bluuebunny/crossref_metadata_2025 huggingface dataset:
Assessment of Drug-Prescribing Problems in a Multidisciplinary Primary Care Clinic
Authors: Otaguro Jill E , Kruse Leann E
Published: July 2017

Objective:

To identify drug classes prone to prescribing problems in a multidisciplinary primary care clinic in a Department of Veterans Affairs Medical Center.

Methods:

Over a 10-week study period, the ambulatory care pharmacists reviewed the prescription profiles and medical records of every patient with an appointment in the Comprehensive Health Care Unit primary care clinic. Based on this review, the pharmacists made patient-specific consultations to the providers. They were also available during clinic hours for additional consultations and patient referrals. A standard data collection form was used to document all consultations.

Results:

The pharmacists made 1,701 consultations concerning 1,665 patients. The most problematic drug classes identified included anticoagulants, lipid-lowering agents, antiulcer agents, antihypertensive/ cardiovascular agents, chronic obstructive pulmonary disease/asthma agents, oral antidiabetic agents, nonsteroidal antiinflammatory drugs, and anticonvulsants. Anticoagulants and lipid-lowering agents were the most problematic drug classes, with most of the consultations related to dosing and monitoring requirements. Consultations had an 88.6% acceptance rate and resulted in a total monthly drug cost avoidance of $1,525.

Conclusions:

As a result of identifying the most problematic drug classes, computer programs have been developed to streamline the pharmacist review process, and clinical practice guidelines, posters, and educational handouts have been developed to promote appropriate prescribing.
Octreotide in the Treatment of Pancreatic Pseudocysts
Authors: Lam Annie Y , Kracke Susan E
Published: July 2017

Objective:

To describe the potential use of octreotide in the treatment of pancreatic pseudocysts through a brief review of anecdotal case reports.

Case Summary:

Octreotide has been used in a few patients to effectively inhibit pancreatic secretions and shrink the size of persistently draining pseudocysts. The dosage of octreotide is 100–200 μg bid or tid sc, for up to 36 days or until resolution of the pseudocysts is achieved.

Discussion:

Persistent pancreatic pseudocysts of varying size and duration have been successfully treated with the use of octreotide. Larger pseudocysts, which are unlikely to resolve spontaneously, may remain unresolved with the use of octreotide and may still require conventional surgical intervention. The use of octreotide in such cases, however, may still be beneficial. Shrinkage of the pseudocysts, even without complete resolution, may result in reduction of pain and may prevent other complications that often accompany the unresolved pseudocysts.

Conclusions:

Anecdotal reports suggest that octreotide may be useful as a noninvasive alternative or adjunct to traditional surgical treatment of pancreatic pseudocysts. Further research with well-designed studies involving randomized comparative controls are necessary to correlate the degree of pseudocyst shrinkage with the dosage and duration of octreotide therapy. The apparent effectiveness of octreotide in reducing the size of persistent pancreatic pseudocysts and providing pain relief suggests that it may be a useful adjunct to surgical interventions. With smaller persistent pseudocysts, octreotide may be a treatment alternative to surgery.
Beliefs of Community Pharmacists on Prevention and Correction of Potential Drug Therapy Problems
Authors: Farris Karen B , Kirking Duane M
Published: July 2017

Objective:

To describe likelihood and affective evaluation ratings for salient beliefs of community pharmacists about trying to prevent and correct potential drug therapy problems, and to describe normative belief and motivation to comply ratings about trying to prevent and correct potential drug therapy problems.

Design:

Descriptive statistics from a self-administered mail survey.

Participants:

A convenience sample identified salient beliefs about trying to prevent and correct potential drug therapy problems, and a random sample of Michigan community pharmacists (n = 555) completed a self-administered mail survey regarding these beliefs.

Main Outcome Measures:

Likelihood and affective evaluation ratings of 22 salient beliefs and normative belief and motivation to comply ratings of six salient others.

Results:

Pharmacists believed that trying to prevent and correct drug therapy problems could lead to valuable consequences, regardless of whether the efforts were a success or a failure. The pharmacists also believed they could have a positive impact on the quality of drug therapy; however, they seemed less convinced that failure would lead to health complications in patients or unnecessary health expenditures. Pharmacists were most motivated to comply with the expectations of patients.

Conclusions:

Assisting community pharmacists in adopting pharmaceutical care can be accomplished by (1) providing programs where the process of trying to prevent and correct drug therapy problems can be experienced, (2) promoting an understanding of the relationships between drug product costs and healthcare costs due to patient morbidity, (3) devising mechanisms to increase patient demand for pharmaceutical care and drug utilization review, and (4) assisting community pharmacists to obtain reimbursement for time spent trying to prevent and correct drug therapy problems.
Benzodiazepine Utilization Review for Inpatients at a Tertiary Medical Center in Taiwan
Authors: Hsu Rou-Yee Chen , Tang Kwong-Yui
Published: July 2017

Objectives:

To examine benzodiazepine prescribing patterns by physicians for inpatients relative to indications and drug characteristics in a tertiary medical center.

Design:

Prescription pattern analysis was done by checking computer-based pharmacy records. Benzodiazepine utilization was evaluated through retrospective chart review.

