of this interaction, close monitoring of INR and warfarin dosage adjustment is recommended in patients receiving warfarin along with levamisole and 5-FU.
Preventing Adverse Drug Events in Hospitalized Patients
Authors: Evans R. Scott , Pestotnik Stanley L. , Classen David C. , Horn Susan D. , Bass Sheron B. , Burke John P.
Published: January 2017

OBJECTIVE:

To use computerized adverse drug event (ADE) surveillance to help identify methods to reduce the number of ADEs in hospitalized patients.

DESIGN:

Prospective study of 79 719 hospitalized patients during a 44-month period.

SETTING:

LDS Hospital, a 520-bed tertiary care center affiliated with the University of Utah School of Medicine, Salt Lake City.

INTERVENTION:

Sequential study periods of at least one year each were compared. In the first period, data were collected but not reported to physicians, pharmacists, or nurses. In the subsequent study periods, three interventions (computerized alerts of drug allergies, standardized antibiotic administration rates, and timely physician notification of all ADEs) were made to reduce the number of type B (allergic or idiosyncratic reactions) and severe ADEs.

RESULTS:

In the first study period, we identified 56 type B ADEs during 120 213 patient days. During two subsequent study periods that included alerts to physicians of known drug allergies and standardized antibiotic administration rates, 8 type B events were identified during 113 237 patient days and 18 during 107 868 patient days, respectively (p<0.OO2). Early notification of physicians of all confirmed ADEs regardless of severity was associated with asignificant reduction of ADEs classified as severe from 41 during 113 859 patient days in the first study period to 12 during 103 071 patient days and 15 during 108 320 patient days in two subsequent study periods, respectively (p<0.00 1).

CONCLUSIONS:

Prospective surveillance of computer-based medical records for known drug allergies and appropriate drug administration rates can reduce the number of type B ADEs. Early ADE detection and notification of physicians permit drug and dosage changes that reduce the progression of mild and moderate ADEs to more severe conditions.
Drug-and Nutrition-Induced Hypophosphatemia: Mechanisms and Relevance in the Critically Ill
Authors: Brown Glen R. , Greenwood Jan K.
Published: January 2017

OBJECTIVE:

To provide an outline of the drugs and nutritional therapy that could contribute to the development of hypophosphatemia in the critically ill patient.

DATA SOURCES:

Computerized abstracting services, references to primary literature articles, and review publications were screened for references to drug- or nutrition-related hypophosphatemia.

STUDY SELECTION:

Studies primarily describing responses in adults were selected. Animal research is described that illustrates findings in humans.

DATA EXTRACTION:

Information was abstracted from the findings of individual case reports and clinical trials.

DATA SYNTHESIS:

Data are organized by mechanism of possible effect on serum phosphate concentration. No reference is made to drugs that do not have an effect on phosphate metabolism.

CONCLUSIONS:

Hypophosphatemia can have significant effects that would hinder recovery of the critically ill patient. Antacids, catecholamines, beta-adrenergic agonists, sodium bicarbonate, and acetazolamide are commonly used therapeutic agents that could contribute significantly to the development of hypophosphatemia. Provision of nutrition 10 the chronically malnourished individual or chronic administration of phosphate-depleted parenteral nutrition could produce symptoms associated with hypophosphatemia. Other drugs could have a mild effect on lowering serum phosphate concentrations, but would be unlikely to produce symptoms unless combined with other etiologies of hypophosphatemia.
Steady-State Pharmacokinetics of Cefoperazone and Sulbactam in Patients with Acute Appendicitis
Authors: Danziger Larry H. , Piscitelli Stephen C. , Occhipinti Donna J. , Resnick Daniel J. , Rodvold Keith A.
Published: January 2017

OBJECTIVE:

To determine the steady-state pharmacokinetics of intravenously administered cefoperazone and sulbactam when given in combination to patients with acute appendicitis.

METHODS:

Six patients with normal renal and hepatic function received cefoperazone 2 g with sulbactam 1 g prior to appendectomy and then every 12 hours. Serial blood samples were collected after each patient received at least three doses of cefoperazone/sulbactam.

