bluuebunny/crossref_metadata_2025 huggingface dataset:
Cytokines and T Cell Switching
Authors: Gemmell Erica , Seymour Gregory J.
Published: January 2017

In recent years, the phenotypic characterization of T cell subsets has given way to a functional dichotomy based essentially on their cytokine profiles. In this context, the CD4+ helper T cell subset has been shown to consist of two types, termed Th1 and Th2. In general, Th1 cells produce interleukin (IL)-2 and interferon (IFN)-gamma, while Th2 cells characteristicaly produce IL-4, IL-5, and IL-6. The major function of the Th1 subset is to mediate delayed-type hypersensitivity reactions and their secondary function is suppression of B cell activity. In contrast, the major function of the Th2 subset is to provide B cell help, while their secondary function is cell-mediated immune suppression. A similar dichotomy has also been described for CD8+ T cells. The role that these functional T cell subsets and their cytokines play in terms of their protective and nonprotective outcomes in a variety of infectious and oral diseases is reviewed.
Signal Transduction Mechanisms in Mesenchymal Cells
Authors: McAllister Bradley S. , Walters John D. , Olson Merle S.
Published: January 2017

Mesenchymal cells are continually stimulated by a wide spectrum of biological mediators. These mediators bind to receptors on the cell surface and initiate a cascade of signaling events. The initial signal transduction pathways known to be stimulated in mesenchymal cells include phospholipase C, phospholipase D, phospholipase A2, adenylate cyclase, receptor tyrosine kinases, and receptor serine/threonine kinases. These pathways are reviewed and specific applications for therapeutic intervention in wound healing and regenerative therapy in the periodontium are discussed.
Faculty Turnover within Academic Pharmacy Departments
Authors: Carter Orly , Nathisuwan Surakit , Stoddard Gregory J , Munger Mark A
Published: January 2017

BACKGROUND:

Pharmacy faculty manpower has been debated within the academic pharmacy community over the last several decades. Previous investigations studied job satisfaction among faculty members, but have not evaluated faculty retention and turnover among academic pharmacy departments.

OBJECTIVE:

To evaluate retention and turnover rates in the departments of Pharmacy Practice and Basic Science (Pharmacology/Toxicology, Pharmaceutics, Medicinal Chemistry) over the last 5 years.

METHODS:

Individual instructors and assistant, associate, and full professors across 80 colleges of pharmacy in the US were tracked between the years 1996 and 2001 using the American Association of Colleges of Pharmacy published rosters. Differences between departments were analyzed by year-stratified cross-tabulation table analysis.

RESULTS:

A greater percentage of Pharmacy Practice faculty resigned (10.6%) compared with Basic Science faculty (6.0%; percent ratio 1.76; 95% CI 1.58 to 1.95; p < 0.001), which remained constant across each academic year. Approximately 2.7 faculty members left their academic institutions per year in Pharmacy Practice compared with 1.1 faculty members in the aggregate of Basic Science departments. A higher percentage of women resigned in Pharmacy Practice (13.2%) than did men (8.7%; percent ratio 1.5; 95% CI 1.34 to 1.68; p < 0.001), despite a 1.3-fold male to female ratio. Likewise, regardless of a 4.1-fold male to female ratio in the Basic Science group, a higher percentage of women resigned (8.0%) than men (5.5%; percent ratio 1.45; 95% CI 1.18 to 1.78; p < 0.001).

CONCLUSIONS:

Over a 5-year period, Pharmacy Practice exhibited a higher turnover compared with Basic Science. Women displayed significantly higher turnover than men across all pharmacy academic departments. New retention approaches, especially for female faculty members, should be explored.
Resolution of Risperidone-Induced Hyperprolactinemia with Substitution of Quetiapine
Authors: Kunwar Arun Raj , Megna James L
Published: January 2017

OBJECTIVE:

To report a case of risperidone-induced hyperprolactinemia that was successfully managed with quetiapine.

CASE SUMMARY:

A 30-year-old white woman with schizoaffective disorder, depressive type, and comorbid alcohol and cocaine abuse was treated successfully for her psychotic symptoms with risperidone until she developed adverse effects consistent with hyperprolactinemia. This was confirmed by laboratory blood tests, as her prolactin level was 186.9 ng/mL (normal for nonpregnant women 2.8–29.2). The woman had experienced similar effects in the past, which had led to noncompliance and subsequent psychotic relapse. Normalization of prolactin levels and associated adverse effects were achieved upon switching to quetiapine. No psychotic symptoms reoccurred.

DISCUSSION:

Dopamine type 2 (D2) receptor blockade in the mesolimbic tract is thought to mediate the therapeutic effects of antipsychotics. This action in the tuberoinfundibular system produces prolactin level elevation. Risperidone has a relatively higher affinity for the D2 receptor in comparison with other atypical antipsychotics, which may explain why it is associated with a higher incidence of hyperprolactinemia. Quetiapine, which has one of the lowest D2 receptor affinities, is not known to increase prolactin levels to any significant degree. This pharmacologic property allows quetiapine to be a reasonable treatment option for patients who develop risperidone-induced hyperprolactinemia.

CONCLUSIONS:

Quetiapine may be a suitable substitute when a patient taking risperidone develops hyperprolactinemia.
Clopidogrel-Associated Leukopenia
Authors: McCarthy Michelle W , Kockler Denise R
Published: January 2017

OBJECTIVE:

To report a case of leukopenia in a patient receiving clopidogrel following intracoronary stent placement.

