bluuebunny/crossref_metadata_2025_split huggingface dataset:
Design, Implementation, and Use of a New Antimicrobial Order Form: A Descriptive Report
Authors: Lipsy Robert J. , Smith Gary H. , Maloney Marie E. 
Published: January 2017

OBJECTIVE: To describe the development, implementation, and use of an antimicrobial order form. The article provides the design of the form and the rationale for including key aspects, and a report of the authors' experiences with the form over a three-year period. An analysis of compliance with the form and its impact on selected prescribing practices is also presented. DESIGN: Three thousand five hundred antimicrobial orders in four discrete sets over a three-year period were analyzed to assess compliance and characterize prescribing patterns with respect to duration of therapy and dosing frequency. SETTING: The setting of the study was a 300-bed, university-affiliated, tertiary-care, teaching hospital. MAIN OUTCOME MEASURES: Analysis of the forms was organized into the following sections: (1) compliance with use of the form, (2) duration of therapy, and (3) impact on antimicrobial dosing intervals. RESULTS: Use of the form was essentially 100 percent. Seventy-eight percent of the forms had all required data elements completed in the period following implementation; this fell to 67 percent at the end of three years. Duration of surgical prophylaxis went beyond the recommended 24 hours in 10 percent of all cases in period 1, and in 18, 8, and 4 percent in periods 2, 3, and 4, respectively. Declines in inappropriate dosing frequency were seen with cefazolin (from 14 to 2.3 percent), ceftriaxone (from 23 to 4 percent), cefuroxime (from 21 to 0 percent), and clindamycin (from 43 to 7 percent). CONCLUSIONS: Our experience with implementation and use of the form was very positive. Significant difficulties with compliance were not encountered. Benefits of the form included reductions in the duration of surgical prophylaxis and in the frequency of inappropriate dosing intervals.
Response to Pancuronium after Loss of Atracurium-Induced Neuromuscular Blockade
Authors: Kelly Karl J. , Clarens Diann M. , Kohls Philip R. , Nahum Avi , Vance-Bryan Kyle 
Published: January 2017

OBJECTIVE: To describe a previously unreported event in which a patient became refractory to atracurium-induced neuromuscular blockade, but subsequently was adequately paralyzed with a standard dosage of pancuronium. CASE SUMMARY: A previously healthy 17-year-old woman who sustained multiple trauma developed tolerance to an atracurium infusion she was receiving while undergoing mechanical ventilation. On day 3 of neuromuscular blockade, she became unresponsive to atracurium as evidenced by excessive physical movement, increased peak airway pressures, and overbreathing assist control ventilation. Repeat boluses and increases in the atracurium infusion rate to a maximum of 1.27 mg/kg/h failed to provide a desired clinical response. A bolus dose of pancuronium 0.15 mg/kg was administered and the constant infusion was then changed to pancuronium 0.078 mg/kg/h. Within minutes, decreased respirations, peak airway pressures, and agitation were noted. The pancuronium infusion rate was then tapered to 0.045 mg/kg/h over 72 hours and continued to maintain adequate neuromuscular blockade. DISCUSSION: Potential pharmacokinetic and pharmacodynamic causes of loss of neuromuscular blockade in this patient are postulated. Possible explanations for loss of neuromuscular blockade include increased degradation of atracurium and/or a change in acetylcholine receptor physiology. CONCLUSIONS: The development of resistance to a specific neuromuscular blocking agent in the intensive care setting does not necessarily imply cross-tolerance or resistance to alternative agents. Also, loss of respiratory control by one neuromuscular blocking agent may be overcome by changing agents.
Evaluation of Plasmapheresis in the Treatment of an Acute Overdose of Carbamazepine
Authors: Kale Pramodini B. , Thomson Peter A. , Provenzano Robert , Higgins Martha J. 
Published: January 2017

