bluuebunny/crossref_metadata_2025 huggingface dataset:
A new combination in Thelypteridaceae
Authors: Mazumdar Jaideep
Published: September 2013

Sledge (1981) described the fern Trigonospora obtusiloba Sledge (1981: 18) of Thelypteridaceae as a new endemic species from Sri Lanka. Fraser-Jenkins (2008: 595) suspected that this species was a probable synonym of Cyclosorus caudipinna (Ching) Panigrahi (1993: 66) but it differs from C. caudipinna in smaller size and lack of caudate pinnae apices (Sledge 1981). It can further be distinguished by its strongly dimorphic fronds, i.e., fertile fronds have narrower pinnae and longer stipes than sterile fronds. This is clearly evident in all specimens listed below and has not been reported from any other species of Cyclosorus subgenus Trigonospora (Holttum) Panigrahi (1991: 13). Since the opinion of Fraser-Jenkins (2008) is not supported, it is logical to maintain T. obtusiloba as a distinct species until further molecular data clarify its position. According to present generic concept of Thelypteridaceae (Christenhusz et al. 2011, Rothfels et al. 2012) T. obtusiloba should be transferred to Cyclosorus Link (1833: 128) and consequently a new combination under Cyclosorus is proposed here.
A Closure for Updraft–Downdraft Representation of Subgrid-Scale Fluxes in Cloud-Resolving Models
Authors: Moeng Chin-Hoh
Published: September 2013

A closure relationship between subgrid-scale (SGS) updraft–downdraft differences and resolvable-scale (RS) variables is proposed and tested for cloud-resolving models (CRMs), based on a data analysis of a large-eddy simulation (LES) of deep convection. The LES flow field is partitioned into CRM-RS and CRM-SGS using a cutoff scale that corresponds to a typical CRM grid resolution. This study first demonstrates the capability of an updraft–downdraft model framework in representing the SGS fluxes of heat, moisture, and momentum over the entire deep convection layer. It then formulates a closure scheme to relate SGS updraft–downdraft differences to horizontal gradients of RS variables. The closure is based on the idea that largest SGS and smallest RS motions are spectrally linked and hence their horizontal fluctuations must be strongly communicated. This relation leads to an SGS scheme that expresses vertical SGS fluxes in terms of horizontal gradients of RS variables, which differs from conventional downgradient eddy diffusivity models. The new scheme is shown to better represent the forward and backscatter energy transfer between CRM-RS and CRM-SGS components than conventional eddy-viscosity models.
The gender gap in the business elite
Authors: Bihagen Erik , Nermo Magnus , Stern Charlotta
Published: September 2013

Using unique Swedish register data on all employees in large private companies, we study trends in the gender composition of top wage employees from 1993 to 2007. The analyses reveal that the likelihood of women holding top wage positions has more than doubled since the early 1990s, but men are still markedly over-represented in this group of employees. We focus on educational choices, considering level and field of study as well as university attended. One important conclusion is that, although education is important in reaching a top wage position, field of education and university attended only marginally explain the gender gap. However, relative to other women, having a career signalling degree (i.e. economics, law or engineering) from a more prestigious university helps women. Dividing the sample into different cohorts indicates that the gender gap is partly a cohort effect, i.e. it is smaller among those born in the 1960s compared to cohorts born in the 1940s and 1950s. It should be noted that there is still a gender gap among employees born in the 1960s and that the gap widens after age 30. Future studies should focus more deeply on this family-related ‘period of divergence’.
‘Volto di Medusa’: Monumentalizing the self in Petrarch's Rerum vulgarium fragmenta
Authors: Feng Aileen A
Published: September 2013

Scholarship on Petrarch has generally intepreted the figure of Laura-as-Medusa as a projection of the poet's internal conflict between sacred and profane love. Such a reading takes Medusa as a threat to Petrarch's agency. Yet Petrarch's Laura-Medusa is suggestively figured as only her disembodied head, a weapon ultimately manipulated by Perseus. This reversal of agency has an impact on Petrarch's complicated theory of poetic inspiration, and reaches beyond the relationship between poet and beloved to encompass another fraught paradigm of power: the relationship between poet and patron. By recalling the disembodied head of Medusa in the figure of Laura, and recovering the political symbolism of the appropriation of her petrifying gaze, Petrarch creates a model of poetic agency that he uses to stage his relationship to patronage in the Latin Africa and a poem addressed to his Colonna patrons.
Bringing it all back home? Social media practices by Swedish municipalities
Authors: Larsson Anders Olof
Published: September 2013

Since the mid-1990s, the Internet has often been pointed to as having the potential for reinvigorating democratic processes. While such overly optimistic claims have largely been disproven by empirical research, a similar rhetoric is now commonly heard in conjunction with the rise of so-called social media like Twitter or Facebook. This study assesses social media practices by politicians on the local level. Featuring a quantitative structural analysis of social media practices by all 290 Swedish municipalities, the study gauges the spread of these types of emerging online platforms in local governments and uses statistical analyses to explain the observed variations. Results indicate that the uptake of social media by municipality governments is slow and in some cases decreasing, perhaps due to the legal and operational risks involved. Overall, the study mainly supports the normalization hypothesis, concluding that offline patterns of municipality characteristics are largely translatable to the online also in the era of ‘Web 2.0’.
Physically routing robots in a multi-robot network: Flexibility through a three-dimensional matching graph
Authors: Liu Lantao , Shell Dylan A
Published: September 2013

Many multi-robot scenarios involve navigation of a set of networked robots through a constrained environment to achieve coverage, maintain a predefined shape, sense at predefined locations, or to satisfy some other distance-defined property. When new robots and tasks are added to a network of already deployed interchangeable robots, a trade-off arises in seeking to minimize cost to execute the tasks and the level of disruption to the system. This paper examines a navigation-oriented variant of this problem in which robots are physically routed through an existing network. We propose a parametrizable method to tune emphasis between minimizing global travel cost (or energy, or distance), minimizing interruption (i.e. obtaining the fewest number of robot reassignments), reducing travel distance per robot, and completing all operations as soon as possible. Since these are related optimization criteria, a single parameter provides sufficient flexibility to balance between them.

