bluuebunny/crossref_metadata_2025 huggingface dataset:
Amiodarone for the Maintenance of Sinus Rhythm in Patients with Atrial Fibrillation
Authors: Howard Patricia A
Published: January 2017

Objective:

To discuss the role of amiodarone for the maintenance of normal sinus rhythm in patients with atrial fibrillation (AF) and review the clinical trial data evaluating the efficacy and safety of amiodarone in patients with AF.

Data Sources:

A MEDLINE search was used to identify pertinent literature. Additional references were identified from the articles obtained in the search. Key search terms were atrial fibrillation, amiodarone, and sinus rhythm.

Study Selection:

All studies available at the time the article was prepared evaluating the efficacy and safety of amiodarone in AF were included. In addition, review articles discussing the role of amiodarone in AF were selected.

Data Extraction:

NO large, prospective, randomized trials have been performed. Data from 8 nonrandomized and 2 randomized trials are reported. Information derived from review articles is discussed.

Data Synthesis:

In patients with AF, maintenance of normal sinus rhythm is desirable to eliminate symptoms, improve functional capacity, and reduce the risk of thromboembolic complications. Class IA agents traditionally have been used; however, concerns about long-term effects on mortality have focused attention on other agents such as amiodarone. A number of nonrandomized, uncontrolled trials have found amiodarone to be effective for maintaining normal sinus rhythm in patients with AF that is refractory to conventional agents. Two randomized, nonblind trials have found amiodarone's efficacy to be equal to or superior to that of class IA drugs. The findings of these trials must be weighed, however, against the significant potential for toxicity and drug interactions associated with amiodarone. Cardiovascular toxicities, including proarrhythmic effects, appear to be relatively rare. In contrast, noncardiovascular effects are common and potentially serious.

Conclusions:

Although the preliminary data using amiodarone in AF are encouraging, many questions remain unanswered. Prospective, randomized trials are needed to evaluate the long-term efficacy and safety of amiodarone in patients with AF. Studies also are needed to determine the optimal dosing regimen. Until these data are available, each patient must be evaluated individually, taking into account the relative benefits and risks of therapy. Amiodarone may be particularly useful in patients with significant risks for proarrhythmia and those whose AF is refractory to traditional therapy.
Meta-Analysis of Parenteral Clindamycin Dosing Regimens
Authors: Rovers John P , Ilersich A Lane , Einarson Thomas R
Published: January 2017

Objective:

We used meta-analysis to compare clinical cure and success rates for parenteral clindamycin 600 mg q8h or 900 mg q8h therapy to treat adult intraabdominal or female pelvic infections.

Data Sources:

We located English-language articles describing clindamycin use in humans using MEDLINE, International Pharmaceutical Abstracts, and Embase and from personal and drug information center files, plus all article references.

Study Selection:

Eligible studies used parenteral clindamycin 600 mg q8h or 900 mg q8h to treat intraabdominal or pelvic infection in at least I aim of a study and provided a definition of clinical outcome. Accepted were comparative trials in adults who were not critically ill or expected to die.

Data Synthesis:

The DerSimonian and Laird method was used to calculate weighted overall success rates for cure and success (cure plus improved) rates along with 95% confidence intervals for each dosage in intraabdominal and pelvic infections. Regimens were compared with respect to both cure and success rates using the Mann-Whitney U test.

Main Results:

Twenty-three articles were eligible for inclusion. Abdominal cure rates were 75.6% and 90.5% for clindamycin 600 mg q8h and 900 mg q8h, respectively (p = 0.03); success rates were 89.8% and 92.5%, respectively (p = 0.29). Pelvic cure rates were 82.8% and 89.4%, respectively (p = 0.51); success rates were 87.2% and 89.9%, respectively (p = 0.51).

Conclusions:

In pelvic infections, a dosage of clindamycin 600 mg q8h appears to be clinically acceptable for all patients. Although clinical outcomes for intraabdominal infections are generally similar for both regimens, the significantly higher cure rate with a dosage of clindamycin 900 mg q8h suggests that dosage recommendations should be patient specific.
Lymphopenic Effect of Carbamazepine in a Patient with Chronic Lymphocytic Leukemia
Authors: Silverman David A , Chapron Dennis J
Published: January 2017

Objective:

To report a dramatic and reproducible suppressive effect of carbamazepine on circulating lymphocytes in an elderly woman with chronic lymphocytic leukemia.

Case Summary:

An elderly woman taking phenytoin for a stroke-associated seizure disorder had lymphocyte count of 28 800 × 106 cells/L. Speculating an unusual lymphadenopathic effect of the phenytoin therapy, carbamazepine therapy was substituted. After 15 weeks of carbamazepine treatment, the lymphocyte count declined to 3200 × 106 cells/L. Because of severe diarrhea, carbamazepine therapy was stopped and phenytoin therapy was reinstituted. At the end of 4 months of phenytoin treatment, the lymphocyte count had increased to 23 200 × 106 cells/L. Phenytoin therapy was discontinued and carbamazepine therapy was begun. The lymphocyte count decreased to 10 700 × 106 cells/L. Severe diarrhea recurred and phenytoin treatment was reinstituted. Over 12 days the lymphocyte count increased to 28 900 × 106 cells/L. Phenytoin therapy was stopped and valproic acid therapy was started. The lymphocyte count continued to increase during valproic acid therapy, reaching a peak of 114 300 × 106 cells/L.