Results:

A total of 2,195 inpatients were surveyed, of whom 945 were given benzodiazepines. Of these, 827 charts were available for review. The mean number of prescriptions written for benzodiazepines was 1.62 per patient. Of the benzodiazepines available, triazolam was most frequently prescribed. The use of benzodiazepines ranged from 38.7% in the internal medicine ward to 85.1% in the oncology ward. We found that 60% of prescriptions were appropriate, 24.9% were prescribed without documentation, and 15.1% were used inappropriately.

Conclusions:

Proper prescribing of benzodiazepines is essential in the management of the symptoms of mental illness. From both a diagnostic and treatment perspective, more education efforts are needed in the investigation, documentation, and treatment of mental illness symptoms.
Impact of Federal Law on Dispensing Activities in Hospital Pharmacies
Authors: Williams Karl G
Published: July 2017

Objective:

To review federal laws that have an impact on dispensing in hospital pharmacies.

Data Synthesis:

Information has been extracted from the Robinson-Patman Act, the Prescription Drug Marketing Act, the Internal Revenue Code, and associated regulations, policies, and court cases. Hypothetical situations are used to illustrate the application of federal law to routine dispensing functions.

Conclusions:

Each of these legal areas has a significant impact on dispensing by hospital pharmacies. Understanding these can simplify practice in many ways.
Heparin Dosing Order Form Use in an Academic-Affiliated Veterans Affairs Medical Center
Authors: Hoffman Nannette B , Frohnapple David J
Published: July 2017

Objective:

Because a drug utilization evaluation (DUE) showed poor intravenous heparin prescribing practice in our medical center, we developed a preprinted intravenous heparin order form for use by physicians to improve heparin administration.

Methods:

Two DUEs were performed, one prior to use of a weight-based heparin dosing order form and another after the introduction of the form. Indicators that were evaluated included dosing, laboratory monitoring, and intramuscular injections. DUE results before and after introduction of the order form were statistically compared using Fisher's exact text.

Results:

The initial DUE showed that only 3% of patients who were administered intravenous heparin received appropriate dosing, and only 60% had a therapeutic activated partial thromboplastin time (aPTT) ratio within the first 24 hours. Blood samples for the aPTTs were drawn at incorrect × in 27% of patients, and 9% of patients received intramuscular injections of other drugs. After implementation of the preprinted intravenous heparin order form, 73% of the patients received appropriate heparin dosing (p < 0.00001), and 79% of the patients had a therapeutic aPTT ratio within the first 24 hours (p = 0.08). The aPTTs were drawn at incorrect × in 12% of patients, and 3% of patients received intramuscular injections (NS for both). All patients receiving appropriate heparin dosing achieved a therapeutic aPTT ratio within the first 24 hours, whereas only 29% of patients on the acute wards and 50% of those in the intensive care units achieved a therapeutic ratio when dosing was inappropriate (p < 0.0001).

Conclusions:

We improved the intravenous heparin prescribing practice in an academic-affiliated tertiary Veteran's Affairs Medical Center using a preprinted intravenous heparin order form for physician use. The form was also effective in achieving the desired aPTT ratio within 24 hours.
Multidisciplinary Approach to Improving Antibiotic Turnaround Time in a Medical Intensive Care Unit
Authors: Watling Sharon M , Harter Phyllis J , Lee Susan M , Yanos John
Published: July 2017

Objective:

To improve the timeliness of antibiotic therapy.

Setting:

A 13-bed university hospital medical intensive care unit.

Interventions:

Inservice presentations regarding the importance of antibiotic administration time, preprinted antibiotic orders, and a rearrangement of the order processing system were implemented.

Results:

Overall antibiotic turnaround time decreased from a median of 2.2 hours (March–May 1993) to 1.4 hours (March–May 1994) (p = 0.001).

Conclusions:

A multidisciplinary team working together developed a system to significantly improve antibiotic turnaround time.
Quality of Prescribing at Primary Care Centers in Saudi Arabia
Authors: Khoja Tawfik A , Al-Shammari Sulaiman Ai , Farag Mohammad Kamel , Al-Mazrou Yagob
Published: July 2017

Objective:

To assess serious prescribing errors, prescribing rate per patient, and ranking of common illnesses and medications prescribed at primary care centers in Saudi Arabia. A proposal for improvement measures will be formulated.

Methodology:

A cross-sectional study of a randomly selected afternoon shift (4 working h) was carried out on November 1, 1994. All of the 367 physicians working in the health centers in Riyadh, Saudi Arabia participated. All prescriptions issued by physicians during this shift were entered into the study and examined with regard to a number of variables. The variables included patient demographic characteristics, vital signs, the physician's name and center, diagnosis, and prescription items. Demographic variables were excluded from analysis for purposes of confidentiality.

Results:

During the study period, 11,326 patients were seen, and 6,350 prescriptions were issued (for 20,320 drug entries). The average number of consultations per primary health care (PHC) physician was 30 ± 9. The average number of prescriptions per PHC physician was 17.3 ± 6, for a total of 0.56 prescriptions per patient. Of all prescriptions, 11.6% were found to have at least one error. The average number of drugs per prescription was 3.2 ± 0.4. The average number of drugs per patient was 1.8 ± 0.3. Of all patients, 73% had two or fewer drug items prescribed. Upper respiratory tract infection was the most frequent diagnosis, and accounted for 31.0% of the illnesses seen. Antibiotics, analgesics/antipyretics, and tonics/vitamins were the most common items prescribed (to 16.8%, 15.4%, and 11.8% of the patients, respectively). The most common errors were those considered type B (5.39%), where the pharmacist must contact the physician before dispensing the prescription, and type C (4.59%), where the pharmacist must make a professional decision before dispensing the prescription. Missing drug strength and missing quantity of medication and frequency of dosing were observed in relatively high proportions (3.8% and 3.2%, respectively). Frequency of the daily dose, generic name of the drug, and strength of the drug were the top three missing pieces of information (89.5%, 86%, and 76.3%, respectively).