Paths through the network are computed via a task-allocation formulation in which destination locations of newly deployed robots are added as tasks to an existing allocation. We adapt the graph matching variant of the Hungarian Algorithm—originally designed to solve the optimal assignment problem in complete bipartite graphs—to construct routing paths in sparse networks. We do this by constructing a three-dimensional graph that incorporates logical aspects of the Hungarian bipartite graph, and spatial elements of the Euclidean graph. The approach has several useful features including being particularly effective at generating multiple simultaneous, non-interfering paths. When new agent–task pairs are inserted, the assignment is globally reallocated in an incremental fashion so that it requires only linear time when the robots’ traversal options have bounded degree. The algorithm is studied systematically in simulation and also validated with physical robots.
Effect of Platelet-Rich Plasma and Porcine Dermal Collagen Graft Augmentation for Rotator Cuff Healing in a Rabbit Model
Authors: Chung Seok Won , Song Byung Wook , Kim Yeun Ho , Park Kyoung Un , Oh Joo Han
Published: September 2013

Background:

The rate of healing failure after surgical repair of chronic rotator cuff tears is considerably high.

Purpose:

To verify the effect of platelet-rich plasma (PRP) with and without porcine dermal collagen graft augmentation on tendon-to-bone healing, using the rabbit supraspinatus tendon.

Study Design:

Controlled laboratory study.

Methods:

A total of 80 rabbits were randomly allocated into 4 groups (20 rabbits per group: 12 for histological and 8 for mechanical testing): repair (R), repair + patch augmentation (RPa), repair + PRP (RPr), and repair + patch + PRP (RPaPr). The right shoulder was used for experimental interventions, and the left served as a control. Six weeks after the detachment of the supraspinatus, the torn tendon was repaired in a transosseous manner, simulating double-row repair in all groups. Platelet-rich plasma was prepared and applied onto the repair site in the RPr and RPaPr groups, and the patch was used to augment the repair in the RPa and RPaPr groups. The mechanical tensile strength test was performed at 8 weeks after repair and the histological evaluation at 4 and 8 weeks.

Results:

At 4 weeks, the collagen fibers were poorly organized, and fiber continuity was not established in all groups. However, vascularity and cellularity were higher with granulation tissue formation in the PRP-treated groups (RPr and RPaPr) than the nontreated groups (R and RPa). At 8 weeks, tendon-to-bone integration was much improved with more collagen fibers, and longitudinally oriented collagen fibers were visible in all groups. The PRP-treated groups showed better collagen fiber continuity and orientation than the nontreated groups; however, no distinctive difference was found between the patch-augmented groups (RPa and RPaPr) and nonaugmented groups (R and RPr). The mean load-to-failure results were 61.57 ± 29.99 N, 76.84 ± 16.08 N, 105.35 ± 33.82 N, and 117.93 ± 12.60 N for the R, RPa, RPr, and RPaPr groups, respectively, and they were significantly different between the R and RPr ( P = .018), R and RPaPr ( P = .002), and RPa and RPaPr ( P = .029) groups.

Conclusion:

This animal study showed the enhancement of tendon-to-bone healing after local administration of autologous PRP assessed by histological and biomechanical testing in a rabbit model of chronic rotator cuff tears. However, there was little additive effect of the patch graft.

Clinical Relevance:

The use of PRP might be a biological supplement to increase the rotator cuff healing rate, which still remains low even after successful cuff repair, but this result should be interpreted with caution regarding clinical applications.
Acute Transverse Myelitis Associated With Human Parvovirus B19 Infection
Authors: Suzuki Masashi , Yoto Yuko , Ishikawa Aki , Asakura Hirofumi , Tsutsumi Hiroyuki
Published: September 2013

We describe severe acute transverse myelitis in a previously healthy 9-year-old boy in whom primary human parvovirus B19 infection was confirmed serologically and B19 DNA was detected in his serum and cerebrospinal fluid. Besides erythema infectiosum, parvovirus B19 infection has various clinical manifestations; however, central nervous system involvement is rare. Even more unusual is parvovirus B19–associated acute transverse myelitis.
The frequency of and associations with hospitalization secondary to lupus flares from the 1000 Faces of Lupus Canadian cohort
Authors: Lee J , Peschken CA , Muangchan C , Silverman E , Pineau C , Smith CD , Arbillaga H , Zummer M , Clarke A , Bernatsky S , Hudson M , Hitchon C , Fortin PR , Pope JE
Published: September 2013

Objectives

Hospitalization is a major factor in health care costs and a surrogate for worse outcomes in chronic disease. The aim of this study was to determine the frequency of hospitalization secondary to lupus flare, the causes of hospitalization, and to determine risk factors for hospitalization in patients with systemic lupus erythematosus (SLE).