RESULTS:

Cefoperazone and sulbactam could be best described by a two-compartment model. Mean ± SD values for cefoperazone steady-state volume of distribution (Vssd), elimination half-life (t1/2β), clearance (Cl), and area under the curve (AUC0-t) were 19.8 ± 8.0 L, 3.97 ± 1.06 h, 62.6 ± 16.3 mL/min, and 556.9 ± 122.0 mg·h/L, respectively. Sulbactam Vssd, t1/2β, Cl, and AUC0-t were 34.7 ± 13.9 L, 1.39 ± 0.4 h, 288.6 ± 68.2 mL/min, and 64.8 ± 24.5 mg·h/L, respectively.

CONCLUSIONS:

Compared with data from healthy volunteers, cefoperazone exhibited a decreased Cl and increased Vssd and t1/2β in patients with acute appendicitis. An increased Vssd also was observed for sulbactam. The disposition of cefoperazone/sulbactam is altered in this group of patients; however, these changes are not likely to warrant a dosage reduction.
Assessment of Methods and Outcomes: Using Modified Inpatient Ciprofloxacin Criteria in Community-Based Drug Use Evaluation
Authors: Rovers John P. , Bjornson Darrel C.
Published: January 2017

OBJECTIVE:

To determine if published drug use evaluation (DUE) criteria for inpatients could be modified to describe and evaluate drug therapy in outpatients.

DESIGN:

Retrospective review of drug profiles and diagnostic codes in outpatients included in the Iowa Medicaid Management Information System database.

METHODS:

Criteria specifying clinical indication, process indicators, complications, and outcomes were modified from existing inpatient DUE criteria for ciprofloxacin. The Iowa Medicaid database provided demographics, drug profiles, and diagnostic codes for outpatients prescribed ciprofloxacin between March 1 and March 15, 1993.

RESULTS:

539 patients were evaluated. Mean (±SD) age was 62.1 ± 23.8 years; 70.9 percent were women, 44.9 percent were nursing home patients who received lower doses (p=0.04). Of 146 patients (27.1 percent) with infection-related International Classification of Diseases-Clinical Modification, 9th Revision (ICD-9CM) codes, 43.8 percent did not meet indication for use criteria, 15.8 percent met criteria, and 40.4 percent were equivocal/other. Process indicators in 539 patients revealed that 2.4 percent were <18 years old and potential interactions existed for theophylline (9.3 percent), iron (9.7 percent), warfarin (4.8 percent), sucralfate (2.2 percent). Two patients (0.4 percent) received prenatal vitamins. Dosage and duration of therapy could not be linked to disease severity. Complications of therapy were not evaluable. Outcomes were assessed indirectly by using concurrent antibiotic histories. These histories showed that patients received a mean 2.7 ± 2.4 (median 2, range 1–16) ciprofloxacin prescriptions during the study period. There was frequent concurrent use of antibiotics, and 29 percent of prescriptions were preceded or followed by additional quinolone therapy within 30 days.

CONCLUSIONS:

Evaluating appropriateness of therapy with this methodology is feasible if validated ICD-9CM codes are reported consistently in sufficient numbers of patients. Low levels of reporting of relevant disease codes require that large numbers of patients be screened to use this method effectively. Descriptive use data are readily obtained. Data obtained by this method indicated several apparent deficiencies in ciprofloxacin therapy.
Cough Induced by Quinapril with Resolution after Changing to Fosinopril
Authors: Sharif M. Nabi , Evans Barb L. , Pylypchuk George B.
Published: January 2017

OBJECTIVE:

To report a case of chronic, nonproductive cough secondary to the angiotensin-converting enzyme (ACE) inhibitor quinapril, with complete resolution after switching to another ACE inhibitor, fosinopril.

DATA SOURCES:

All relevant articles from January 1985 through February 1993 were identified, primarily through MEDLINE search and review of pertinent articles' bibliographies.