Conclusions:

These results represented a challenge and justified setting standards and indicators to ensure the quality of these vital activities of prescribing and dispensing. There is a need to design and implement training programs to improve PHC team prescribing and dispensing skills and establish an accurate system of error reporting.
Sugar Paste for Treatment of Decubital Ulcers
Authors: Valls Laura Tuneu , Altisen Magdalena Trullás , Poblador Ramón Plá , Alvarez Angels Ciurán , Biosca Rosa Garriga
Published: July 2017

Objective:

To review the use of sugar paste in the treatment of decubital ulcers.

Data Sources:

A MEDLINE, IDIS, and current journal search of English-language articles published between 1978 and 1993 on sugar paste in the treatment of ulcers.

Study Selection:

Case reports, cohort, epidemiologic, in vivo, and in vitro studies were evaluated.

Data Extraction:

Reports using granulated sugar or derivatives in the treatment of refractory cutaneous ulcers were evaluated.

Data Synthesis:

All the studies show that sugar paste treatment has satisfactorily resolved decubital ulcers, although a wide variability in treatment length has been seen. Considering the likely mechanisms of action for sugar paste, this wide variability may be a result of dressing frequency. In other words, for sugar paste to be most effective it has to be applied in such a way that a continuous optimal sugar concentration in the ulcer is maintained. To achieve this, dressing frequency should not be standardized, but individualized according to ulcer type, depth, and exudate, as well as patient healing capacity. Healing could probably have been achieved earlier if dressing had been individualized. Besides effectiveness and low cost, sugar paste is also safe, with few adverse events associated with its use.

Conclusions:

In spite of difficulties in evaluating the use of sugar paste in treatment of decubital ulcers, it has been shown to be an effective therapy for this disorder. However, we recommend that length of treatment be individualized for each patient.
Recognition of Medication Adverse Effects in Female Veteran and Nonveteran Psychiatric Patients
Authors: Nand Surinder S , Grossman Linda S , Bailey LaGenia , Pater Debra M , Mian Rubeena H
Published: July 2017

Objective:

To provide information about knowledge of adverse effects of psychotropic medications in a group of female veteran and nonveteran psychiatric outpatients.

Design:

Questionnaire.

Setting:

Westside Veterans Affairs (VA) Medical Center and the University of Illinois at Chicago (UIC).

Patients:

Thirty-five female psychiatric outpatients, 17 from the VA Medical Center and 18 from UIC.

Main Outcome Measure:

Number of adverse effects patients were able to recognize.

Results:

Veterans demonstrated significantly more knowledge of adverse effects than did nonveterans for antipsychotic, antidepressant, and anxiolytic medications.

Conclusions:

The data support the provision of extensive personalized psychoeducation consisting of structured group programs for didactic lessons, discussion, and question and answer, such as those provided by the VA Medical Center studied here. As funding for mental services decreases, clinicians should recognize the ongoing benefits that personalized interactive patient education can provide.
Can Response to Bedtime Insulin with Daytime Sulfonylurea Be Predicted in Patients with Type 2 Diabetes Mellitus?
Authors: Oki Julie C , Tal Alexander , Graves Leland , Isley William L
Published: July 2017

Objective:

To determine characteristics predictive of response in patients with Type 2 diabetes mellitus (Type 2 DM) who demonstrate good or poor blood glucose control while receiving bedtime insulin with daytime sulfonylurea (BIDS) therapy.

Methods:

A retrospective chart review of patients with Type 2 DM receiving BIDS therapy was performed. The criterion for responders was the mean of two consecutively obtained glycosylated hemoglobin (Hb) concentrations being less than or equal to 10.2% (HbA1c ≤7.0%).

Setting:

A university-affiliated diabetes specialty clinic staffed consistently by a pharmacist diabetes educator, four endocrinologists, and a pharmacotherapy specialist.

Patients:

Thirty-one patients with Type 2 DM who were predominantly African-American and women who had documented regular follow-up examinations for more than 12 months while receiving BIDS therapy.

Data Collection and Measurements:

Gender, ethnicity, height, weight, calculated body mass index, age of onset of diabetes mellitus, duration of diabetes mellitus before BIDS therapy, pre-BIDS treatment regimen, dosages of NPH insulin and glyburide, glycosylated Hb concentration, fasting blood glucose concentration, and duration of BIDS therapy were recorded.

Results:

There were no differences in age of onset of diabetes mellitus, duration of diabetes mellitus before BIDS was initiated, duration of therapy with BIDS, or baseline glycosylated Hb concentration between responders (n = 15) and nonresponders (n = 16). Patients in the responder group weighed less, had a lower body mass index, required smaller dosages of both glyburide and NPH insulin, and achieved a lower fasting blood glucose concentration.

Conclusions:

In this study population, with the exception of body mass index, there was no difference in suggested clinical characteristics of response between responders and nonresponders.
Antimicrobial Liquid Formulations: A Blind Comparison of Taste of 13 Commonly Prescribed Medications
Authors: Chan Debora Schotik , Demers Denise M , Bass James W
Published: July 2017

Objective:

To rate the perception of taste, texture, smell, and aftertaste of 13 commonly prescribed liquid medications, including four new drugs: Zithromax, Cedax, Ceftin, and Biaxin.