Methods

Data were collected as part of the 1000 Canadian Faces of Lupus, a prospective cohort study, where annual major lupus flares including hospitalizations were recorded over a 3-year period.

Results

Of 665 patients with available hospitalization histories, 68 reported hospitalization related to a SLE flare over 3 years of follow-up. The average annual hospitalization rate was 7.6% (range 6.6–8.9%). The most common reasons for hospitalization were: hematologic (22.1%), serositis (20.6%), musculoskeletal (MSK) (16.2%), and renal (14.7%). Univariate risk factors for lupus hospitalization included (OR [95% CI]; p < 0.05): juvenile-onset lupus (2.2 [1.1–4.7]), number of ACR SLE criteria (1.4 [1.1–1.7], baseline body mass index (BMI) (1.1 [1.0–1.1]), psychosis (3.4 [1.2–9.9]), aboriginal race (3.2 [1.5–6.7]), anti-Smith (2.6 [1.2–5.4]), erythrocyte sedimentation rate >25 mm/hr (1.9 [1.1–3.4]), proteinuria >0.5 g/d (4.2 [1.9–9.3], and SLAM-2 score (1.1 [1.0–1.2]). After multivariate regression only BMI, number of ACR criteria, and psychosis were associated with hospitalization for lupus flare.

Conclusions

The mean annual rate of hospitalization attributed to lupus was lower than expected. Hematologic, serositis, MSK and renal were the most common reasons. In a regression model elevated BMI, more ACR criteria and psychosis were associated with hospitalization.
Effect of Factor XIII-A Val34Leu Polymorphism on Myocardial Infarction Risk
Authors: Chen Fei , Qiao Qi , Xu Peng , Fan Bing , Chen Zaoping
Published: September 2013

The association between factor XIII-A (FXIII-A) Val34Leu polymorphism and myocardial infarction (MI) risk remained controversial. We performed a meta-analysis. Online databases were searched. Twenty-eight studies were included. The FXIII-A Val34Leu polymorphism was significantly associated with MI risk (odds ratio (OR) = 0.83, 95% confidence interval [CI] 0.76-0.91; P < .0001). This result remained statistically significant when the adjusted ORs were combined (OR = 0.77, 95% CI 0.65-0.92; P = .004). When stratifying for race, this polymorphism showed decreased MI risk in Caucasians. In the subgroup analysis by age group, significant associations were observed in early-onset patients and in late-onset patients. In the subgroup analysis by gender, there was a significant association in women but not in men. In the subgroup analysis stratified by smoking status, MI risk was decreased in both smokers and nonsmokers. This study suggested that FXIIIA Val34Leu polymorphism was a protective factor for MI in caucasians.
Propagation of torsional wave in a composite layer overlying an anisotropic heterogeneous half-space with initial stress
Authors: Dhua Sudarshan , Singh Abhishek Kumar , Chattopadhyay Amares
Published: September 2013

In this paper we have discussed the propagation of torsional wave in a composite layer overlying an anisotropic heterogeneous half space with initial stress. The method of separation of variables is applied to find the dispersion equation. Numerical results analyzing the dispersion equation are discussed and presented by means of graphs. The effect of reinforcement, inhomogeneity parameter and the initial stress on the propagation of torsional surface wave is the main objective in our study. It has been observed that the directional rigidities of the half space have a favoring effect on the phase velocity, whereas the density and initial stress parameter in the half-space have the adverse effect on the velocity of torsional surface wave. It is remarkable to quote that reinforcement prevails in the medium, the phase velocity increases significantly.
Hydrodynamic cavitation kills prostate cells and ablates benign prostatic hyperplasia tissue
Authors: Itah Zeynep , Oral Ozlem , Perk Osman Yavuz , Sesen Muhsincan , Demir Ebru , Erbil Secil , Dogan-Ekici A Isin , Ekici Sinan , Kosar Ali , Gozuacik Devrim
Published: September 2013

Hydrodynamic cavitation is a physical phenomenon characterized by vaporization and bubble formation in liquids under low local pressures, and their implosion following their release to a higher pressure environment. Collapse of the bubbles releases high energy and may cause damage to exposed surfaces. We recently designed a set-up to exploit the destructive nature of hydrodynamic cavitation for biomedical purposes. We have previously shown that hydrodynamic cavitation could kill leukemia cells and erode kidney stones. In this study, we analyzed the effects of cavitation on prostate cells and benign prostatic hyperplasia (BPH) tissue. We showed that hydrodynamic cavitation could kill prostate cells in a pressure- and time-dependent manner. Cavitation did not lead to programmed cell death, i.e. classical apoptosis or autophagy activation. Following the application of cavitation, we observed no prominent DNA damage and cells did not arrest in the cell cycle. Hence, we concluded that cavitation forces directly damaged the cells, leading to their pulverization. Upon application to BPH tissues from patients, cavitation could lead to a significant level of tissue destruction. Therefore similar to ultrasonic cavitation, we propose that hydrodynamic cavitation has the potential to be exploited and developed as an approach for the ablation of aberrant pathological tissues, including BPH.
Efficacy of Urokinase and Alteplase to Reopen Occluded Central Venous Catheters in Children
Authors: Bussières Jean-François , Therrien Roxane , David Michèle , Leclair Jean-Pierre , Harel François
Published: September 2013

Objective:

To compare the efficacy of alteplase with that of urokinase (UK) in restoring the patency of occluded central venous catheters in children.