CASE SUMMARY:

A 58-year-old white man presented to the emergency department (ED) with fever and chills. Seven days prior to presentation, he underwent intracoronary stent placement and clopidogrel 75 mg once daily was initiated. In the ED, laboratory evaluation revealed leukopenia with negative blood and urine cultures. The patient was released but returned the following day with fever and sweating. Infectious complications were ruled out, and clopidogrel was discontinued. Leukopenia resolved within 7 days, and the patient has experienced no further hematologic complications. Based on the Naranjo probability scale, the leukopenia was rated as a probable reaction to clopidogrel.

DISCUSSION:

Ticlopidine and clopidogrel are the 2 commercially available thienopyridine antiplatelet agents. Risk of myelotoxicity with ticlopidine is well known and requires frequent hematologic monitoring. Clopidogrel is better tolerated, less toxic, and has more extensive indications, including use in acute coronary syndrome. These factors have resulted in the replacement of ticlopidine by clopidogrel. The 4 previously published reports of clopidogrel-associated white blood cell (WBC) toxicity are described. The mechanism of myelotoxicity with clopidogrel is not known.

CONCLUSIONS:

Better tolerability, reduced toxicity (particularly hematologic), and the convenience of once-daily dosing have resulted in the replacement of ticlopidine with clopidogrel. WBC toxicity associated with clopidogrel therapy is very infrequent and has occurred weeks to months following therapy initiation. Clinicians should be aware of the potential for this adverse effect.
Desloratadine: A Nonsedating Antihistamine
Authors: Limon Lynn , Kockler Denise R
Published: January 2017

OBJECTIVE:

To review information on desloratadine, a nonsedating antihistamine.

DATA SOURCES:

An English-language MEDLINE search was conducted (1966–July 2002). References of identified articles were subsequently reviewed for additional data. Schering Corporation provided unpublished information.

STUDY SELECTION/DATA EXTRACTION:

Articles and abstracts pertaining to desloratadine were considered for inclusion, with emphasis on randomized, placebo-controlled, double-blind trials.

DATA SYNTHESIS:

Desloratadine is approved for the treatment of symptoms associated with seasonal allergic rhinitis (SAR), perennial allergic rhinitis (PAR), and chronic idiopathic urticaria (CIU) in patients aged ≥12 years. In placebo-controlled trials, desloratadine demonstrated superior efficacy as a once-daily treatment of SAR, PAR, and CIU. Data suggest that desloratadine has antiinflammatory and decongestant activity.

CONCLUSIONS:

Desloratadine appears to be a “me-too” agent, with no major differences compared with other second-generation antihistamines.
Nesiritide: A Novel Approach for Acute Heart Failure
Authors: Vichiendilokkul Aungkana , Tran Alison , Racine Eric
Published: January 2017

OBJECTIVE:

To review preclinical and clinical information related to nesiritide, a recombinant form of B-type natriuretic peptide approved for treatment of acutely decompensated heart failure.

DATA SOURCES:

Primary and review articles were identified by MEDLINE search (1966–May 2002) using the key words natriuretic peptide and heart failure, and through secondary sources. Natrecor's document submitted for the Food and Drug Administration (FDA) New Drug Application were obtained from the FDA Web site.

STUDY SELECTION/DATA EXTRACTION:

Peer-reviewed articles and abstracts of randomized clinical trials in humans were included in this review.

DATA SYNTHESIS:

Nesiritide has beneficial actions for treatment of heart failure, including arterial and venous dilatation, enhanced sodium and urinary excretion, and suppression of the renin–angiotensin–aldosterone and sympathetic nervous systems. It has been shown to improve hemodynamic parameters, primarily pulmonary capillary wedge pressure, as well as clinical symptoms in patients with acutely decompensated heart failure. Nesiritide produced more rapid hemodynamic improvement and caused significantly fewer adverse effects than intravenous nitroglycerin. The incidence of hypotension, the most common adverse effect, was comparable between nesiritide and nitroglycerin. Additionally, nesiritide is associated with a lower incidence of arrhythmias than dobutamine and has a neutral effect on mortality.

CONCLUSIONS:

Nesiritide offers an alternative for management of acutely decompensated heart failure. It is considered an option for patients who do not respond to other vasodilators, inotropes, or diuretics and for those at high risk of arrhythmias. Further pharmacoeconomic investigations for nesiritide are warranted.
A Prospective Review of Cimetidine use
Authors: Gee Joseph P. , Jim Lucia K. , Leibowitz Alan , McLeod Don C.
Published: January 2017

A prospective-drug-use analysis was conducted on the first 60 patients receiving cimetidine in a general hospital. Only 18 percent had FDA-approved cimetidine indications, although another 62 percent received the drug for reasons supported by the medical literature. Other than a few cases of use for inappropriate reasons, the major limitation was that almost all patients received intensive antacid therapy along with cimetidine before being given an adequate trial with either drug alone. Thus, an assessment of cimetidine's efficacy was impossible.
Feasibility of Symbolic Directions on Prescription Labels
Authors: Hardie Nancy Richardson , Gagnon Jean Paul , Eckel Frederick M.
Published: January 2017

This project presents the results of a study designed to evaluate the usefulness of graphic labels in assisting functionally illiterate patients to understand how and when to take medication. The project's results indicate that comprehension of symbolic directions did not increase as rapidly as comprehension of typed directions. Symbolic directions did, however, reduce the variation in interpretation of directions among patients with a 0–4 grade education. Neither age, nor sex, nor the order of label presentation affected level of comprehension of typed or symbolic prescription labels.