Design:

Each category was scored on a scale of 1 to 5 by 30 volunteers in a blinded study. The order in which the drugs were sampled was randomized for 15 of the participants. The order was reversed for the remaining 15 participants. The drugs used in the study were Amoxil (amoxicillin), Biaxin (clarithromycin), Ceclor (cefaclor), Cedax (Ceftibuten), Ceftin (cefuroxime), Cefzil (cefprozil), Dynapen (dicloxacillin), Keflex (cephalexin), Suprax (Cefixime), Trimox (amoxicillin), Vantin (Cefpodoxime), VeeTids (penicillin VK), and Zithromax (azithromycin).

Setting:

A 537-bed US Army teaching hospital.

Participants:

Participants included 30 healthy adult volunteers from the Departments of Pediatrics, Nursing, and Pharmacy.

Main Outcome Measures:

Drugs received cumulative scores in each category as well as an overall total score ranking. The data were analyzed by using one-way ANOVA for repeated measures with a post hoc Duncan's multiple-range test to determine significant differences between individual means. The level of significance was set at a p value of 0.05 or less.

Results:

Overall, Trimox was better than all other drugs tested except Suprax; Dynapen was inferior to all except Biaxin and VeeTids. Zithromax scored higher than Biaxin in the texture, taste, and overall categories. Biaxin scored lower than all other drugs tested in the texture category. Ceftin was better than Cedax in the smell category, but Cedax was superior to Ceftin in the texture, taste, aftertaste, and overall categories.

Conclusions:

All of the new drugs tested were significantly different from each other (Cedax > Zithromax > Ceftin > Biaxin).
Understanding Technician Roles and Educating Students to Assist in Role Definition
Authors: Janke Kristin Kari , MacDonald Margaret L
Published: July 2017

Objective:

To develop a process for defining an ideal technician role in pharmaceutical care and to communicate this process to technician educators and the pharmacy community.

Background:

A process for defining the technician role was developed as part of Dalhousie's Pharmaceutical Care Project in Halifax, Nova Scotia, Canada. In May 1995, technician-related work began with the staff from a community demonstration site. Through interviews, observation, surveys, and review of the literature, an optimal technician role was defined.

Results:

The technician role definition is composed of four components: Technician tasks, work-flow priorities, levels of pharmacist supervision, and performance standards. Technician tasks must be identified by each dispensary to address site-specific concerns. Once a technician task list has been developed, consideration can be given to priorities, levels of pharmacist supervision, and performance standards. After the technician role has been defined, an implementation plan and training can be devised. This process for defining technician roles can be used in other dispensaries.

Conclusions:

Students in pharmacy-related educational programs may graduate to work in a dispensary without a defined technician role or with a technician role that requires further development. Therefore, a concerted effort should be made to equip pharmacy and technician students with the skills and resources needed to help create the necessary roles. In addition, consideration should also be given to discussion of technician role components during in-house training.
Dexrazoxane: A New Cardioprotective Agent
Authors: Abbott Beverly D , Ippoliti Cindy M
Published: July 2017

Objective:

To review the literature discussing the use of dexrazoxane (e.g., Zinecard, ICRF-187) to prevent doxorubicin-induced cardiotoxicity.

Data Sources:

Pertinent English-language reports of studies in humans were retrieved from a MEDLINE search (January 1980-January 1997); search terms included chelating agents, razoxane, dexrazoxane, Zinecard, ICRF-187, ADR-529, and ICRF-159.

Study Selection:

Representative articles discussing the chemistry, pharmacology, pharmacokinetics, dosing, and administration of dexrazoxane and those discussing clinical trials were selected.

Data Extraction:

Data were extracted and analyzed if the information was relevant and consistent. Studies were selected for review in the text on the basis of study design and clinical end points.

Data Synthesis:

Dexrazoxane is a chemoprotective agent developed to prevent cardiac tissue toxicity. Dexrazoxane exerts a cardioprotective effect with some clinically significant toxicities; it may also interfere with the antitumor activity of doxorubicin. Until there are sufficient data to support its use in first-line supportive care therapy, dexrazoxane should be reserved for use in patients responding to doxorubicin-based chemotherapy but who have risk factors for cardiac toxicity or have received a cumulative doxorubicin bolus dose of 300 mg/m2.

Conclusions:

The management of doxorubicin-induced cardiotoxicity has led to the development of supportive care drugs that specifically counteract the dose-limiting toxicities. Dexrazoxane may not completely eliminate the concern about doxorubicin-induced cardiotoxicity, but it may open new avenues for continuing doxorubicin-based chemotherapy.
A Comparison of Retrospective and Concurrent Drug Utilization Review of Omeprazole
Authors: Chabot Isabelle , Morin Johanne , Bourbeau Kateri , Moisan Jocelyne
Published: July 2017

Objective:

To compare the appropriateness of omeprazole prescriptions in a concurrent drug utilization review (DUR) with the assessed appropriateness of a retrospective DUR.