Study Design:

Retrospective case–control study at Hôpital Ste-Justine, a pediatric teaching hospital.

Results:

87 UK and 46 alteplase prescriptions were studied. Alteplase was effective in 93.2% of cases of occluded central venous catheters and UK in 54.5% of cases (p < 0.001).

Conclusions:

Alteplase was clearly superior to UK for restoring the patency of occluded central venous catheters in children. The study is limited by its retrospective design.
Pioglitazone Used for Reduction in Clozapine-Associated Hypertriglyceridemia
Authors: Lea Jessica Wehner , Stoner Steven C
Published: September 2013

Objective:

To report a case of reduction of triglycerides and hemoglobin (Hb)A1C concentrations as a result of the use of the thiazolinedione pioglitazone in a psychiatric patient stabilized on clozapine therapy.

Case Summary:

A 49-year-old obese white man, who had uncontrolled diabetes and elevated triglycerides, was stabilized on an antipsychotic regimen using clozapine. After failing sulfonylurea therapy, metformin therapy, and fibric acid therapies, pioglitazone was used to reduce fasting blood glucose and HbA1c concentrations and reduce mean triglyceride concentrations.

Discussion:

Because of the necessity to keep this patient on his current antipsychotic medication and the possible association of exacerbation of diabetes and lipid abnormalities with clozapine, it was necessary to attempt to control the patient's blood glucose and triglycerides through therapeutic means. Numerous attempts to use other diabetic therapies failed. After the addition of pioglitazone to the patient's regimen, significant improvement was observed in the laboratory values, indicating an improvement in diabetes control.

Conclusions:

It appears that pioglitazone has played a role in reducing fasting plasma glucose concentrations and improving insulin sensitivity, while reducing triglycerides and increasing high-density lipoprotein concentrations in this patient. Expanded trials and further investigation are recommended to evaluate the clinical utility of pioglitazone in antipsychotic-associated diabetes and lipid abnormalities.
Various Dosing Weights and Correction to Serum Digoxin Assays in Hemodialysis Patients
Authors: Hirata Sumio , Uenishi Koji , Izumi Satoshi , Furukubo Taku , Ota Miyuki , Fujita Minori , Yamakawa Tomoyuki , Ohtani Hisakazu , Sawada Yasufumi
Published: September 2013

Background:

Digoxin is distributed in skeletal muscles in high concentrations. The most reliable parameter to measure the distribution of digoxin in patients undergoing hemodialysis is not known.

Objective:

To estimate which distribution parameter—estimated lean body mass (E-LBM) calculated by subtracting the fat mass from the dry weight, lean body mass, dry weight, and ideal body weight—is the most reliable predictor for assessing the accuracy of a digoxin dosing regimen in patients undergoing hemodialysis.

Methods:

A retrospective study was conducted to evaluate 21 patients undergoing hemodialysis who were administered digoxin. The patients were divided into 2 groups: digoxin 0.125 mg administered twice a week (low-dose group) or 3 times per week (high-dose group). The differences between E-LBM, lean body mass, dry weight, and ideal body weight for the low- and high-dose groups were determined. The relationships between serum digoxin concentrations and the weekly digoxin dose per E-LBM, lean body mass, dry weight, and ideal body weight were also determined.

Results:

E-LBM, lean body mass, dry weight, and ideal body weight in the high-dose group were significantly larger than those in the low-dose group (p = 0.021, 0.015, 0.024, and 0.0029, respectively), although no significant difference in serum digoxin concentrations was evident. Significant correlation was found between serum digoxin concentrations and the weekly digoxin dosage per E-LBM, dry weight, lean body mass, and ideal body weight (r = 0.746, p < 0.0001; r = 0.638, p = 0.0014; r = 0.645, p < 0.0011; r = 0.553, p = 0.0083, respectively).

Conclusions:

E-LBM appears to reflect the best parameter for predicting serum digoxin concentrations. The use of the dry weight parameter could be generally useful for adjusting the dosage of digoxin in patients undergoing hemodialysis.
Continuing Professional Development in Pharmacy
Authors: Rouse Michael J
Published: September 2013

Objective:

To summarize a resource document that explains the concept and components of continuing professional development (CPD) for pharmacists, describes some of the drivers behind the reevaluation of current systems of continuing pharmacy education (CE), defines relevant terms, and outlines some experiences with CPD in selected countries that have already adopted the model.

CPD is an approach to lifelong learning being discussed as a potential model for pharmacists in the United States. CPD does not replace CE, but quality-assured CE is an essential component of CPD. Evidence is mounting, however, that traditional methods of CE do not adequately meet the lifelong learning and professional development needs of health care professionals (HCPs) and are not always successful in affecting practice behavior and improving patient outcomes. The Institute of Medicine has concluded that the education and training of HCPs are in need of major overhaul. CPD, which is based on sound principles and adopts educational strategies that have been shown to be effective, potentially offers a quality improvement to the current systems for pharmacist CE.