The results of this study indicate that use of symbols may not be the sole answer to the problem of assisting patients with inadequate reading abilities. Symbolic prescription directions should be evaluated before their use. Then, when used, they should be accompanied by oral reinforcement.
Cognitive Variants in the Elderly: An Integral Part of Medication Counseling
Authors: Lamy Peter P. , Moore Steven R.
Published: January 2017

The elderly population continues to be a major consumer of drugs. In working with this population, special consideration should be given to the specific problems that make drug use in the elderly more complex. One area that is often not considered is cognitive aspects of information receipt, storage, retrieval, and utilization. By considering these factors in working with the elderly, more appropriate and useful outcomes may be achieved.
Compliance among Adults with Cystic Fibrosis
Authors: Fong Samantha L.C. , Dales Robert E. , Tierney Michael G.
Published: January 2017

Advances in therapy have largely contributed to the increased life expectancy of patients with cystic fibrosis. Unlike children, adults with cystic fibrosis must take responsibility for their own care. We administered a questionnaire to 23 adult patients (aged 18–39 years) with cystic fibrosis to (1) determine patients' degree of compliance with medications and chest physiotherapy; (2) collect information on their self-assessment of health motivation, disease severity, and benefits of treatment; and (3) identify barriers to receiving medical care. Patients reported better compliance with medications than with chest physiotherapy. Nine percent of the patients missed at least 25 percent of prescribed medication, whereas 47 percent missed at least 25 percent of prescribed physiotherapy. We observed a trend toward better compliance in patients who were highly worried about their health, who believed their illness to be serious, and who felt that their medications were very effective. Less than half of the study participants believed physiotherapy to be effective, and that adhering to a physiotherapy schedule was very difficult. Among adults with cystic fibrosis, compliance can be a serious problem that minimizes the benefits of good medical care. We suggest that emphasizing the severity of disease and usefulness of therapy may improve compliance and requires study.
Narcotic Use in the Hospital: Reasonably Safe?
Authors: Whipple Julianne K. , Ausman Robert K. , Quebbeman Edward J.
Published: January 2017

OBJECTIVE:

To determine the causes and frequency of overdoses associated with the administration of opioid analgesics in hospitalized patients.

DESIGN:

Case series.

SETTING:

Two acute care teaching hospitals.

PATIENTS:

Eighty-one hospitalized patients who received naloxone for a clinically suspected narcotic overdose.

INTERVENTIONS:

Three investigators reviewed each patient who received naloxone during a 12-month period. The patients were judged to have a narcotic overdose if caregivers documented an immediate improvement in mental status, respiratory rate, or blood pressure after naloxone administration.

MAIN OUTCOME MEASURES:

The number and causes of narcotic overdoses were determined. The frequency of morphine and meperidine overdoses was calculated. The number of incidents reported using incident or adverse drug reaction reports or the appropriate International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code.

RESULTS:

In the 22 overdoses that occurred, 14 (64 percent) were caused by medication prescribing, compounding, or administration errors and potentially were preventable. The remaining eight patients experienced an overdose despite receiving appropriate amounts of opioids. The frequency of overdoses was 0.4 and 0.2 percent of total patients receiving morphine or meperidine, respectively, at the two hospitals. Nonreporting of these narcotic overdoses was frequent. In one hospital, 1 incident report and 3 adverse drug reactions were reported for 17 overdoses. At the second hospital, 1 incident report and 1 adverse drug reaction were reported for 6 overdoses. None of the patient charts included an ICD-9-CM code that documented the problem.

CONCLUSIONS:

The causes of overdoses are not limited to prescribing and administration errors. Some patients, despite proper execution of appropriate orders, develop a narcotic overdose. Caregivers must be aware of this problem and monitor patients for a decrease in mental status and respiratory rate. In addition, we conclude that an important number of hospitalized patients develop an overdose even though the frequency is low related to the number of patients receiving narcotics.
Weight Gain Associated with Cinnarizine
Authors: Navarro-Badenes Joaquin , Martínez-Mir Inocencia , Palop Vicente , Rubio Elena , Morales-Olivas Francisco J.
Published: January 2017

OBJECTIVE:

To report four cases of cinnarizine-induced weight gain.

DATA SOURCES:

Case reports from a local obesity center and review articles.

DATA EXTRACTION:

Data were abstracted from spontaneous comments made by patients to one of the authors, who was a doctor at the clinic, and reviewed by the remaining authors.

DATA SYNTHESIS:

We reviewed the cases of four women, aged 50–57 years without endocrine or metabolic pathologies, that showed weight gain associated with the intake of cinnarizine for one to two years. No other drugs usually were administered during the period in which the women gained weight, although in two cases cinnarizine was associated with dihydroergocristine in the same medicine (Clinadil). The mean weight increase was 6.25 kg (range 4–10). The increases do not appear to be related to whether the patients' initial weight was ideal or excessive. The weight gain was always associated with increased appetite and food intake. One patient discontinued cinnarizine treatment and her weight returned to its previous level.