Methods:

A retrospective DUR of omeprazole was conducted on prescriptions written from August 23, 1993, to October 8, 1993, in a 340-bed university hospital. This DUR served as a baseline for a concurrent DUR that began on January 27, 1995, and ended on March 16, 1995. The concurrent DUR integrated three steps aimed at improving the quality of omeprazole use: Approval of the criteria by the pharmacology and therapeutics committee of the hospital, distribution of a drug bulletin to all physicians, and a pharmacist's verbal recommendations to physicians whose prescriptions did not meet explicit criteria.

Results:

Twenty-nine and 64 prescriptions were reviewed in the retrospective and concurrent DURs, respectively. During the concurrent DUR, the pharmacist made 34 verbal recommendations. Of these, 25 (74%) were agreed to by the prescribers. In comparison with the retrospective DUR, the percentage of prescriptions meeting the criteria of indication, combination therapy, and dosage went from 38% to 75% (p < 0.05), from 76% to 95% (p < 0.05), and from 83% to 100% (p > 0.05), respectively, during the concurrent DUR.

Conclusions:

The concurrent DUR appeared to successfully improve the quality of omeprazole utilization in the hospital.
Current Concepts in the Management of Heart Failure
Authors: Alex Sumana , Mehrotra Prafulla P
Published: July 2017

Objective:

To give an overview of the epidemiology, etiology, and symptoms and signs of heart failure (HF), and the role of various therapeutic modalities that influence functional status, morbidity, and mortality in HF.

Data Sources:

Computerized search of the MEDLINE database (1976–1998) and review chapters from medical textbooks.

Data Extraction:

Clinical trials evaluating the effect of drugs on morbidity and mortality of patients with HF.

Data Synthesis:

HF is a clinical syndrome with high prevalence and mortality. The treatment approach varies depending on the etiology and type of HF. Several large-scale clinical trials with angiotensin-converting enzyme (ACE) inhibitors demonstrate improved survival and reduced hospitalization in patients with all degrees of HF. Several other trials report similar benefits in postmyocardial infarction patients with HF. Angiotensin II type 1 receptor blocking agents have also been shown to reduce morbidity and mortality in elderly patients with HF and may be used in patients who cannot tolerate ACE inhibitors. Therapy with hydralazine and isosorbide dinitrate also improves exercise tolerance as well as survival in patients with HF. The combination of these agents with ACE inhibitors may be useful in patients who remain symptomatic while taking ACE inhibitors. Such second-generation dihydropyridine calcium-channel blockers as amlodipine have also been shown to improve symptoms, exercise tolerance, and survival in nonischemic patients. Diuretics are effective in reducing the symptoms of HF resulting from fluid overload. Inotropic drugs such as digoxin may improve symptoms and reduce hospitalization for patients with HF but do not reduce overall mortality. Long-term, continuous use of inotropic agents, such as amrinone, milrinone, dobutamine, and high-dose vesnarinone, may improve quality of life but increase mortality in HF. Beta-blockers, particularly Carvedilol, with vasodilating properties demonstrate positive survival results in patients with mild-to-moderate HF.

Conclusions:

ACE inhibitors are the initial drug of choice in the treatment of HF; however, angiotensin II receptor antagonists may be used in patients who are intolerant to ACE inhibitors. Diuretics are useful mainly to control the fluid overload in HF. Digoxin is helpful in patients with atrial fibrillation and rapid ventricular response and in patients who are resistant to ACE inhibitors and diuretics. Hydralazine and isosorbide dinitrate therapy is valuable in patients whose symptoms cannot be controlled with optimal doses of diuretics, digoxin, and ACE inhibitors. Careful use of newer beta-blockers, with optimal titration of diuretics, in mild-to-moderate HF may help prolong life. Newer dihydropyridine calcium-channel blockers may be beneficial in nonischemic patients with HF.
Thiamine-Responsive Lactic Acidosis, Encephalopathy, and Shock
Authors: Witkowski Alina A , Sarnaik Ashok P , Heidemann Sabrina M , Abella Esteban
Published: July 2017

Objective:

To report a case of severe lactic acidosis, encephalopathy, and hypotension in a patient receiving total parenteral nutrition without multivitamin supplementation and the dramatic response to intravenous administration of thiamine.

Case Summary:

A 15-year-old African-American girl undergoing treatment for chronic myelogenous leukemia with allogenic bone marrow transplantation and requiring total parenteral nutrition was admitted to our intensive care unit for management of life-threatening lactic acidosis, encephalopathy, and hemodynamic instability. Because of the manufacturing shortage of parenteral multivitamin preparations, oral multivitamins were prescribed; however, the patient was unable to swallow the oral multivitamins because of oral mucositis. Intravenous administration of thiamine promptly reversed the profound metabolic, neurologic, and hemodynamic abnormalities.

Discussion:

Carbohydrate loading associated with inadequate thiamine intake may result in potentially lethal metabolic, neurologic, and hemodynamic alterations. Prompt intravenous administration of thiamine can rapidly reverse metabolic acidosis, encephalopathy, and shock in such situations.

Conclusions:

Adequate administration of multivitamins must be ensured in all patients receiving total parenteral nutrition.
Undiagnosed Triazolam Withdrawal
Authors: Ibrahim Zafar Y , Pathan Mohammad H , Schwartz Eileen M , Sangster Joe N , Gould-Williams Kathleen A
Published: July 2017

Objective:

To report a case of triazolam withdrawal.