Conclusion:

Interest in and support for the concept of CPD is growing. Case studies of successful implementation in the United States and other countries now exist. Further discussion on the implications of widespread implementation for pharmacists in the United States is needed.
Long-Acting Angiotensin-Converting Enzyme Inhibitors in Congestive Heart Failure: Does Multiple-Daily Dosing Provide Additional Benefit over Once-Daily Dosing?
Authors: Belgeri Myra T
Published: September 2013

Objective:

To determine if there is clinical evidence supporting the use of twice-daily long-acting angiotensin-converting enzyme (ACE) inhibitors in congestive heart failure (CHF).

Data Sources:

Articles were identified through searches of MEDLINE and PubMed (1966–June 2005). Search terms included angiotensin-converting enzyme inhibitors, congestive heart failure, dosing, dosing schedules, captopril, enalapril, fosinopril, lisinopril, quinapril, ramipril, and trandolapril. Only articles published in English were included. Additionally, bibliographies of articles cited were used to identify additional articles.

Study Selection and Data Extraction:

All available articles identified by the data sources were reviewed and those deemed relevant to the review were included.

Data Synthesis:

Data have suggested that long-acting ACE inhibitors are more effective than short-acting ACE inhibitors for the treatment of CHF. A few ACE inhibitors approved for the treatment of CHF have twice-daily dosing schedules; these same ACE inhibitors have once-daily dosing schedules when used in the treatment of hypertension. Recent data propose greater adrenergic blockage, and, thus, decreased stimulation of the renin–angiotensin–aldosterone system, with the twice-daily dosing schedule of the long-acting ACE inhibitors. This controversy has led some providers to prescribe all long-acting ACE inhibitors twice daily in the setting of CHF, which, when unnecessary, can lead to decreased compliance, increased morbidity, and decreased quality of life.

Conclusions:

The available clinical studies comparing dosing schedules of long-acting ACE inhibitors have many limitations. Until a well-designed, randomized, double-blind trial of appropriate duration evaluating clinical outcomes is conducted, multiple-daily dosing schedules do not provide additional benefit over once-daily dosing schedules of long-acting ACE inhibitors in the treatment of CHF.
Surveying Physicians' Attitudes about Herbal Supplements, Resources, and Pharmacy Consultations
Authors: Bouwmeester Carla J
Published: September 2013

Objective:

To investigate whether physicians discuss herbal supplement use with their patients and document this information in the medical record, to determine the perceived barriers to discussing herbal supplement use, and to assess all resources currently available to physicians in their office setting and additional resources needed to answer questions about herbal supplements.

Methods:

An electronic survey was conducted of physicians enrolled in a managed care electronic network as of November 2002; data were collected from December 2002 through March 2003.

Results:

Of the 203 physicians who responded to the survey, 18% always discussed herbal supplements with their patients, 57% sometimes carried on these discussions, 21% rarely did, and 4% never asked. These responses correlated roughly with how often herbal supplement use was documented in the medical chart (always 27%, sometimes 51%, rarely 20%, never 2%). The strongest barriers to discussing herbal supplements were lack of resources and lack of time. The largest number of physicians used Web sites or print resources for information on herbal supplements. The most preferred resources were Web sites, computer databases, and pharmacy consultations.

Conclusions:

Awareness of herbal supplement use is vital for the healthcare practitioner to deliver comprehensive health services. Physicians' attitudes regarding herbal supplements are influenced by the resources available and by personal bias. Pharmacists can play a pivotal role in providing consultation services, educational materials, and screening for drug–herb interactions.
Overview of Pharmacologic Treatment of Obesity: Past Experiences, Present Options, and Future Directions
Authors: Harrell T Kristopher , Ross Leigh Ann , King Deborah S
Published: September 2013

Objective:

To review the literature regarding the past, present, and future pharmacologic agents used in the treatment of obesity.

Data Sources:

Articles were identified by searching MEDLINE (1966–April 2005) and International Pharmaceutical Abstracts (1970–April 2005) using the key words obesity, antiobesity agents, sibutramine, orlistat, phentermine, and leptin. Additional resources were identified by examining the references of the articles cited. Searches were limited by human subject and English language, but were not limited by time of publication.

Study Selection and Data Extraction:

Large-scale clinical studies of pharmacologic agents used to treat obesity were selected for this review including agents that were previously available, currently available, and those currently undergoing clinical trials.

Data Synthesis:

Thyroid hormone was the first antiobesity agent used. Several other agents have been withdrawn from the market due to adverse effects. Current therapies indicated for obesity management include orlistat, sibutramine, and noradrenergic agents. Future therapies include both newer agents and existing agents that are principally used for other indications, mainly diabetes, depression, and seizure disorders.

Conclusions:

Obesity is a major epidemic in the US, affecting over half of the population. Past experiences with the pharmacologic treatment of obesity have been disappointing and, in some cases, harmful to patients. Current options are available that include noradrenergic agents, orlistat, and sibutramine. However, these agents still have only demonstrated limited efficacy for short-term use plus some undesirable adverse effects. Newer treatment options are being evaluated as new pathways are being identified and other related factors are being discovered.
A Pharmacotherapy Clinic in a Neurologic Practice
Authors: Swims Melanie P , Reed Pamala
Published: September 2013

Background:

Limited information exists on therapeutic drug monitoring of neurology patients. Although multiple reviews on anticoagulation clinics have shown good outcomes, the therapeutic endpoints achieved in patients enrolled in a pharmacotherapy clinic serving only those with a history of stroke/transient ischemic attack (TIA) have not been noted previously.

Objective:

To illustrate the drug therapy management role of a pharmacotherapist in a neurology clinic and provide evidence on the quality of the service by presenting data on therapeutic endpoints in the subset of patients who are on anticoagulant therapy for stroke prevention.