Discussion:

In this patient with chronic lymphocytic leukemia, carbamazepine therapy had a significant and reproducible lymphopenic effect that was readily reversible upon discontinuation of the drug. Unfortunately, this effect was associated with severe diarrhea, preventing further attempts at exploiting this potentially beneficial action.

Conclusions:

Carbamazepine had a reproducible suppressive effect on lymphocyte counts in an elderly patient with chronic lymphocytic leukemia. This unique observation raises the possibility that carbamazepine therapy may have a useful effect in patients with chronic lymphocytic leukemia.
Macrolides Versus Azalides: A Drug Interaction Update
Authors: Amsden Guy W
Published: January 2017

Objective:

To describe the current drug interaction profiles for all approved and investigational macrolide and azalide antimicrobials, and to comment on the clinical impact of these interactions when appropriate.

Data Sources:

MEDLINE was searched to identify all pertinent studies, review articles, and case reports from 1975 to 1995. When appropriate information was not available in the literature, data were obtained from the product manufacturers.

Study Selection:

All available data were reviewed to give an unbiased account of possible drug interactions.

Data Extraction:

Data for some of the interactions were not available from the literature, but were available from abstracts or from company-supplied materials. Although the data were not always entirely explicative, the best attempt was made to deliver the pertinent information that clinical practitioners would need to formulate practice opinions. When more in-depth information was supplied in the form of a review or study report, a thorough explanation of pertinent methodology was supplied.

Data Synthesis:

Since the introduction of erythromycin into clinical practice, there have been several clinically significant drug interactions identified throughout the literature associated with this drug. These interactions have been caused mostly by inhibition of the CYP3A subclass of hepatic enzymes, thereby decreasing the metabolism of any other agent given concurrently that is also cleared through this mechanism. With the development and marketing of several new macrolides, it was hoped that the drug interaction profile associated with this class would improve. This has been met with variable success. Although some of the extensions of the 14-membered ring macrolides have shown an incidence of interactions equal to that of erythromycin, others have shown improved profiles. In contrast, the 16-membered ring macrolides have demonstrated a much improved, though not absent, interaction profile. The most success in avoiding drug interactions through structure modification has been accomplished with the development of the azalide class, of which azithromycin is the first to be approved for marketing. This agent has to date produced none of the classic drug interactions that most macrolides have demonstrated in patient care.

Conclusions:

The introduction of new 14- and 16-membered ring macrolides appears to have had a variable effect in modifying the incidence of drug interactions associated with this class. Azithromycin, a member of the new azalide class, has to date produced fewer clinically significant interactions than other azalides with any agent that is cleared through the CYP3A system. Overall, the available data are promising, and the final test should come from conducting studies in patients who are taking potentially interacting compounds on a chronic basis, as most available data are from trials in healthy volunteers.
Hiv Infection and Aids: Attitudes and Knowledge of Arizona Pharmacists
Authors: Katz Michael D , Draugalis Jolaine R , Lai Rita P
Published: January 2017

Objective:

To assess Arizona pharmacists' attitudes and knowledge regarding HIV infection and AIDS.

Methods:

Mailing of a 7-page survey, which included demographic and attitudinal items, as well as preparedness, comfort, and knowledge scales.

Setting:

Randomly selected pharmacists registered and residing in Arizona.

Participants:

Of the 479 pharmacists surveyed, 41 were removed from the sample because they had moved with no forwarding address, were retired or not practicing, or had died. The response rate was 46% for the remaining 438 pharmacists. A final sample size of 199 was obtained.

Results:

The respondents had a high level of preparedness and comfort in addition to positive attitudes. Overall, their knowledge level was low. Inpatient pharmacists had a higher level of therapeutic knowledge (p < 0.0001) and were more willing to work with a person infected with HIV than were outpatient pharmacists (p = 0.05). Pharmacists who had attended at least 1 HIV/AIDS-related continuing education (CE) program had higher levels of preparedness (p < 0.0001), comfort (p = 0.01), and knowledge (p < 0.0001) than those who had not. The majority of respondents believed that an HIV/AIDS CE program should be mandatory.

Conclusions:

Although Arizona pharmacists feel prepared, are comfortable, and have positive attitudes regarding patients with HIV/AIDS, their level of knowledge is low. The results of this study may be used by CE providers to design programs to meet the educational needs of pharmacists.
Establishment of a Drug Information Service on a Public-Access Computer Bulletin Board
Authors: Bednarczyk Edward M , Kyllonen Kay S
Published: January 2017

Objective:

Computerized bulletin board services (BBSs) have existed for several decades; in recent years there has been increased use and acceptance. We have established a drug information service called The Pharmacy on a local public-access BBS, the Cleveland FreeNet. The goal of this service is to provide drug information to the lay public as well as healthcare professionals.

Description:

The Pharmacy is divided into 4 areas: (1) About the Pharmacy, which provides instructions for use; (2) Drug Information, which contains postings on selected drug information topics that are prepared by the BBS staff; (3) Pharmacy Questions, the most popular feature, where FreeNet users are invited to post questions, the answers to which are provided by clinical, staff, and consultant pharmacists, as well as baccalaureate and graduate pharmacy students; and (4) Investigational Studies, where patient recruitment for investigational studies is done.

Results:

A total of 259 questions have been posted in the first 3 years of operation. An average of 5.2, 7.78, and 8.7 questions/month have been posted in 1992, 1993, and 1994, respectively. Four drug information monographs have been prepared and posted, and approximately 5 investigational studies have been advertised.