Case Summary:

A 65-year-old white man was admitted to the hospital for a total left hip arthroplasty. Within 12 hours after the surgery, the patient became agitated and confused, and reported severe chest pain. He was treated for a non-Q-wave myocardial infarction, but continued to experience fluctuating consciousness, confusion, agitation, auditory and visual hallucinations, and memory deficits, which did not respond to treatment with haloperidol and discontinuation of meperidine, which was administered after the surgery. He responded briefly to midazolam. A detailed history of the patient's preoperative medications was obtained from his wife. This led to the diagnosis of triazolam withdrawal, and the patient was successfully treated.

Discussion:

The covert use and misuse of medications is a common cause of psychosis in otherwise healthy individuals. This case emphasizes how obtaining a detailed medication history from the patient or other sources can prevent serious complications.

Conclusions:

Benzodiazepine withdrawal can present with psychiatric symptoms. This case highlights the importance of obtaining information from patients and family on the use of medications that can cause acute withdrawal reactions.
Antibiotic Prophylaxis in Acute Necrotizing Pancreatitis
Authors: Segarra-Newnham Marisel , Geber Jean M
Published: July 2017

Objective:

To review the use of antibiotic prophylaxis in acute necrotizing pancreatitis.

Background:

Acute necrotizing pancreatitis is a complication that occurs in a minority of patients with acute pancreatitis, but has a high incidence of morbidity and mortality. Surgery and supportive care are important in the management of this disease. However, the role of antibiotic prophylaxis has been debated for decades.

Data Sources:

English-language clinical studies and review articles involving human subjects and appropriate in vitro data were located through a literature search (MEDLINE, January 1966-July 1998).

Study Selection and Data Extraction:

Relevant studies describing the use of antibiotic prophylaxis in acute necrotizing pancreatitis were reviewed.

Data Synthesis:

Earlier studies of antibiotic prophylaxis in patients with acute necrotizing pancreatitis did not show any benefit compared with placebo. Newer studies have shown a decrease in mortality and morbidity when antibiotic prophylaxis is given to patients with severe necrotizing pancreatitis. Conflicting results leave many questions unanswered, such as the effect of antibiotic use in resistance patterns, which antibiotic to use, duration of therapy, and cost-effectiveness of this strategy.

Conclusions:

With the available data, it is adequate to recommend that patients with at least 30% necrosis of the pancreas receive antibiotics to prevent infectious complications and to decrease potential mortality. Use of imipenem/cilastatin is supported by the largest prospective trial to date; however, the drug was compared with no treatment. Cefuroxime is the only drug shown to decrease mortality and should be considered an alternative that may be more cost-effective than therapy with imipenem/cilastatin. A comparison trial is needed before further recommendations are given.
Probable Nafcillin—Warfarin Interaction
Authors: Baciewicz Anne M , Heugel Anne M , Rose Peter G
Published: July 2017

Objective:

To report a case of probable nafcillin—warfarin interaction and to discuss the occurrence of this event.

Case Summary:

A 74-year-old white woman with stage IV ovarian cancer was given warfarin and nafcillin concurrently for a subclavian venous thrombus and an infected subclavian mediport. After 10 days of therapy, the patient's prothrombin time remained within the range of 11.6–13.8 seconds (control range 10.4–12.8). Her international normalized ratio (INR) ranged from 1.0 to 1.45 and her activated partial thromboplastin time ranged from 49 to 80 seconds (22–34). Nafcillin was discontinued. Continuous intravenous heparin was continued, and the patient was given warfarin 10 mg po for four days. A maintenance regimen of warfarin 5 mg po daily was then initiated. Within seven days of discontinuing nafcillin, the INR increased from 1.08 to 2.10.

Discussion:

Several cases of nafcillin—warfarin interaction have been reported in the literature. The case reported here is similar to a previously reported one in which a lower dose of nafcillin (6 g/d) was used for a short time (10 d). Therapeutic warfarin doses were started simultaneously with nafcillin. The interaction usually occurs within three to 10 days and abates within one to eight weeks. The postulated mechanism of interaction is induction of hepatic microsomal enzymes by nafcillin, leading to warfarin resistance.

Conclusions:

When nafcillin is prescribed concomitantly with warfarin, high doses of warfarin are usually required and close monitoring is necessary to keep the patient's INR within a designated range. Clinicians should be aware of a potential nafcillin—warfarin interaction because warfarin has a narrow therapeutic window that may readily lead to therapeutic failure or toxicity. Frequent review of clinical signs and symptoms of bleeding or thromboembolism and warfarin dosage adjustment are necessary if both drugs are used concurrently, and also when nafcillin is discontinued.
Stability of Low-Dose Vancomycin Hydrochloride in Heparin Sodium 100 IU/mL
Authors: Mayer Jennifer LR , Pascale Valentine J , Clyne Lionel P , Malkus Herbert , Santos Florecita S , van Hoff Jack
Published: July 2017

Objective:

To determine the stability of low-dose vancomycin hydrochloride 25 μg/mL and preservative-free heparin sodium 100 IU/mL stored at room temperature versus refrigerated temperature for 100 days.

Design:

A prospective, controlled pharmacologic study.

Materials:

The test article (V-H) was prepared by mixing vancomycin hydrochloride 25 μg/mL in heparin sodium 100 IU/mL. The antibiotic control (V) was the same dose of vancomycin in NaCl 0.9% only The heparin control (H) was commercially available 100 IU/mL vials of this agent.