Methods:

Reported therapeutic endpoints included recurrent stroke/TIA, bleeding, time in therapeutic range (international normalized ratio [INR] range 2–3), adherence, and patient satisfaction with pharmaceutical care. Patients completed the Morisky self-report compliance questionnaire and the Pharmaceutical Care Satisfaction Questionnaire. Other information included medical history, medications, anticoagulation rationale, referring service, and therapeutic endpoints.

Results:

There were few adverse outcomes of bleeding or stroke. Time in therapeutic range for an INR of 2–3 was 59.67%. Of 251 INRs, 2 (0.8%) were greater than 5. Patient satisfaction with pharmaceutical care was high, as was adherence.

Conclusions:

The incidence of recurrent stroke/TIA and bleeding was rare, despite the inherently higher bleeding risk for stroke patients. Times in range of INRs were equivalent to those of other anticoagulation clinics. Patient satisfaction and adherence were good despite polypharmacy. Pharmacotherapists can be valuable additions to neurology clinics by helping neurologists in the management of the pharmacotherapy of their patients, including those on anticoagulation therapy for stroke/TIA.
Hospital Telepharmacy Network: Delivering Pharmacy Services to Rural Hospitals
Authors: Peterson Charles D , Rathke Ann , Skwiera John , Anderson Howard C
Published: September 2013

Objective:

To provide a detailed description of the Hospital Telepharmacy Network established in North Dakota for delivering pharmacy services to rural hospitals, including its overall purpose, goals, and how it works; and to provide valuable information for pharmacists and rural hospitals on how to successfully implement a telepharmacy program designed to serve small rural hospitals that do not have 24 hour pharmacist staffing and pharmacy services.

Discussion:

Seven rural hospitals (4 acute care, 3 critical access) in northern and central frontier counties of North Dakota that established a hospital telepharmacy network for delivering pharmacist staffing and pharmacy services between the institutions are described. Through use of audio, video, and computer links, rural hospitals in Rugby, Devils Lake, Harvey, Rolla, Carrington, Mandan, and Cando with an average of 32 beds (range 20–50), 11,214 doses filled per month (range 7,000–23,000), 1 staff pharmacist, and 1 pharmacy technician participated in the project. Hours of service for the pharmacies are Monday through Friday 8:00 am to 5:00 pm (3 hospitals), 8:00 am to 4:30 pm (1 hospital), 8:30 am to 4:30 pm (2 hospitals), and 8:30 am to 5:00 pm (1 hospital).

Conclusions:

National pharmacist shortages have made it difficult for small rural hospitals to find pharmacist relief help in covering routine hours, evenings, nights, weekends, vacations, sick time, and professional meetings. The Hospital Telepharmacy Network in North Dakota provides a convenient and affordable solution for rural hospitals to meet their pharmacist staffing needs. It also provides a mechanism for rural hospitals to satisfy the new Joint Commission on Accreditation of Healthcare Organizations' requirement of pharmacy being accessed after hours by only pharmacy personnel and provides future strategies for hospitals to address the issue of 24 hour pharmacist review of all medication orders.
Denosumab: A Novel Agent for Osteoporosis
Authors: Horning Kristin K , Hegge Karly A , Bottenberg Michelle M
Published: September 2013

Objective:

To review the pharmacology, pharmacokinetics, clinical efficacy, and safety of denosumab, a biologic antiresorptive agent for treatment of osteoporosis and other bone-related disorders.

Data Sources:

Primary literature and review articles were obtained via a MEDLINE search (1966–July 2008), using the following key terms: denosumab, AMG 162, and RANKL. Additional articles were identified from the bibliographies of reviewed literature.

Study Selection and Data Extraction:

English-language articles identified from the data sources were reviewed. All pertinent preclinical and clinical information was included. Randomized controlled trials were evaluated to assess the efficacy of denosumab in osteoporosis, rheumatoid arthritis (RA), and breast cancer—related bone metastases.

Data Synthesis:

Denosumab is a humanized monoclonal antibody that neutralizes receptor activator of nuclear factor-κB-ligand, thereby decreasing osteoclast-mediated bone resorption. This agent has been compared with placebo and intravenous bisphosphonates in randomized, double-blind controlled trials. In studies involving patients with osteoporosis, RA, or breast cancer—related bone metastases, denosumab significantly improved bone mineral density and markers of bone turnover when compared with placebo. Adverse events were minimal among patients receiving denosumab, although long-term safety data are not available.

Conclusions:

Denosumab is a novel therapeutic agent that improved BMD and bone turnover markers in clinical studies, suggesting that it may be promising for the treatment of a variety of bone remodeling disorders.

ACPE Universal Program Numbers:

407-000-09-051-H01-P (Pharmacists); 407-000-09-051-H01-T (Technicians)
Impact of a Community Pharmacist on Patient Knowledge of NPMs
Authors: Watts Amber , Castleman Landon , Phillips Beth Bryles
Published: September 2013

Background:

Nonprescription medications (NPMs) account for more than 100,000 products for approximately 450 ailments. It has been estimated that 59% of the American population self-medicates with NPMs. A recent survey found that patients are deficient in reading drug labels and identifying active ingredients and that they are exceeding the recommended daily dose of NPMs.