Conclusions:

A computerized BBS is a new means of distributing drug information to the public and healthcare professionals. In addition to meeting a need for a public service of drug information in the community, it permits increased visibility for pharmacists and a unique learning experience for students.
Conversions from Captopril to Lisinopril at a Dosage Ratio of 5:1 Result in Comparable Control of Hypertension
Authors: Gill Tajinder H , Hauter Fred , Pelter Mitchell A
Published: January 2017

OBJECTIVE:

To provide clinical support that conversion from Captopril to lisinopril at a daily oral dosage ratio of 5:1 maintains comparable therapeutic efficacy, and to estimate retrospectively cost savings because of conversion from Captopril to lisinopril therapy at the study site and with the associated overall drug conversion program instituted by Kaiser Permanente.

DESIGN:

An open-label, randomized, prospective, parallel study was performed in 56 patients with mild-to-moderate hypertension. In a 4-week prerandomization period, oral maintenance dosages of Captopril were established. Patients then were randomly assigned either to continue taking Captopril or to change to lisinopril at an initial conversion ratio of Captopril 5 mg to lisinopril 1 mg. Blood pressures were evaluated 2, 4, 8, and 12 weeks postrandomization. If necessary, dosages were adjusted to maintain adequate efficacy (i.e., systolic pressure <160 mm Hg and diastolic pressure <90 mm Hg in the prerandomization period; diastolic pressure <90 mm Hg postrandomization). Cost savings for the study site and to the overall program with respect to conversion from Captopril were defined as the difference between the estimated drug costs and the drug costs projected if the conversion had not been made.

SETTING:

Woodland Hills Medical Center of the Southern California Region of Kaiser Permanente Medical Care Program.

MAIN OUTCOME MEASURES:

The main outcome measures were systolic and diastolic blood pressure. The measure for the retrospective cost savings analysis was estimated cost savings based on the number of prescriptions written for Captopril and lisinopril from December 1988 through December 1993, and the average wholesale price.

PARTICIPANTS:

Members of the Kaiser Permanente Medical Care Program who were diagnosed with mild-to-moderate hypertension and whose hypertension was controlled by Captopril alone. Retrospectively, mild-to-moderate hypertension would have been classified as stages 1–3, based on the current guidelines of the Fifth Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure.

RESULTS:

The blood pressures of patients in whom Captopril therapy was switched to lisinopril therapy were maintained throughout the entire study within the defined acceptable limits of control when the conversion was initiated at a daily oral dosage ratio of 5:1. The final dosage conversion ratio was not significantly different statistically from the theoretical dosage conversion ratio of 5:1.

CONCLUSIONS:

The conversion from Captopril (in equally divided daily doses) to lisinopril (once daily) at a dosage ratio of 5:1 maintained comparable control of mild-to-moderate hypertension with no increase in adverse effects. In addition, the cost savings associated with an overall drug conversion program were substantial, and the conversion provided a preferred once-daily dosing regimen.
Association of a Tourette-Like Syndrome with Ofloxacin
Authors: Thomas Robert J , Reagan David R
Published: January 2017

OBJECTIVE:

To describe the association between the use of the fluoroquinolone ofloxacin in an elderly man and an unusual acute encephalopathy with characteristics suggestive of Tourette's syndrome.

CASE SUMMARY:

An unusual syndrome was observed in a 71-year-old man temporally related to the initiation of ofloxacin therapy that resolved completely after discontinuation of the drug. The most remarkable phenomena were spitting and profuse swearing; other features were echolalia, echopraxia, orofacial and limb automatisms, hypersalivation, and amnesia for the episode on recovery. The clinical syndrome had several features in common with Tourette's syndrome and possibly with frontal lobe onset complex partial seizures. The electroencephalographic, neuroradiologic, and cerebrospinal fluid examinations were normal.

DISCUSSION:

The reported neurotoxic effects of the fluoroquinolones include insomnia, seizures, delirium, and psychosis, best explained by the gamma-aminobutyric acid—antagonistic properties of this class of drugs. This is the first reported case of a Tourette-like syndrome associated with the use of any quinolone, suggesting a possible interaction with central dopaminergic neurotransmitter systems.

CONCLUSIONS:

Use of drugs such as ofloxacin that have improved central nervous system penetration, disease- or age-related reductions in renal function, concomitant use of drugs such as theophylline and nonsteroidal antiinflammatory drugs, and possibly increased pharmacodynamic sensitivity place the elderly at special risk for quinolone neurotoxicity. Dosing modifications and an awareness of possible central nervous system adverse effects are warranted.
Low Antituberculosis Drug Concentrations in Patients with AIDS
Authors: Peloquin Charles A , Nitta Annette T , Burman William J , Brudney Karen F , Miranda-Massari Jorge R , McGuinness Margaret E , Berning Shaun E , Gerena Gail T
Published: January 2017

OBJECTIVE:

To determine the frequency and magnitude of below normal apparent peak serum concentrations for antituberculosis drugs in patients with AIDS and CD4 cell counts less than 200 cells/mm3. We also explored the data for potential relationships between response variables and patient characteristics.

DESIGN:

Prospective study of consecutive patients seen in tuberculosis clinics.

SETTING:

Five urban tuberculosis clinics in four major metropolitan areas.

PARTICIPANTS:

Twenty-six patients diagnosed with HIV infection and receiving treatment for active tuberculosis were eligible.

MAIN OUTCOME MEASURES:

After 2 weeks or more of therapy, blood was collected 2 hours after observed doses of the antituberculosis drugs. Serum samples were frozen, shipped to National Jewish Center in Denver, and analyzed by HPLC or GC. Serum concentrations were compared with the proposed normal ranges. Data were analyzed to determine correlations between antituberculosis drug serum concentrations and patient characteristics.