CASE SUMMARY:

A 68-year-old woman developed a dry, irritating cough within one month of starting quinapril therapy for the treatment of essential hypertension. The patient was a nonsmoker with no respiratory illnesses. The cough continued for the duration of therapy with quinapril. One month after changing to fosinopril therapy, the patient reported complete resolution of the cough. She remains cough-free to date.

DISCUSSION:

Cough induced by ACE inhibitors is a frequently documented adverse effect. It is severe enough to require discontinuation of therapy in 1–10 percent of patients. The cough is considered to be a class-related adverse effect with cross-reactions between ACE inhibitors routinely reported. At this time, changing to another ACE inhibitor or additive therapy with nonsteroidal antiinflammatory drugs is not recommended. Discontinuation of the ACE inhibitor results in rapid alleviation of the cough, although this is not always necessary, as most patients may experience a cessation or decrease in cough. We report a case of cough following the administration of quinapril, with complete resolution after changing to the alternative ACE inhibitor fosinopril in a patient with essential hypertension.

CONCLUSIONS:

Cough has been encountered commonly after the administration of ACE inhibitors. Frequency of cough is variable and although this complication has been described as a class effect, patients with a persistent, severe ACE inhibitor-induced cough may benefit from a trial of fosinopril therapy. This may be particularly useful in patients unable to tolerate an alternative class of antihypertensive agents.
Inaccurate Assessment of Drug-Induced Thrombocytopenia: Reason for Concern
Authors: Burnakis Thomas G.
Published: January 2017

OBJECTIVE:

To report two cases in which patients were reputed to have exhibited thrombocytopenia secondary to the histamine-receptor blocking agent ranitidine. Evaluation and the associated time frame of events failed to confirm these observations.

DESIGN:

Two case studies.

RESULTS:

Ranitidine was ordered as part of the therapeutic course of two patients admitted to the medicine service. The development of thrombocytopenia in both patients was attributed to this agent and it was discontinued. In addition to ranitidine, both patients received several other agents with greater potential to cause thrombocytopenia, and had a time course of development of the adverse effect that would not support ranitidine as the offending agent. Both patients required histamine-receptor antagonists at some point following their discontinuation and, based on the available evidence, the pharmacy suggested that these agents be restarted. In neither case did restarting the histamine-receptor antagonist lead to recurrence of thrombocytopenia.

CONCLUSIONS:

Although ranitidine can cause thrombocytopenia, the reported incidence is very low. Spontaneous reporting of adverse effects is essential in establishing a true pattern of safety for a drug. However, reports need to be scrutinized before they are rolled into the collective intelligence. Overzealous or incomplete reporting will lead to cautions that are either unnecessary or, because they deny people necessary treatment, dangerous.
Sertraline-Phenelzine Drug Interaction: A Serotonin Syndrome Reaction
Authors: Graber Mark A. , Hoehns T. Brent , Perry Paul J.
Published: January 2017

OBJECTIVE:

To report a serious drug interaction possibly occurring with the monoamine oxidase inhibitor phenelzine and the selective serotonin reuptake inhibitor sertraline.

CASE SUMMARY:

A 61-year-old woman with treatment-refractory major depressive disorder was being treated unsuccessfully with lithium, phenelzine, thioridazine, and doxepin. Sertraline 100 mg/d was added to the patient's therapy. Within three hours of ingesting the first dose, the patient experienced a dramatic increase in her temperature, pulse, and respirations along with labile blood pressure, and symptoms of rigidity, diaphoresis, shivering, and decreased sensorium. The patient was transported to the emergency room and treated with diazepam 10 mg iv, followed by midazolam 10 mg iv for control of rigidity. She was also intubated. The patient then experienced precipitous falls in her blood pressure and respiratory rate. Ice packs combined with a cooling blanket and dantrolene 80 mg iv were administered to control fever and rigidity, respectively. She had an initial working diagnosis of neuroleptic malignant syndrome, which was later changed to serotonin syndrome. Dantrolene was continued for 72 hours at which time the patient was extubated and transferred to a psychiatric unit.

CONCLUSIONS:

Selective serotonin reuptake inhibitor antidepressants should not be combined with monoamine oxidase inhibitor antidepressants because of the risk of serotonin syndrome.