Objective:

To evaluate the impact of one-on-one pharmacist counseling sessions on patients' knowledge of NPMs, looking at specific patient populations.

Methods:

We conducted a randomized prospective intervention trial. Patients over the age of 18 years taking blood pressure and/or diabetes medications were randomized into control and intervention groups. All patients received baseline preintervention surveys. Patients in the intervention group completed a postintervention survey after a 20-minute NPM counseling session, while patients in the control group completed the postintervention survey without completing a counseling session. t-Test and descriptive analyses were used to evaluate results from the presurvey and postintervention survey to evaluate the impact of a community pharmacist, delineate NPM use in the past 6 months, and reflect the opinions and attitudes toward use and safety of NPMs.

Results:

Patient NPM knowledge improved after a counseling session with a community pharmacist. Drug facts label knowledge scores improved (4.8 vs 5.4; p = 0.02) and basic drug knowledge scores improved (3.9 vs 6.3; p = 0.02) compared with baseline analysis in the intervention group. Patients in the intervention group scored significantly higher compared with the control group on the overall knowledge postintervention survey (11.8 vs 9; p = 0.01).

Conclusions:

Pharmacists can significantly impact the NPM knowledge of patients by dedicating a short amount of scheduled time to educating patients about appropriate use of medications.
Comparison of Desvenlafaxine and Venlafaxine Ingestions Reported to Texas Poison Centers
Authors: Forrester Mathias B , Villarreal C Lizette
Published: September 2013

Background:

Desvenlafaxine is the major active metabolite of the serotonin norepinephrine reuptake inhibitor venlafaxine and is prescribed for the treatment of major depressive disorder.

Objective:

To compare desvenlafaxine and venlafaxine ingestions reported to a statewide poison center system.

Methods:

Cases included all desvenlafaxine and venlafaxine ingestions reported to Texas poison centers during 2008–2009. The distribution of all cases by selected demographic factors was identified. After cases that involved coingestants and/or were not followed to a final medical outcome were excluded, the distribution of the remaining cases by clinical and management factors was determined.

Results:

There were 144 desvenlafaxine and 777 venlafaxine ingestions. The distribution of desvenlafaxine and venlafaxine ingestions was, respectively, female patients 61.8% versus 64.2%, age 0–5 years 31.9% versus 19.3%, unintentional 47.2% versus 39.8%, and involving no coingestants 56.3% versus 46.7%. There were no coingestants and the medical outcome was known for 47 desvenlafaxine and 208 venlafaxine cases. The distribution of this subset of ingestions was, respectively, managed on site 40.4% versus 24.0%, already at or en route to a health-care facility 36.2% versus 52.9%, and referred to a health-care facility 23.4% versus 23.1%. The medical outcome was no effect 72.3% versus 56.3%, minor 14.9% versus 26.4%, moderate 10.6% versus 14.9%, and major 2.1% versus 2.4% for desvenlafaxine and venlafaxine, respectively.

Conclusions:

The patterns of desvenlafaxine and venlafaxine ingestions were generally similar. However, desvenlafaxine ingestions were more likely to involve young children, be unintentional, not involve coingestants, be managed on site, and involve no effect.
The Impact of an Urban Telepharmacy on Patient Medication Adherence in a Federally Qualified Health Center
Authors: Hudd Timothy R , Tataronis Gary R
Published: September 2013

Background:

New and innovative ways to efficiently and effectively deliver pharmacy services are necessary to ensure the future viability of the pharmacy profession. We believe that the practice of telepharmacy may be one potential option for some health-care institutions.

Objective:

To measure the impact of a satellite telepharmacy on medication adherence by making 340B medication pricing more accessible to uninsured, underserved patients in an urban setting and to assess the level of patient acceptance of pharmacy services provided through the use of a telepharmacy.

Methods:

A retrospective electronic review of medication claims data submitted by community pharmacies was used to ascertain medication adherence rates of patients using our telepharmacy. Using a 30-day supply, the mean number of days between refills for all prescriptions was determined for each patient at his/her respective pharmacy setting (telepharmacy, retail chain, or both). Statistical analyses were conducted to determine whether significant differences existed in the overall mean number of days between refills for each setting. Additionally, patient satisfaction surveys were distributed to patients using the telepharmacy.

Results:

There was no statistically significant difference in the mean (SD) number of days between refills for those using telepharmacy (37.1 [7.3]) versus retail chain (38.8 [10.3]; p = 0.610). Among patients using the telepharmacy, 95/250 (38%) completed patient satisfaction survey questionnaires; 87% indicated that the telepharmacy always made it easier to refill prescriptions, while 85% felt that speaking with the pharmacist through the videotelephone improved medication understanding.

Conclusions:

Similar outcomes were observed in the telepharmacy and retail chain settings. Medications were consistently refilled in both settings beyond the time in which they were actually due to be refilled. Patient assessment of the telepharmacy indicated high degrees of satisfaction with accessibility, service, and patient counseling.
Clindamycin-Associated Hyperphosphatemia in a Child with Renal Dysfunction
Authors: Ibach Bethany W , Miller Misty M , Johnson Peter N , Turman Martin A , Lewis Teresa V
Published: September 2013

Objective:

To report a case of hyperphosphatemia associated with administration of intravenous clindamycin phosphate in a child with renal dysfunction.