RESULTS:

Low 2-hour serum concentrations were common for antituberculosis drugs, particularly rifampin and ethambutol. Absorption of isoniazid was generally high. Potential drug—drug interactions were found between rifampin and fluconazole (fluconazole appears to increase rifampin concentrations) and between pyrazinamide and zidovudine (zidovudine may lower pyrazinamide concentrations). Patients receiving pyrazinamide had lower rifampin concentrations than those not receiving pyrazinamide.

CONCLUSIONS:

Low antituberculosis drug serum concentrations occur frequently during the treatment of tuberculosis in patients with AIDS. Additional research is required for patients with drug-resistant tuberculosis, and to clarify the nature of the potential drug—drug interactions.
Propylthiouracil-Lnduced Hepatic Damage
Authors: Özenírler Seren , Tuncer Candan , Boztepe Ülver , Akyol Güien , Alkim Hüseyín , Çakir Nurí , Kandílcí Uğur
Published: January 2017

OBJECTIVE:

To report a case of propylthiouracil-induced hepatic damage.

CASE SUMMARY:

A 64-year-old white woman with hyperthyroidism received propylthiouracil 250 mg/d for 1 year. She developed hepatitis after 1 year of therapy. Alcohol and drug abuse were ruled out and all serologic tests for hepatitis A, B, and C were negative. Cytomegalovirus and Epstein-Barr virus infection were also ruled out. Antinuclear antibody, antimitochondrial antibody, and antismooth muscle antibody were negative. The clinical picture was similar to that of viral hepatitis characterized by nausea, vomiting, and jaundice. Histologic examination of a liver biopsy specimen showed chronic active hepatitis. The patient developed cirrhosis during follow-up.

DISCUSSION:

Propylthiouracil is widely used in the treatment of hyperthyroidism. Despite its widespread use, there have been only a few reported cases of propylthiouracil-induced hepatotoxicity. The precise mechanism of the injury is unknown, although immunologic factors are suggested.

CONCLUSIONS:

Hepatic damage induced by propylthiouracil is a rare complication. However, the danger of permanent hepatic damage should be kept in mind. The best way of preventing propylthiouracil hepatotoxicity is careful screening of patients considered for treatment.
Prevention of Recurrent Vaginal Candidiasis with Weekly Terconazole Cream
Authors: Stein Gary E. , Mummaw Nancy L. , Schooley Sharon L.
Published: January 2017

OBJECTIVE:

To investigate the prophylactic use of weekly terconazole 0.8% cream to prevent recurrent episodes of candidal vaginitis.

DESIGN:

Women with a documented history of recurrent candidal vaginitis (≥4 recurrences/y) were enrolled into a secondary prevention trial. None of these women were HIV positive, pregnant, diabetic, or immunosuppressed. Patients were initially treated for a symptomatic episode of candidal vaginitis and then started on weekly applications of terconazole 0.8% cream for 26 weeks. These women were then followed for an additional 26 weeks after therapy.

SETTING:

A university-affiliated medical school.

PARTICIPANTS:

The study population consisted of 22 healthy women aged 19–41 years.

MAIN OUTCOME MEASURES:

Patients were interviewed by phone each week concerning symptoms and compliance. They were also reminded to notify the study investigators any time vaginal symptoms of candidiasis occurred. Patients were examined whenever they developed vaginal symptoms and were treated on the basis of microscopic and culture results.

RESULTS:

Ten patients had 14 symptomatic cases of vaginitis during the prophylactic phase of the study, but Candida spp. were isolated during only 4 of these episodes. One episode was due to bacterial vaginosis and no pathogenic organisms were found in 9 of these cases. Eighteen of the 20 patients who completed the prophylactic phase were followed after therapy and 14 (78%) of these patients had a current case of candidal vaginitis. This incidence of infection was statistically higher than that observed during the treatment period (p < 0.001).

CONCLUSIONS:

Weekly applications of terconazole 0.8% cream were effective in preventing recurrent episodes of candidal vaginitis and were well tolerated.
Assessment of Medication Management Skills in Older Outpatients
Authors: Ruscin> J Mark , Semla Todd P.
Published: January 2017

OBJECTIVE:

To identify risk factors for poor medication management skills in community-dwelling older adults by using a performance-based medication management assessment instrument.

DESIGN:

A cross-sectional investigation.

SETTING:

A university outpatient geriatric assessment clinic.

PARTICIPANTS:

Fifty-nine community-dwelling older adults aged 62–102 years.

MEASUREMENTS:

Patients were assessed on their ability to perform medication management tasks, including reading prescription labels, interpreting medication instructions, opening safety-capped vials, removing tablets from vials, and differentiating tablet colors. The Mini-Mental State Examination (MMSE) was administered and the Katz index of activities of daily living was obtained during the same clinic visit.

RESULTS:

Cognitive impairment (MMSE <24) and physical dependency (Katz ≥1) were both found to be risk factors for the inability to perform individual tasks and independent risk factors for poor overall outcome on the medication management assessment, odds ratios (95% confidence interval) 9.39 (7.82 to 10.96) and 7.24 (5.60 to 8.88), respectively. Age, gender, education, or number of prescription medications were not associated with the ability to perform individual tasks or to overall outcome on the medication management assessment.