Methods:

Half of the test and control solutions were stored at room temperature (28 °C) and half were kept in a refrigerator (4 °C). On study days 0, 1, 14, 30, 63, and 100, the concentration of vancomycin was measured by Emit. The functional activity of heparin was determined on identical days by the activated partial thromboplastin time (aPTT) assay.

Results:

Sixty-three days after preparation, the refrigerated V-H solution maintained over 90% of its original vancomycin concentration; in contrast, the V-H solution kept at room temperature had a 21% reduction in its antibiotic concentration. All V-H and V solutions had a significant (p = 0.01) drop in their vancomycin concentrations after 100 days of storage. There was no significant change in the measured aPTT of the V-H and H solutions stored in the refrigerator versus room temperature for 0 versus 100 days (p = 0.35 and p = 0.41, respectively).

Conclusions:

An admixture of vancomycin hydrochloride 25 μg/mL and heparin sodium 100 IU/mL is stable for up to 63 days when stored at 4 °C.
Raloxifene: A Selective Estrogen Receptor Modulator for the Prevention of Osteoporosis
Authors: Hagmeyer Kathleen O , Meyer Tamara K
Published: July 2017

Objective:

To review the efficacy and safety of the selective estrogen receptor modulator raloxifene hydrochloride in the prevention of osteoporosis.

Data Sources:

A MEDLINE search (January 1966–May 1998) and unpublished data obtained from the manufacturer were used to identify relevant studies and review articles. Additionally, bibliographies of selected articles were reviewed. Only English-language articles on human studies were obtained.

Study Selection:

Literature was reviewed to evaluate the pharmacology, pharmacokinetics, therapeutic use, adverse effects, and drug interactions of raloxifene. Additional relevant citations were used in the introduction material and clinical controversy section.

Data Extraction:

Clinical trials reviewing raloxifene for the prevention of osteoporosis were evaluated.

Data Synthesis:

Raloxifene hydrochloride is a partial estrogen agonist that displays both estrogenic and antiestrogenic effects. As a result of binding to estrogen receptors, raloxifene therapy, like estrogen treatment, causes positive changes in biochemical markers of bone turnover such as serum osteocalcin, serum alkaline phosphatase, urinary pyridinoline cross-links, and urinary calcium excretion. In addition, raloxifene increases bone mineral density. Furthermore, raloxifene reduces total serum cholesterol and serum low-density lipoprotein cholesterol. Raloxifene has no effect on serum high-density lipoprotein cholesterol. As a selective estrogen receptor modulator, raloxifene does not display the deleterious effects of estrogen in endometrial or breast tissue. The most common adverse effects are hot flashes and leg cramping.

Conclusions:

Clinical trials have found that raloxifene is effective in the prevention of osteoporosis, making the drug an alternative choice for the prevention of osteoporosis in patients who are concerned about the proliferative effects of estrogen replacement therapy on the endometrium or breast tissue. Raloxifene may not be a good alternative in women experiencing troublesome hot flushes during menopause. The use of raloxifene in the treatment of osteoporosis and in the prevention of breast cancer is currently being evaluated.
Bupivacaine-Induced Metallic Taste
Authors: Lo Angela B
Published: July 2017

Objective:

To describe a case of bupivacaine-induced metallic taste.

Case Summary:

A 48-year-old white woman admitted with scleroderma necrosis of the finger was given bupivacaine via an axillary catheter for pain relief. She experienced a metallic taste that abated on discontinuation of bupivacaine and recurred on rechallenge.

Discussion:

The close temporal sequence of bupivacaine-induced metallic taste has not been previously reported in the literature. This supports the existence of a causal relationship between bupivacaine and development of a metallic taste disturbance.

Conclusions:

Alterations in taste are an underrecognized effect of many drugs. This case illustrates this adverse drug reaction.
Low Dose of Dicyclomine Associated with Respiratory Distress and Death in an Infant
Authors: Aziz Noorizan Abdul , Teja Muhammad Bayu , Hassan Yahaya , Rujhan Muhammad Roziha , Jaalam Kamaruddin
Published: July 2017

Objective:

To report a case of a low dose of oral dicyclomine associated with respiratory distress and death in an infant.

Case Summary:

A 35-day-old Malay boy was given a total of 1.0 mL of Colimix syrup (per 5 mL containing dicyclomine HCl 5 mg and simethicone 50 mg) by a general practitioner for vomiting. About 24 hours later, the boy was referred to the hospital because of abdominal distension and difficulty in breathing. On admission to the intensive care unit, the patient was unconscious, hypotensive, tachycardic, apneic, and cyanotic. His condition continued to deteriorate despite acute treatment and resuscitation, and the patient died about 72 hours later.

Discussion:

Metabolic disorder and septic shock were not likely and not convincing diagnoses considering the laboratory data and other patient information. Furthermore, this patient's condition deteriorated within a short time and did not respond to antibiotics and other drug treatments. Dicyclomine is highly suspected because the respiratory distress began after he was given the drug. This drug is contraindicated in children younger than six months and has been reported to cause respiratory distress and death. Most of the cases reported occurred after the patient received one to two oral doses (5–10 mg) of dicyclomine. Unfortunately, in our patient, respiratory distress developed even with a very low dose (0.5–1 mg). The causal relationship of this incident was classified as “probable” based on the Naranjo method.