Case Summary:

We describe the case of a 12-year-old boy who developed hyperphosphatemia while receiving intravenous clindamycin phosphate. The child had a history of asthma but was otherwise healthy. He was transferred to our facility for management of methicillin-resistant Staphylococcus aureus bacteremia, periorbital cellulitis, osteomyelitis, and necrotizing pneumonia. He received intravenous vancomycin and clindamycin 930 mg administered every 8 hours. Concurrently, he developed acute kidney injury. His baseline phosphorus concentration was within the normal range but increased as high as 11.7 mg/dL while he received clindamycin. Despite receiving oral phosphate binder therapy and a low phosphorus diet, he had little reduction in serum phosphorus values. Intravenous clindamycin was suspected as a potential cause for hyperphosphatemia, and a recommendation was made to switch from intravenous to oral clindamycin solution since it contains a different salt formulation. Given the severity of the child's disseminated infection and questions of whether he could absorb the enteral formulation, the decision was made to continue intravenous clindamycin and he was ultimately transferred to a rehabilitation facility for further care on intravenous clindamycin.

Discussion:

Excess oral or intravenous intake of phosphorus can result in hyperphosphatemia, as the body's plasma phosphate concentration exceeds the kidney's diminished filtration capacity. In this patient, use of the Naranjo probability scale indicated a possible adverse event associated with clindamycin. Phosphate intake from intravenous clindamycin and decreased glomerular filtration rate may have contributed to the child's hyperphosphatemia.

Conclusions:

While intravenous clindamycin was not the sole cause for this patient's hyperphosphatemia, health care professionals should be aware of the potential for increased phosphate load when administering this drug to a patient with renal dysfunction.
Multidisciplinary Approach to Improve Venous Thromboembolism Risk Assessment and Prophylaxis Rates in Hospitalized Patients
Authors: Stark Jennifer E , Bird Matthew L , Smith Winter J , Vesta Kimi S , Rathbun Suman W
Published: September 2013

Background:

Venous thromboembolism (VTE) is a preventable disease in hospitalized patients; however, VTE prophylaxis is underutilized. Effective strategies for the assessment of individual patients' VTE risk and the provision of VTE prophylaxis are needed.

Objective:

To evaluate the efficacy of a multidisciplinary intervention designed to improve VTE risk assessment and prophylaxis in at-risk hospitalized patients.

Methods:

The multidisciplinary intervention to improve VTE risk assessment and prophylaxis consisted of 3 strategies: a broad educational effort, nursing assessment, and pharmacist follow-up. Educational programs were delivered to nursing, pharmacy, and physician staff. Upon admission, all patients were assessed for VTE risk factors by nursing staff. Pharmacists reviewed reports of patients screened to have at least 1 VTE risk factor; for patients not prescribed VTE prophylaxis, pharmacists placed a progress note and VTE prophylaxis order form in the chart. If no prophylaxis was prescribed by the following day, the pharmacist contacted the physician with a verbal recommendation. The impact of this intervention was evaluated by comparing the proportion of patients assessed for VTE risk factors on admission and the proportion of VTE prophylaxis candidates who received prophylaxis, both before and after implementation.

Results:

A total of 310 patients were included during the 2-month study period. An increase in patients assessed for the presence of VTE risk factors was observed after the intervention (41% vs 87%, p < 0.001). Similarly, an increase in patients prescribed prophylaxis was observed after the intervention (36% vs 63%, p < 0.001).

Conclusions:

This multidisciplinary approach including education, nursing assessment, and pharmacist follow-up resulted in a significant increase in the rates of VTE risk assessment and prophylaxis.
The Use of Combination Lipid Therapy in a County Health System
Authors: Pio Margaret Youngmi , Piszczor Erin Marie , Quinones Marissa Escobar , Boatright Steven Micheal , Chow Diem Hong , Hulstein Jeffrey Lynn , Moss Elizabeth , Mathew Annie Chathanatt , Budhwar Nitin
Published: September 2013

Background:

With the paucity of clinical outcomes trials and guidelines to make compelling recommendations regarding the treatment of dyslipidemia beyond statin monotherapy, we present a descriptive analysis of the combination lipid-lowering therapies being used at a large county hospital system.

Objective:

To provide a descriptive evaluation of the comparative effectiveness and safety of various combination lipid therapies in conjunction with a statin.

Methods:

Patients of a county health system who received at least 3 months of combination lipid therapy in conjunction with a statin during a 1-year period were eligible for inclusion in this retrospective chart review. The main outcome was a descriptive analysis of the comparative effectiveness among combination lipid therapies, as evidenced by fasting lipid panels.

Results:

A total of 834 patients were included in the analysis. Approximately 88% were on 1 additional lipid-modifying agent beyond a statin; 2 or 3 additional medications were much less common. Fish oils and fibrates were the most common nonstatin agents used, comprising approximately 85% of the combination therapies. Approximately 17% of patients had all 4 lipids at goal. A majority of patients were at goal for low-density lipoprotein cholesterol, non-high-density lipoprotein cholesterol (non-HDL-C), and total cholesterol, but a large proportion were not at goal for HDL-C and triglycerides. No statistically significant differences were found among therapies for effectiveness related to lipid goals, medication adherence, or safety. The chart review did not find an appreciable number of adverse events. The overall adherence rate was subpar at 56% and varied modestly among treatments.

Conclusions:

This retrospective analysis found no significant differences in effectiveness, adherence, and safety among the combination lipid therapies used in a county health system. Further research is warranted to elucidate the recommended approach to using combination lipid therapies.