CONCLUSIONS:

Cinnarizine is a piperazine derivative used in the treatment of vertigo and in the prophylaxis of migraine. In contrast to related drugs, data about cinnarizine are scarce because randomized trials of cinnarizine have been inconclusive. Our observations indicate that cinnarizine may cause weight gain, as observed with other drugs in the same class.
A Description of a Pharmacotherapy Curriculum in a University-Based Family Medicine Program
Authors: Bucci Kathryn K. , Frey Keith A.
Published: January 2017

OBJECTIVE:

To describe the methods by which a family medicine residency program implements a pharmacotherapy curriculum. The goal of the curriculum is to teach family medicine residents the principles of rational drug therapy.

SETTING:

A university-based family medicine residency program.

TEACHING STRATEGIES:

Specific learning objectives are discussed and the following teaching strategies are expanded upon: (1) monthly noon conferences; (2) a printed formulary and pharmacotherapy handbook; (3) a pharmacy and therapeutics committee; (4) policy statements for drug representatives and use of samples; (5) an on-site pharmacy; (6) quarterly newsletter, and (7) inpatient consultation coverage.

PHARMACIST ROLE:

The role and responsibilities of the pharmacy faculty and pharmacist(s) who implement this curriculum and the methods used to evaluate its effectiveness are also described. The availability and funding of the pharmacy faculty member can sometimes be arranged with local schools of pharmacy seeking clerkship sites. Interaction with pharmacy students also serves to enhance the educational experience of the family medicine residents.

CONCLUSIONS:

The family medicine program implements a comprehensive curriculum designed to teach family medicine residents the principles of rational drug therapy. The curriculum may be expanded upon as necessary, or, if the entire program is not feasible, certain elements may be extracted and applied in other institutions.
Controversies in the Management of Mycobacterium Avium Complex Infection in AIDS Patients
Authors: Peloquin Charles A.
Published: January 2017

OBJECTIVE:

To update readers on the clinical management of infections secondary to Mycobacterium avium complex (MAC) in patients with AIDS. A general description of the organism, culture and susceptibility testing, and clinical manifestations of the disease is provided. Several aspects of the treatment of the disease, including an historical perspective, current approaches, and future research opportunities, are described.

DATA SOURCES:

Current medical literature, including abstracts presented at international meetings, is reviewed. References were identified through MEDLINE, Current Contents, and published meeting abstracts.

STUDY SELECTION:

Data regarding the epidemiology, clinical manifestations, culture and susceptibility testing, and treatment of MAC are cited. Specific attention is given to the management of patients with MAC infection.

DATA EXTRACTION:

Information contributing to the discussion of the topics selected by the author is reviewed. Data supporting and disputing specific conclusions are presented.

DATA SYNTHESIS:

Disseminated MAC infection is diagnosed antemortem in approximately 30 percent of patients with AIDS; postmortem rates of isolation exceed 50 percent. The incidence of MAC may increase as attempts at isolating the organism become more aggressive. The traditional approach to the isolation, susceptibility testing, and treatment of MAC has been derived from the management of Mycobacterium tuberculosis, with disappointing results. Newer radiometric in vitro methods of susceptibility testing appear to show more promise. Current mouse models of MAC are not true AIDS models; new CD4-deficient mouse models are being developed. Clinical mycobacteriologic and pharmacokinetic laboratory support have been underused, with treatment generally proceeding empirically. New agents that may contribute to the management of disseminated MAC infection include the macrolide derivatives clarithromycin and azithromycin. Research also continues with new rifamycins (including rifabutin) and fluoroquinolones (ciprofloxacin, sparfloxacin). Preliminary results suggest a central role for macrolides in the treatment of disseminated MAC; effective companion drugs are needed to prevent the rapid emergence of macrolide-resistant MAC.

CONCLUSIONS:

Treatment results for disseminated MAC infection remain poor. Therapy may be improved by selecting drugs on the basis of susceptibility data for each isolate, rather than by using empiric regimens based on susceptibility trends. Significant antimycobacterial drug malabsorption has been documented, and may contribute to poor outcomes. More-potent agents are needed to improve the clinical outcome in AIDS patients with MAC.
Fluvoxamine-Associated Sexual Dysfunction
Authors: Dorevitch Abraham , Davis Hillel
Published: January 2017

OBJECTIVE:

To report two cases of sexual dysfunction induced by fluvoxamine, a selective serotonin reuptake inhibitor (SSRI).

SETTING:

University teaching hospital.

PATIENTS:

Two depressed patients who developed ejaculation and orgasmic difficulties after initiation of fluvoxamine therapy.

DISCUSSION:

The literature concerning sexual dysfunction with serotonergic antidepressants is reviewed, and speculated mechanisms for this untoward effect are discussed.

CONCLUSIONS:

Sexual dysfunction associated with antidepressant drugs, including SSRIs, may be underreported. This troublesome adverse effect may significantly affect patient comfort and compliance. Careful evaluation of sexual function is warranted, prior to and during drug treatment, especially as more serotonergic antidepressant agents become available.
High-Dose Clonidine in a Case of Restless Legs Syndrome
Authors: Zoe Anette , Wagner Mary L. , Walters Arthur S.
Published: January 2017

OBJECTIVE:

To describe a patient with idiopathic restless legs syndrome (RLS).