CONCLUSIONS:

Cognitive deficits and physical dependency appear to be strong predictors for the inability to perform tasks associated with medication management. Assessment of medication management skills in older adults living in the community may help identify specific problems, aid in planning patient care, and promote independence.
Retrospective Drug Utilization Review Software Systems: Perspectives of State Medicaid Dur Directors
Authors: Armstrong Edward P. , Proteau Diane
Published: January 2017

OBJECTIVE:

To determine the desirability or perceived need of retrospective drug utilization review (DUR) software system characteristics.

DESIGN:

A 32-item questionnaire.

SETTING:

Ambulatory DUR directors covering more than 33 million patients.

PARTICIPANTS:

Medicaid DUR directors from 49 states and the District of Columbia.

MAIN OUTCOME MEASURES:

Five-point Likert scale measures of importance of system and vendor characteristics.

RESULTS:

A 100% response rate was achieved. Respondents rated the ability to change or modify criteria as very important and thought it was important to receive criteria sets from software vendors. Respondents believed cost-savings methodologies should be clearly defined and false positive DUR criteria should be minimized.

CONCLUSIONS:

Through the implementation of the Omnibus Budget Reconciliation Act of 1990, considerable experience in ambulatory DUR programs has been achieved. Respondents believed the ability to change DUR criteria was very important and they thought it was important to have a set of criteria supplied from software vendors. Critical issues of criteria development, cost-savings methodologies, minimizing false positive criteria, and outcomes assessment from DUR programs were important issues to DUR directors.
Barriers to Compliance with OBRA'90 Regulations in Community Pharmacies
Authors: Barnes Jillian M. , Riedlinger June E. , McCloskey William W. , Montagne Michael
Published: January 2017

OBJECTIVE:

To identify which barriers have been most significant to community pharmacists in their ability to comply with the Omnibus Budget Reconciliation Act of 1990 (OBRA'90) regulations during its first year of implementation.

METHODS:

Mailing of a two-page survey in April 1994.

SETTING:

Four hundred randomly selected community pharmacies in the Commonwealth of Massachusetts.

PARTICIPANTS:

Of 400 pharmacies surveyed, 156 surveys were completed and returned for analysis.

RESULTS:

Barriers that were considered most significant to pharmacies surveyed in their ability to implement OBRA'90 regulations were excessive workload, lack of financial compensation, and patients' attitudes. Of least significance were inadequate knowledge about drugs, inadequate references, and store layout. Almost half the responding pharmacists indicated that OBRA'90 regulations had not affected or changed their practice, one-quarter of the pharmacists believed their practice was less rewarding after OBRA'90, and about one-fifth believed it was more rewarding.

CONCLUSIONS:

Community pharmacists in Massachusetts are making an attempt to comply with OBRA'90, but there are specific barriers that are affecting their ability to do so. The OBRA'90 regulations appear to have had little impact on the practice of most community pharmacies. Community pharmacy management needs to examine (1) expanded roles of supportive personnel to give pharmacists more time to spend counseling patients, (2) reimbursement mechanisms for cognitive service, and (3) approaches to educating patients about these changes in the pharmacy profession.
Hyperglycemia Induced by Megestrol Acetate in a Patient with AIDS
Authors: Valle Luis Gonzalez Del , Ambrosio Alicia Herrero , Hernandez Pedro Martinez , Diaz Benito Garcia , Caballero Esperanza Jimenez
Published: January 2017

OBJECTIVE:

To report a case of hyperglycemia induced by megestrol acetate in a patient with AIDS.

CASE SUMMARY:

A 28-year-old man with AIDS developed hyperglycemia requiring insulin therapy 5 days after beginning megestrol therapy. The hyperglycemia resolved with discontinuation of the agent and treatment with insulin, and recurred 2 years later, when megestrol acetate treatment was rechallenged. In this case the patient had developed hyperglycemia and pancreatitis 1 year before, related to pentamidine therapy.

DISCUSSION:

To our knowledge this is the first reported case of hyperglycemia that was induced by megestrol acetate as early as 5 days after beginning therapy and confirmed by rechallenge. The mechanism of action is unclear.

CONCLUSIONS:

Clinicians caring for patients with AIDS-related cachexia should be aware that megestrol acetate can cause a severe but reversible hyperglycemic state.
Meningitis and Hepatitis Complicating Intravenous Immunoglobulin Therapy
Authors: Shorr Andrew F. , Kester Kent E.
Published: January 2017

OBJECTIVE:

To report a case of concomitant meningitis and hepatitis complicating the use of intravenous immune globulin (IVIG).

CASE SUMMARY:

A 39-year-old African-American woman with an autoimmune syndrome developed both acute meningitis and hepatitis following administration of IVIG. These resolved over several days and left no sequellae.

DISCUSSION:

This represents the first case of concomitant acute meningitis and hepatitis associated with IVIG. Thorough microbiologic and serologic evaluation of the patient failed to demonstrate an infectious etiology. We postulate that our patient's syndrome resulted from direct toxicity of IVIG.

CONCLUSIONS:

Both acute meningitis and hepatitis may simultaneously complicate IVIG therapy. The specific mechanism remains unclear.
Inappropriate Prescribing and Health Outcomes in Elderly Veteran Outpatients
Authors: Schmader Kenneth E , Hanlon Joseph T , Landsman Pamela B , Samsa Gregory P , Lewis Ingrid K , Weinberger Morris
Published: January 2017

OBJECTIVE:

To determine the relationship of inappropriate prescribing in the elderly to health outcomes.

SETTING:

General Medical Clinic of the Durham Veterans Affairs Medical Center.

PATIENTS:

A total of 208 veterans more than 65 years old who were each taking five or more drugs and participated in a pharmacist intervention trial.