Conclusions:

A low dose of oral dicyclomine was probably the cause of respiratory distress and death in this infant. Drugs that are contraindicated should not be administered, even at very small doses.
Pharmacy Litigation Review: Hospital Administration and the Pharmacy Department
Authors: Brushwood David B
Published: July 2017

Objective:

To review some essential legal points in the relationship between hospital administration and pharmacists, and outline some of the responsibilities both groups have to one another and to the institution that employs them.

Case Summaries:

Issues discussed in the seven case summaries presented include whether: (1) a hospital can be liable for negligence if an error is made by a nonpharmacist and it is likely the error would not have occurred if a pharmacist had been on staff; (2) nurses may routinely compound intravenous admixtures for administration by other nurses when this practice is the responsibility of pharmacists; (3) practices falling below the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) guidelines automatically fall below standards of care applicable in malpractice cases, negating the need for expert testimony; (4) a hospital is liable for failure to meet the standard of care when no expert has testified to such standards, and the plaintiff has relied solely on JCAHO standards, the Physicians' Desk Reference, and the drug package insert; (5) a hospital's formulary system establishes a standard of practice for medical staff practicing at the hospital; (6) the responsibility of a hospital to control drug distribution within the hospital extends to purchases of nonprescription drugs by patients in the hospital gift shop; and (7) state statutes or public policy shield quality assurance activities from discovery in malpractice litigation brought against a hospital.

Conclusions:

Institutional responsibilities have become a significant focus of pharmacist attention. When institutions have responsibilities related to drug distribution or the use of medicines, they turn to pharmacists to find ways of meeting these responsibilities. As these case studies show, the legal ramifications of both groups individually and to each other within an institution are complex and require continued study.
Association of Serum Vancomycin Concentration with Renal Dysfunction
Authors: Westrum Paula J , Koo Ji M , Carson Paul J
Published: July 2017

Objective:

To evaluate the association of vancomycin-related renal dysfunction with age; serum vancomycin trough concentration; baseline serum creatinine concentration; duration of vancomycin treatment; comorbid medical conditions of congestive heart failure, chronic renal failure, diabetes mellitus, and hepatic cirrhosis; and the concurrent use of drugs that can cause impairment of renal function.

Design:

A retrospective analysis of medical records of hospitalized patients who received intravenous vancomycin was conducted.

Setting:

This study was conducted in a 125-bed, tertiary care, government teaching hospital.

Methods:

Data were collected on 122 men, ranging in age from 41 to 95 years, who received vancomycin during a five-year period starting in 1991. Vancomycin-related renal dysfunction, defined as an increase of ≥0.5 mg/dL in serum creatinine concentration from the baseline value, was examined for an association with age; baseline serum creatinine concentration; duration of vancomycin treatment; serum vancomycin trough concentrations >15 μg/mL; and comorbid conditions of congestive heart failure, chronic renal failure, diabetes mellitus, and hepatic cirrhosis. The concurrent use of aminoglycosides, amphotericin B, diuretics, angiotensin-converting enzyme (ACE) inhibitors, Cimetidine, and intravenously administered contrast medium was also analyzed.

Results:

Stepwise logistic regression and odds ratio analyses failed to identify an association between vancomycin-related renal dysfunction and any factor examined except concurrent use of diuretics and ACE inhibitors.

Conclusions:

Patients receiving intravenous vancomycin concurrently with diuretics or ACE inhibitors have a higher risk of renal impairment. No incident of renal dysfunction was attributed to vancomycin alone.
The Risk of Hypersensitivity Reactions to Trimethoprim/Sulfamethoxazole as a Function of the CD4+ Count in HIV-Infected Patients
Authors: Morikawa Susan J , Cortese Linda M , Walker Janet S , Oster Charles N , Stoute José A
Published: July 2017

Background:

Trimethoprim/sulfamethoxazole (TMP/SMX) is an important antibiotic for the treatment and prevention of opportunistic infections in patients infected with HIV. However, the high rate of hypersensitivity reactions in this population of patients significantly limits the use of this drug.

Objective:

To determine whether early initiation of Pneumocystis carinii pneumonia prophylaxis with TMP/SMX in patients with HIV whose CD4+ lymphocyte count is >200 cells/mm3 results in a decrease in the number of hypersensitivity reactions.

Methods:

Retrospective cohort study. The main outcomes measured were the number of and the time to hypersensitivity reactions.

Results:

There were 134 patients who met the eligibility criteria (62 with a CD4+ cell count ≤200 cells/mm3 and 72 with a CD4+ cell count >200 cells/mm3). Overall, 47 (35.1%) patients had adverse reactions including 29 (21.6%) episodes of hypersensitivity. The mean time to a hypersensitivity reaction for the group with a CD4+ cell count ≤200 cells/mm3 was 155 days and for the group with a CD4+ cell count >200 cells/mm3 it was 261 days (mean difference = 106; p = 0.07; 95% CI 66 to 146 days). The number of episodes of hypersensitivity reactions was similar among the two groups: 15 (24.2%) and 14 (19.4%), respectively (p = 0.5; relative risk for CD4+ cell count ≤200 cells/mm3 = 1.14; 95% CI 0.7 to 1.7). Log-rank test did not reveal a significant difference in reaction-free survival among the groups (p = 0.3).

Conclusions:

Our data suggest that initiation of P. carinii pneumonia prophylaxis with TMP/SMX at a CD4+ cell count >200 cells/mm3 would lead to prolongation of the mean time to a hypersensitivity reaction, but would not significantly decrease the risk of a reaction over time.