CASE SUMMARY:

A 37-year-old man developed severe symptoms of RLS. Treatment using combinations of levodopa, opioids, benzodiazepines, and baclofen provided only partial benefit or resulted in intolerable adverse effects. Higher dosages of clonidine than previously reported in the literature (0.9 mg/d in divided doses) were needed to completely relieve his RLS symptoms. The only prominent adverse effect was dry mouth. The RLS symptoms returned after subsequent reductions in the dosage. After the dosage of clonidine was again increased, complete relief of the symptoms was achieved again. After several months, clonidine was tapered to zero and the patient entered a period of spontaneous remission. When his symptoms returned four months after clonidine had been discontinued, clonidine therapy was restarted.

DISCUSSION:

Clonidine alleviated RLS symptoms in 30 of 41 patients reported in the literature, indicating that the adrenergic nervous system may playa role in RLS.

CONCLUSIONS:

High-dose clonidine appears to be useful in treating RLS when other therapies fail. However, well-controlled, polysomnographic studies are needed.
Pleural Effusions: Pathophysiology and Management
Authors: Andrews Carlota O. , Gora Mary Lea
Published: January 2017

OBJECTIVE:

To review the pathophysiology and management of pleural effusions, including available agents for pleural sclerosis.

DATA SOURCES:

A MEDLINE search (1966 to present) was performed that included clinical studies in the English language involving the pathophysiology and management of pleural effusions; references used in those articles were screened for additional published information.

STUDY SELECTION:

All clinical trials were considered for potential inclusion in the review.

DATA SYNTHESIS:

Pleural effusion is an accumulation of fluid in the pleural space that results when homeostatic forces that control the flow into and out of the area are disrupted. The management of transudative pleural effusions is primarily directed at treatment of the underlying disease. There are several treatment options for pleural effusions, including chemical pleurodesis. Many of the trials that examine the use of talc, bleomycin, and doxycycline have poorly described study designs and end points, with inconsistent evaluation of patients. Each agent is considered to be generally effective and safe, with fever and pain as the most frequently reported adverse effects. The use of talc requires sterilization, and many clinicians use general anesthesia with instillation, which increases the risk associated with the procedure. Bleomycin is generally safe; however, it should not be used in doses exceeding 40 mg/m2. Only uncontrolled trials support the use of doxycycline; however, it provides an effective, safe, and relatively inexpensive alternative.

CONCLUSIONS:

Pleural effusions are defined as an accumulation of fluid in the pleural space. Treatment is generally palliative. Intrapleural administration of talc, bleomycin, and doxycycline are effective sclerosing agents for treatment of recurrent, symptomatic pleural effusions. Although the most cost-effective agent has not been determined, doxycycline is an inexpensive alternative to bleomycin, and may have fewer adverse effects than talc.
Amphotericin B-Associated Hypertension
Authors: Le Ysa , Rana Khurram Z , Dudley Michael N
Published: January 2017

OBJECTIVE:

To report two cases of hypertension related to amphotericin B infusion.

CASE SUMMARY:

A 63-year-old woman with Candida albicans bacteremia and an 84-year-old man with Aspergillus fumigatus pneumonia developed hypertension within minutes of amphotericin B administration. Both patients' blood pressure returned to baseline soon after the infusion of amphotericin B was stopped. Neither patient was rechallenged.

DISCUSSION:

A causal relationship may exist between the administration of amphotericin B and these hypertensive episodes. Blood pressure in both patients normalized without treatment on discontinuation of the infusion. The mechanism of amphotericin B-associated hypertension is unclear but could include vasoconstricting properties of the drug or the administration of intravenous NaCl 0.9% prior to amphotericin B infusion. We recommend that intravenous NaCl 0.9% be administered following amphotericin B infusion and that the infusion be stopped if hypertensive episodes arise.

CONCLUSIONS:

Both acute hypertension and hypotension can occur in patients receiving amphotericin B for systemic fungal infections.

OBJETIVO:

Reportar dos casos de hipertensión relacionados a la infusión de anfotericina B.

RESUMEN DEL CASO:

Una paciente de 63 años de edad con bacteremia debida a la Candida albicans y un paciente de 84 años de edad con neumonía debida al Aspergillus fumigatus desarrollaron hipertensión a los pocos minutos de comenzar la administración de anfotericina B. La presión sanguínea de ambos pacientes retornó a la línea de base tan pronto como se detuvo la infusión de anfortericina B. Ninguno de los dos pacientes fue reexpuesto a la anfotericina B para determinar si el evento se repeatía.

DISCUSIÓN:

Puede existir una relación causal entre la adminstración de anfotericina B y estos episodios de hipertensión reportados, ya que la presión sanguínea se normalizó en ambos pacientes sin necesidad de tratamiento adicional después de que se suspendió la infusión de anfotericina B. El mecanismo por el cual anfotericina está asociada al desarrollo de hipertensión no está claro pero se especula que se debe a las propiedades vasoconstrictoras del medicamento o a la administración de cloruro de sodio intravenosamente antes de comenzar la infusión de anfotericina B. Por consiguiente, los autores recomiendan que el cloruro de sodio sea administrado después de que se haya concluido la infusión de anfotericina B. En el caso de que se reporten episodios hipertensivos, la infusión de anfotericina B debería ser suspendida inmediatamente.