MEASUREMENTS:

Prescribing appropriateness was assessed by a clinical pharmacist using the medication appropriateness index (MAI). A summed MAI score was calculated, with higher scores indicating less appropriate prescribing. The health outcomes were hospitalization, unscheduled ambulatory or emergency care visits, and blood pressure control.

RESULTS:

Bivariate analyses revealed that mean MAI scores at baseline were higher for those with hospital admissions (18.9 vs. 16.9, p = 0.07) and unscheduled ambulatory or emergency care visits (18.8 vs. 16.3, p = 0.05) over the subsequent 12 months than for those without admissions and emergency care visits. MAI scores for antihypertensive medications were higher for patients with inadequate blood pressure control (> 160/90 mm Hg) than for those whose blood pressure was controlled (4.7 vs. 3.1, p = 0.02).

CONCLUSIONS:

Inappropriate prescribing appeared to be associated with adverse health outcomes. This finding needs to be confirmed in future studies that have larger samples and control for potential confounders.
Reliability of Drug Utilization Evaluation as an Assessment of Medication Appropriateness
Authors: Shelton Penny S , Hanlon Joseph T , Landsman Pamela B , Scott Mollie A , Lewis Ingrid K , Schmader Kenneth E , Samsa Gregory P , Weinberger Morris
Published: January 2017

OBJECTIVE:

To test the reliability of drug utilization evaluation (DUE) applied to medications commonly used by the ambulatory elderly.

METHODS:

A DUE model was developed for four domains: (1) justification for use, (2) critical process indicators, (3) complications, and (4) clinical outcomes. DUE criteria specific to use in the elderly were developed for angiotensin-converting enzyme (ACE) inhibitors and histamine2 (H2)-antagonists, and consensus was reached by an external expert panel. After pilot testing, two clinical pharmacists independently evaluated these medications, applying the DUE criteria and rating each item as appropriate or inappropriate. Interrater and intrarater reliability was assessed by using κ statistics.

RESULTS:

In a sample of 208 ambulatory elderly veterans, 42 (20.2%) were taking an ACE inhibitor and 56 (26.9%) an H2-antagonist. The interrater agreement for individual domains, represented by κ statistics, were 0.10–0.58 and 0–0.83 for ACE inhibitors and H2-antagonists, respectively. The κ statistic for overall agreement, which considered ratings from all criteria across all domains, was 0.24 for ACE inhibitors and 0.18 for H2-antagonists. Intrarater reliability was assessed 3 months later, and κ statistics were 0.61–0.65 (0.49 overall) and 0–0.96 (0.81 overall) for ACE inhibitors and H2-antagonists, respectively.

CONCLUSIONS:

Intrarater reliability for DUE was good to excellent. However, interrater reliability exhibited only marginal reproducibility, particularly where evaluators were required to use subjective judgment (i.e., complications, clinical outcomes). DUE may not be a suitable standard for assessing medication appropriateness in ambulatory elderly patients.
Development of an Intravenous-to-Oral Route Conversion Program for Antimicrobial Therapy at a Canadian Tertiary Care Health Facility
Authors: Zamin Monique T , Pitre Monique M , Conly John M
Published: January 2017

OBJECTIVE:

To describe the effect of introducing a route conversion program on the prescribing of antimicrobials for the treatment of respiratory tract infections and skin/soft tissue infections in a sample population.

DESIGN:

Concurrent, pre- and postintervention study.

SETTING:

Four general internal medicine wards at The Toronto Hospital, a 1170-bed, tertiary care health center in Toronto, Ontario, Canada.

PARTICIPANTS:

Patients receiving antimicrobial therapy for respiratory tract infections and skin/soft tissue infections.

INTERVENTION:

Written guidelines and education sessions were presented to residents, interns, medical students, and pharmacists responsible for the care of patients admitted to four general internal medicine wards.

MAIN OUTCOME MEASURES:

Clinical and laboratory parameters related to the status of the infection were monitored prospectively and compared with the course of drug therapy, with consideration of the patient's ability to meet the criteria established in the guidelines. The number of days of intravenous therapy prescribed despite appropriateness of oral therapy was tallied.

RESULTS:

Twenty-seven patients (28 infections) were identified for inclusion in the 7-week preliminary audit, and 30 patients (32 infections) were included in the audit after the program, which continued for 5 weeks. Following implementation of the program, the number of days that intravenous therapy was continued despite the appropriateness of oral therapy was reduced from 41% to 26% of the total days of intravenous therapy prescribed.

CONCLUSIONS:

The program had a positive influence on antimicrobial prescribing behavior in the population studied. Strategies to ensure continued benefit from the program have been developed.
Interaction between Quinupristin/Dalfopristin and Cyclosporine
Authors: Stamatakis Mary K , Richards Joelyn G
Published: January 2017

OBJECTIVE:

To describe a case of a drug interaction between cyclosporine and quinupristin/dalfopristin (QND).

CASE SUMMARY:

A patient who had undergone a kidney transplant and was receiving chronic cyclosporine therapy was treated with the investigational streptogramin antibiotic QND. Baseline trough cyclosporine concentrations ranged from 80 to 105 ng/mL. Two and 3 days after initiation of QND therapy, trough cyclosporine concentrations increased to 261 and 291 ng/mL, respectively. Following discontinuation of QND, the cyclosporine blood concentration decreased and the dosage was subsequently increased to the previous regimen.

DISCUSSION:

A patient's cyclosporine blood concentration tripled 3 days after initiating therapy with QND. A one-third reduction in the cyclosporine dosage was required. QND was the most likely cause for the change in cyclosporine blood concentrations, probably due to inhibition of cyclosporine metabolism. This represents the first published case of an interaction between cyclosporine and QND.

CONCLUSIONS:

Frequent monitoring of cyclosporine concentrations with attention to the need for dosage modification is recommended when initiating or discontinuing QND therapy.
Combination of Low-Dose Niacin and Pravastatin Improves the Lipid Profile in Diabetic Patients without Compromising Glycemic Control
Authors: Gardner Stephanie F , Marx Michael A , White Laura M , Granberry Mark C , Skelton David R , Fonseca Vivian A
Published: January 2017

OBJECTIVE:

To determine the efficacy and tolerability of the addition of low-dose niacin (1.5 g/d) in a diabetic hypercholesterolemic population who were unable to attain desired lipid control with low-dose (20 mg) pravastatin monotherapy.

RESEARCH DESIGN AND METHODS:

This was a prospective, open-label study conducted over a 14-week period. Twenty-three diabetic patients with low-density lipoprotein (LDL) cholesterol concentrations of at least 150 mg/dL after dietary therapy were recruited from the outpatient diabetes clinic of a university teaching hospital. After 4 weeks of dietary stabilization and baseline determination of the lipid profile and glycemic control, patients received pravastatin 20 mg once daily for 4 weeks. Laboratory parameters were reassessed and niacin was added to the regimen in qualifying patients. Over 2 weeks, patients' regimens were titrated to a maximal dosage of 500 mg tid. Patients continued to receive the combination regimen for 4 weeks and were reassessed.

MEASUREMENTS AND MAIN RESULTS:

Sixteen patients (14 non-insulin-dependent diabetes mellitus, 2 insulin-dependent diabetes mellitus) completed the study. Mean fasting blood sugar and fructosamine concentrations were unchanged throughout the study. Five patients required minor alterations (3 increased, 2 decreased) in their hypoglycemic regimens during the study. The addition of low-dose niacin to pravastatin therapy resulted in a significant lowering of LDL cholesterol compared with pravastatin monotherapy.

CONCLUSIONS:

Low-dose niacin is a promising addition to hydroxymethylglutaryl-coenzyme A reductase inhibitor therapy in the treatment of hypercholesterolemia in patients with diabetes mellitus.
Assessment of the Enzymuria Resulting from Gentamicin Alone and Combinations of Gentamicin with Various β-Lactam Antibiotics
Authors: Nix David E , Thomas Jennifer K , Symonds William T , Spivey J Michael , Wilton John H , Gagliardi Nick C , Schentag Jerome J
Published: January 2017

OBJECTIVE:

To determine the propensity of β-lactam antimicrobials to ameliorate or potentiate aminoglycoside-induced renal enzymuria.

DESIGN:

Two open, randomized, double-blind, parallel-group studies were conducted in young, healthy, male volunteer subjects. Using a common protocol, 24-hour urine collections were analyzed for the renal tubular enzymes alanine aminopeptidase (AAP) and N-acetyl-β-d-glucosaminidase (NAG), as well as for creatinine. Antimicrobial combinations studied included gentamicin plus placebo and gentamicin plus ticarcillin/clavulanate (protocol 1); and gentamicin plus placebo, gentamicin plus piperacillin, and gentamicin plus ceftazidime (protocol 2). The antimicrobial regimens were administered for 7 days. Eight subjects completed each treatment group.

RESULTS:

There were no significant differences between treatment groups with regard to urine creatinine excretion or serum gentamicin concentrations in either protocol. Enzymuria (AAP [p = 0.039] and NAG [p = 0.337]) was decreased in the gentamicin plus ticarcillin/clavulanate treatment compared with that in the gentamicin plus placebo treatment. Increased enzymuria, as indicated by increased urine concentrations of AAP and NAG, was observed in the gentamicin plus ceftazidime treatment (p < 0.05) compared with the other two treatments.

CONCLUSIONS:

Based on relative enzymuria, ticarcillin/clavulanate may be renal protective. Piperacillin neither potentiated nor ameliorated aminoglycoside-induced enzymuria. Since acute elevations in AAP and NAG reflect insults to the kidney, these studies suggest that ceftazidime may enhance aminoglycoside- induced renal injury. Piperacillin had no effect on enzymuria and would appear not to enhance or protect against aminoglycoside- induced renal injury.
Isradipine Therapy in Hypertensive Pediatric Patients
Authors: Johnson Cary E , Jacobson Pamala A , Song Min H
Published: January 2017

OBJECTIVE:

To evaluate the dosage and effectiveness of isradipine to control acute or chronic hypertension in pediatric patients.

DESIGN:

Retrospective medical record review.

SETTING:

University teaching hospital.

PARTICIPANTS:

Hospitalized pediatric patients aged 1 day to 16 years with hypertension treated with isradipine between January 1994 and March 1996.

MEASURES:

Patient age, gender, weight, disease states, current medications, isradipine dosage and formulation, pre- and postsystolic, and pre- and postdiastolic blood pressure measurements with each dose of isradipine.

RESULTS:

Fifty-three patients with a mean age of 5.8 ± 4.0 years were evaluated. A mean change in the blood pressure measurements taken before the first dose of isradipine compared with the values recorded after the last dose or at discharge for all patients was −11.8% ± 12.5% and −17.4% ± 19.6%, respectively, for systolic and diastolic pressure. The mean dosage of isradipine in 46 patients who received regularly scheduled doses was 0.38 ± 0.22 mg/kg/d. Patients who demonstrated a response received a mean dosage of 0.40 ± 0.20 mg/kg/d. The total daily dosage was administered in one dose for 1 patient, two doses for 15 patients, three doses for 27 patients, and four doses for 3 patients.