CONCLUSIONES:

Casos de hipertensión o hipotensión pueden ocurrir en pacientes que reciben anfotericina B para el tratamiento de infecciones fungosas sistémicas.
Dibenzepin Overdose Causing Pulmonary Edema
Authors: Wirtheim Eytan , Bloch Yuval
Published: January 2017

OBJECTIVE:

To report a case of pulmonary edema due to dibenzepin overdose.

CASE SUMMARY:

A 39-year-old woman was hospitalized 24 hours after she ingested eight tablets of dibenzepin hydrochloride delayed-release 240 mg/tablet (∼35 mg/kg body weight). On admission the patient was confused, and physical examination revealed sinus tachycardia (HR 130 beats/min). Forty-five hours after ingestion of the dibenzepin she developed pulmonary edema and was treated with furosemide, morphine, and mechanical ventilation through an endotracheal tube for 48 hours. Repeated echocardiography revealed left ventricular dysfunction that resolved as the medical condition of the patient improved. Appropriate studies excluded pneumonia, pneumonitis, adult respiratory distress syndrome, myocardial infarction, and pulmonary emboli as contributing factors to this patient's condition.

DISCUSSION:

Tricyclic antidepressant overdose is known to cause cardiopulmonary complications, including pulmonary edema. To the best of our knowledge, this is the first reported case of pulmonary edema as a result of dibenzepin overdose. The most probable mechanism for this complication is depression of left ventricular function.

CONCLUSIONS:

As with other tricyclic antidepressants, dibenzepin toxicity may cause pulmonary edema. Close patient monitoring is essential for at least 48-72 hours after the overdose.
Understanding Allergic Reactions to Local Anesthetics
Authors: Eggleston Steven T , Lush Lori W
Published: January 2017

OBJECTIVE:

To review the pharmacology and mechanisms by which local anesthetics cause allergic reactions. Recommendations concerning appropriate use of local anesthetics and alternative therapies in patients with documented local anesthetic allergies are given. DATA SOURCE: A MEDLINE search of the English-language literature identified pertinent clinical studies, case reports, and reviews. The periods of review were Med1, 1990-present; and Med2, 1985-1989, using the MeSH terms drug hypersensitivity and anesthetics. References from the selected studies, case reports, and reviews were reviewed.

STUDY SELECTION:

Controlled and uncontrolled prospective studies and case reports pertaining to local anesthetic allergies were reviewed. The selection focused on information pertaining to the etiology and diagnosis of allergic reactions to local anesthetics and alternative therapies for patients with local anesthetic allergies.

DATA SYNTHESIS:

Local anesthetics are classified as either ester or amide compounds. Esters are associated with a higher incidence of allergic reactions, due to a p-aminobenzoic acid (PABA) metabolite. Amide agents do not undergo such metabolism. However, preservative compounds (methylparaben) used in the preparation of amide-type agents are metabolized to PABA. Patients who are allergic to ester local anesthetics should be treated with a preservative-free amide local anesthetic. If the patient is not allergic to ester local anesthetics, these agents may be used in amide-sensitive patients. In the rare instance that hypersensitivity to both ester and amide local anesthetics occurs, or if skin testing cannot be performed, then alternative therapies including diphenhydramine, opioids, general analgesia, or hypnosis can be used.

CONCLUSIONS:

A true immunologic reaction to a local anesthetic is rare. Intradermal skin testing of local anesthetic compounds, methylparaben, and metabisulfite should be performed in patients when a thorough history does not rule out a possible allergic reaction to local anesthetics and future local anesthesia is necessary. Skin testing enables the clinician to identify autonomic responses to minor surgical procedures and toxic reactions to anesthetics so that patients are not incorrectly labeled as “caine” allergic. Diphenhydramine can be used as an alternative to ester and amide local anesthetics in minor procedures of short duration.
Inappropriate Medication Prescribing for the Elderly by Office-Based Physicians
Authors: Aparasu Rajender R. , Fliginger Shana E.
Published: January 2017

OBJECTIVE:

To estimate the prevalence of inappropriate medications prescribed by office-based physicians for patients 65 years or older.

DESIGN:

A nationwide cross-sectional survey of office visits by the elderly.

SETTING:

The National Ambulatory Medical Care Survey (NAMCS) 1992, a national probability sample survey of office visits by ambulatory patients within the continental US.

SUBJECTS:

A national probability sample of patients 65 years or older visiting office-based physicians. National estimates are based on the National Center for Health Statistics weighting procedure for the NAMCS sample.

MAIN OUTCOME MEASURES:

Prevalence of 20 inappropriate medications that should be entirely avoided in the elderly, using criteria developed by a panel of national experts in geriatric medicine and geriatric pharmacology.

RESULTS:

In the US during 1992, an estimated 8.47 million (95% CI 7.66 million to 9.28 million) office visits by the elderly indicated prescribing of at least 1 of the 20 inappropriate medications. Approximately 7.75 million (95% CI 6.98 million to 8.52 million) visits by the elderly involved 1 inappropriate medication and 0.72 million (95% CI 0.51 million to 0.93 million) visits included 2 inappropriate medications. According to the NAMCS, office-based physicians prescribed at least 1 inappropriate medication to 7.58% of the elderly who received prescriptions. The most frequently prescribed inappropriate medications were propoxyphene, amitriptyline, dipyridamole, diazepam, and chlorpropamide. Elderly patients rarely received prescriptions from office-based physicians for drugs such as secobarbital, isoxsuprine, trimethobenzamide, and carisoprodol. Furthermore, office-based physicians did not prescribe cyclandelate, pentobarbital, or phenylbutazone for the elderly.