CONCLUSIONS:

Isradipine was an effective antihypertensive agent to reduce the systolic and/or diastolic blood pressure 10% or more compared with pretreatment measurements in 43 (81 %) of 53 pediatric patients. The mean dosage was 0.38 ± 0.22 mg/kg/d, most frequently administered in two or three equally divided doses, which is higher than the normal recommended dosage for adults.
The Use of Alternate-Day Lovastatin in Hypercholesterolemic Men
Authors: Dennis Vincent C , Britton Mark L , Sirmans Susan M , Letassy Nancy A , Freeman Dale A
Published: January 2017

OBJECTIVE:

To quantitate the therapeutic effects of alternate-day lovastatin on serum lipoprotein values in a small group of men with primary hypercholesterolemia.

DESIGN:

Retrospective review of medical, pharmacy, and laboratory records. A paired Student's t-test was performed on absolute changes in lipoprotein values with an a priori p value less than or equal to 0.05 being statistically significant.

SETTING:

A lipid clinic within a tertiary care Department of Veterans Affairs Medical Center.

PATIENTS:

Twenty men (mean age 62.5 ± 8.3 y) with mean ± SD baseline low-density lipoprotein cholesterol (LDL-C) concentration of 161.3 ± 21.9 mg/dL and triglyceride concentrations below 400 mg/dL.

INTERVENTION:

All patients had been prescribed lovastatin 20 mg every other day.

MAIN OUTCOME MEASURES:

The mean absolute and percent changes in lipoprotein values from baseline for patients receiving lovastatin 20 mg every other day and the percentage of patients attaining a target mean LDL-C concentration as defined by the National Cholesterol Education Panel Adult Treatment Panel II guidelines.

RESULTS:

Mean ± SD total cholesterol and LDL-C were significantly reduced by 32.4 ± 17.8 (14.0% ± 7.8%) and 34.1 ± 14.6 mg/dL (21.5% ± 9.7%), respectively. No significant changes were seen in high- density lipoprotein cholesterol or triglycerides. Four of 20 patients (20%) attained a goal LDL-C concentration.

CONCLUSIONS:

Lovastatin 20 mg every other day may effectively lower LDL-C in some elderly men, and target LDL-C concentrations may be obtained in some patients.
Trimethoprim/Sulfamethoxazole-Induced Hypoglycemia in a Patient with Acute Renal Failure
Authors: Lee Audrey J , Maddix Daniel S
Published: January 2017

OBJECTIVE:

To report a case of trimethoprim/sulfamethoxazole (TMP/SMX)-induced hypoglycemia in a patient with acute renal failure.

DATA SOURCES:

English-language references identified via a MEDLINE search from January 1966 to August 1996 and a bibliographic review of pertinent articles.

DATA SYNTHESIS:

Similar to sulfonylureas, sulfonamides are thought to cause hypoglycemia by increasing pancreatic secretion of insulin. To date, nine cases of TMP/SMX-induced hypoglycemia have been reported in the literature. This case represents the second report in which a patient experienced TMP/SMX-induced hypoglycemia that resolved after the dosage was adjusted for the patient's decreased renal function. This case involved a 73-year-old comatose white man initiated on high-dose TMP/SMX for nosocomial pneumonia caused by Stenotrophomonas maltophilia. After 5 days of therapy, the patient presented with severe hypoglycemia that persisted over 8 hours despite multiple intravenous bolus doses and infusions of dextrose. The patient had several risk factors that may have compounded his risk for hypoglycemia, including food deprivation and acute renal failure. After management with dextrose and dose adjustment of the patient's TMP/SMX regimen according to renal function, the hypoglycemia resolved.

CONCLUSIONS:

TMP/SMX may cause reversible hypoglycemia that may be prolonged (approximately 12 h), particularly in patients with risk factors for hypoglycemia. Common risk factors include compromised renal function, prolonged fasting conditions, malnutrition, and the use of excessive doses. Patients with these risk factors should be monitored closely and, more importantly, initiated on a dosing regimen adjusted for renal impairment.
Possible Toxic Encephalopathy following High-Dose Intravenous Haloperidol
Authors: Maxa Jan L , Taleghani Akram M , Ogu Chris C , Tanzi Mario
Published: January 2017

OBJECTIVE:

To describe a case of possible toxic encephalopathy in a surgical patient receiving high-dose intravenous haloperidol.

CASE SUMMARY:

A 54-year-old African-American man was admitted for spinal fusion. His medical history included bipolar disorder and a cerebrovascular accident. His recovery from surgery was complicated by the development of agitation, which was treated with increasing doses of intravenous haloperidol. An electroencephalogram was consistent with toxic encephalopathy. The patient's mental status returned to normal 8 days after discontinuation of haloperidol.

DISCUSSION:

High-dose intravenous haloperidol for severe agitation has been reported as an effective and safe treatment option for the hospitalized patient. We report the occurrence of toxic encephalopathy in a patient who received high-dose intravenous haloperidol.

CONCLUSIONS:

Caution should be used when high-dose intravenous haloperidol is used in an agitated patient. If the patient's clinical response is paradoxical to what is anticipated and the resulting agitation is mistakenly attributed to inadequate treatment, increasingly higher doses may only aid in the development of toxic encephalopathy.