CONCLUSIONS:

The prescribing of inappropriate medications by office-based physicians raises concerns regarding the quality of care for the elderly in ambulatory settings. The crux of improving patient care in ambulatory settings rests with collaborative efforts between physicians and pharmacists.
Fatal Cardiac Event following Initiation of Risperidone Therapy
Authors: Ravin Donna S. , Levenson James W.
Published: January 2017

OBJECTIVE:

To describe a patient who developed fatal pulseless electrical activity following treatment with risperidone.

CASE SUMMARY:

A 34-year-old white woman with no history of cardiac disease was initiated on risperidone therapy for an acute exacerbation of chronic schizophrenia. The patient developed postural hypotension and the risperidone dosage was held at 2 mg bid. On day 5 of risperidone therapy, the patient developed cardiac arrest and was treated for pulseless electrical activity. Her electrocardiogram revealed a prolonged QRS interval of 160 msec and an abnormal QTc interval of 480 msec. Despite resuscitative efforts, the patient became asystolic and was pronounced dead.

DISCUSSION:

Adverse cardiac events are rarely associated with risperidone therapy. Prolongation of the QRS and QTc intervals have been reported to occur following two cases of presumed risperidone overdose and also in 8 of 380 patients in a double-blind study reported by the manufacturer. Although other possibilities exist, risperidone cannot be ruled out as the cause of this patient's fatal episode of pulseless electrical activity.

CONCLUSIONS:

Prolongation of the QTc interval with severe adverse effects remains a possibility with the use of risperidone.
Young Author Spotlight
Authors: Alexander Hilary
Published: January 2017

Dr. Hilary Alexander interviews David Petrovic, a motivational speaker and author whose work has been used with youths preventing autism spectrum disorders and their families. The interview focuses on mastering developmental milestones and transitioning to independent living in college. Petrovic also describes support services and resources, including his involvement in musical theater.
Australia's Oceans Policy: Sink or Swim?
Authors: Alder Jacqueline , Ward Trevor
Published: January 2017

In 1999, Australia introduced an ecosystem-based oceans policy. This article analyzes the issues that must be addressed in implementing this policy. Institutional arrangements and regional marine management plans are the keys to translating ecosystem management principles into day-to-day operation. The proposed institutional arrangements have the potential to overcome the historical problems of coordination and jurisdictional disputes, but implementation has further polarized federal and state agencies and stakeholders. Even if these issues are resolved, the authors note that substantial development is required in the areas of designing nested ecosystem-based management frameworks at the appropriate geographic scales, methods for integrating across the range of users and ecosystem values, and tools for evaluating and assessing ocean management decisions before the policy will affect the ecologically sustainable use of Australia's ocean estate.
The Future of Antarctica under the Environmental Protocol
Authors: Marks Beth C. , Barnes James N.
Published: January 2017

The continent of Antarctica holds immense value as a wilderness area and a repository of scientific knowledge. This report maintains that the Protocol to the Antarctic Treaty on Environmental Protection, signed in 1991, is a positive first step in ensuring that Antarctica preserves its status as a global scientific laboratory, wildlife refuge, and arena for international cooperation.
Mexican Environmental Policy Revisited
Authors: Stern Marc A.
Published: January 2017

Mexican environmental policy has received a great deal of criticism but very little analytical attention. In this report the Mexican effort is reevaluated with an emphasis on the technical and structural difficulties that threaten to undermine progress towards the government's stated environmental goals. Some of the key issues identified include the cost and availability of funds to the private sector, the dominance of political over technical priorities, and the weakness of social participation. The report indicates a need for greater attention to the political factors that shape policy choices, particularly if the lessons available from Mexico's experience are to be of use for other developing countries.1
First Metatarsophalangeal Joint Arthrodesis: An Evaluation of Hardware Failure
Authors: Bennett Gordon L. , Kay David B. , Sabatta James
Published: January 2017

Background: First metatarsophalangeal joint (MTPJ) arthrodesis is commonly used for the treatment of a variety of conditions affecting the hallux. We used a method incorporating a ball-and-cup preparation of the first metatarsal and proximal phalanx, followed by fixation of the arthrodesis with a lag screw and a dorsal plate (Synthes Modular Hand Set). Methods: Ninety-five consecutive patients had first MTPJ arthrodesis using fixation with the Synthes Modular Hand Set. All patients were evaluated preoperatively, at regular intervals postoperatively, and at final followup. The American Orthopaedic Foot and Ankle Society (AOFAS) forefoot scoring system was used preoperatively and at final followup. Results: Solid fusion occurred in 93 of 107 feet (86.9%). In the 14 that did not fuse, either the screws or plate, or both, broke. Ten of the 14 feet were symptomatic, but only three required further operative treatment. There were no hardware problems or failures in patients who had solid fusions. Preoperative AOFAS scores were improved after surgery in all patients. Conclusions: A solid first MTPJ fusion results in excellent function and pain relief, but the Synthes Modular Hand Set implants do not appear to be strong enough in all patients for this application; nonunion at the arthrodesis site and failure of hardware occurred in 13% of arthrodeses. We no longer recommend this implant for this application.
Effects of a UCBL Orthosis and a Calcaneal Osteotomy on Tibiotalar Contact Characteristics in a Cadaver Flatfoot Model
Authors: Havenhill Timothy G. , Toolan Brian C. , Draganich Louis F.
Published: January 2017

Background: A flatfoot deformity alters the contact characteristics of the ankle joint, shifting the location of articulation posterolaterally, increasing pressure, and decreasing the contact area within the ankle. These changes may explain the pattern of articular degeneration and subsequent angulation observed in a long-standing adult acquired flatfoot. Corrective orthoses and surgical reconstruction have been used to realign pes planovalgus feet, but the effects of these treatments on tibiotalar contact characteristics are unknown. We hypothesized that realignment of a flatfoot with either corrective orthosis or surgical reconstruction would restore the contact characteristics of the ankle to the intact state. Methods: The mean value of the contact area, contact pressure, peak contact pressure, and the relative locations of the global contact area and peak pressure within the ankle joint were determined from imprints created on pressure sensitive film for a series of cadaver lower limbs subjected to a weightbearing load in simulated midstance phase of gait. Each limb was loaded sequentially under four conditions: intact, flatfoot, flatfoot realigned with UCBL orthosis, and flatfoot realigned with a medial translational osteotomy of the calcaneus. Results: The use of the UCBL orthosis and calcaneal osteotomy altered the contact characteristics of the ankle when compared with the flatfoot condition. Both interventions significantly decreased the mean global contact pressure from the flatfoot value, with the orthosis, demonstrating a significantly greater correction than the osteotomy. The orthosis also significantly reduced the peak contact pressure from the flatfoot value. Both interventions significantly corrected the lateral shift of the center of the peak contact pressure from the flatfoot value. The shift in the center of the global contact area approached significance when the orthosis was compared with the flatfoot. Conclusions: The changes observed in the magnitude and location of the mean and peak pressures indicate that the UCBL orthosis and calcaneal osteotomy altered hindfoot alignment to significantly influence tibiotalar contact characteristics. The results further suggest that the UCBL orthosis corrected ankle malalignment better than the calcaneal osteotomy in an adult acquired flatfoot. This study provides biomechanical data to support the clinical impression that realignment of the hindfoot corrects the pathologic tibiotalar contact characteristics associated with an adult acquired flatfoot. The results support the conclusion that the clinical management of a pes planovalgus foot with a UCBL orthosis or a medial translational osteotomy of the calcaneus may avert the onset of pantalar disease seen with late-stage posterior tibial tendon dysfunction.
Analysis of Ankle-Hindfoot Stability in Multiple Planes: An in vitro Study
Authors: Fujii Tadashi , Kitaoka Harold B. , Luo Zong-Ping , Kura Hideji , An Kai-Nan
Published: January 2017

Background: It is necessary to have an understanding of ankle and hindfoot motion and stability to accurately diagnosis and treat ankle-hindfoot disorders. Methods: We devised an ankle ligament testing apparatus to more critically determine ankle stability in all planes with a constant rotational force applied (inversion, eversion, internal rotation, external rotation) throughout the range of sagittal plane motion in 13 cadaver specimens. Three-dimensional kinematics were determined with a magnetic tracking device. Results: With inversion force applied, calcanealtibial inversion was greatest in maximal plantarflexion (mean 22.1 ± 6.0 degrees) and gradually decreased with dorsiflexion, which indicated that the ankle had the most inversion instability in plantarflexion. With eversion force applied, calcaneal-tibial eversion gradually increased with increasing dorsiflexion to 12.7 ± 7.4 degrees indicating that the most eversion instability was in dorsiflexion. With internal rotation force applied, calcaneal-tibial internal rotation from plantarflexion to neutral ankle position increased. With external rotation force application, external rotation from neutral to maximal dorsiflexion increased. Conclusions: Ankle laxity was not constant but varied depending on the plantarflexion-dorsiflexion position and the direction of the applied force. The degree of ankle laxity was greater with inversion and internal rotation torque. Variation in laxity between specimens was observed, consistent with previous reports. These data indicate that the ankle is less stable in plantarflexion when inversion and internal rotation forces are applied. This may explain why the lateral ankle ligaments are most prone to injury in this position. The ankle was less stable in dorsiflexion when eversion and external rotation forces were applied. This is consistent with the observation that deltoid ligament injuries occur in the neutral to dorsiflexion position. The study demonstrates the importance of examining patients with suspected ankle ligament injuries in several ankle positions. The ankle testing device has potential application for in vivo testing of patients with suspected ankle ligament instability.
Racial and Ethnic Differences in Access to Medical Care
Authors: Mayberry Robert M. , Mili Fatima , Ofili Elizabeth
Published: January 2017

The authors’ review of the health services literature since the release of the landmark Report of the Secretary’s Task Force Report of Black and Minority Health in 1985 revealed significant differences in access to medical care by race and ethnicity within certain disease categories and types of health services. The differences are not explained by such factors as socioeconomic status (SES), insurance coverage, stage or severity of disease, comorbidities, type and availability of health care services, and patient preferences. Under certain circumstances when important variables are controlled, racial and ethnic disparities in access are reduced and may disappear. Nonetheless, the literature shows that racial and ethnic disparities persist in significant measure for several disease categories and service types. The complex challenge facing current and future researchers is to understand the basis for such disparities and to determine why disparities are apparent in some but not other disease categories and service types.