OBJECTIVE: To report the use of plasmapheresis in the treatment of an acute overdose of carbamazepine. CASE SUMMARY: A 21-year-old black man was admitted unresponsive and combative following a carbamazepine overdose. The total body load of carbamazepine was approximated at 5.91 g using an assumed volume of distribution of 1.4 L/kg. The patient underwent three plasmapheresis treatments. A total of only 335.82 mg of carbamazepine was removed by this process. DISCUSSION: Case reports in the literature were reviewed and compared. Carbamazepine concentrations lack correlation with the clinical outcome. Our patient's symptoms were consistent with the Weaver classification system. Carbamazepine clearance increased by almost 70 percent above its natural clearance during plasmapheresis. However, a significant rebound effect was observed after plasmapheresis: 40.1 percent after the first and 18.3 percent after the second treatment. CONCLUSIONS: Plasmapheresis did not seem to have a great impact on the patient's clinical status. Under the circumstances we find it extremely difficult to recommend plasmapheresis in the treatment of an acute overdose of carbamazepine.
Intrathecal Administration of Amikacin for Treatment of Meningitis Secondary to Cephalosporin-Resistant Escherichia Coli
Authors: Preston Sandra L. , Briceland Laurie L. 
Published: January 2017

OBJECTIVE: To report a case of gram-negative bacillary meningitis (GNBM) secondary to cephalosporin-resistant Escherichia coli that was treated with intrathecal and intravenous amikacin and intravenous imipenem/cilastatin (I/C). CASE SUMMARY: A patient who had undergone two recent neurosurgical procedures developed GNBM and bacteremia. He was treated empirically with ceftazidime. Both bloodstream and cerebrospinal fluid isolates were identified as E. coli, resistant to third-generation cephalosporins, penicillins, tobramycin, and gentamicin. The patient was subsequently treated with intravenous and intrathecal amikacin plus intravenous I/C He experienced subjective and objective improvement on days 2–4 of antimicrobial therapy; two generalized tonic-clonic seizures occurred on days 7 and 12. Intrathecal amikacin was discontinued after 6 days, and intravenous amikacin and I/C were discontinued after 23 and 27 days, respectively. The patient's mental status did not completely return to premeningitis baseline. DISCUSSION: Third-generation cephalosporins are the treatment of choice for GNBM. In the case reported herein, bacterial resistance to these agents prompted the use of a therapy that has not been well studied and is also considered to be less safe and perhaps less efficacious. Treatment of GNBM with an intrathecally administered aminoglycoside or with intravenous I/C plus an aminoglycoside is reviewed. CONCLUSIONS: Patients with GNBM secondary to third-generation cephalosporin-resistant organisms may require therapies that may be less effective and more toxic. Further study of alternative agents is warranted.
Oculogyric Crisis Possibly Related to Pentazocine
Authors: Burstein Aaron H. , Fullerton Terence 
Published: January 2017

OBJECTIVE: To report and describe the apparent first case of acute oculogyric crisis following administration of pentazocine, and to discuss the possible mechanism for this reaction. DATA SOURCES/CASE SUMMARY: Patient case and relevant review of literature. The patient, a 39-year-old woman, developed acute oculogyric crisis following administration of Talacen (pentazocine and acetaminophen) for pain relief. The crisis resolved after discontinuation of the medication and administration of intravenous diphenhydramine 50 mg. CONCLUSIONS: Based on the temporal relationship of drug administration to occurrence of the event, pentazocine is implicated as the cause of this acute oculogyric crisis. A plausible mechanism for precipitation of this crisis is the agonism of pentazocine on sigma opiate receptors, with postulated subsequent modulation of dopamine receptors.
Cefuroxime-Induced Fever
Authors: Mevorach or , Lossos Izidore S. , Oren Ran 
Published: January 2017

OBJECTIVE: To report on three patients with cefuroxime-induced fever. CASE SUMMARIES: Recurrence of fever was noted in three patients after five to seven days of cefuroxime sodium therapy for acute exacerbation of chronic obstructive pulmonary disease. No source of infection was found and the fevers resolved within 30 hours of drug discontinuation. One patient was rechallenged; the same pattern of fever resulted. DISCUSSION: Fever secondary to cephalosporin administration is reviewed and the place of cephalosporins in the differential diagnosis of fever is postulated. CONCLUSIONS: Cefuroxime should be added to the list of cephalosporins that induce fever.
Clindamycin-Induced Lip and Nasal Passage Swelling
Authors: Segars Larry W. , Threlkeld Kathy R. 
Published: January 2017

OBJECTIVE: To report a severe case of clindamycin-induced lip and nasal passage swelling. DESIGN: Single case report. SETTING: Six hundred eighty-four-bed community hospital. CASE SUMMARY: A 34-year-old, insulin-dependent diabetic white man with worsening cellulitis and osteomyelitis of the left great toe was admitted for treatment with intravenous antibiotics. Intravenous clindamycin was the first agent administered. Within 5 minutes after initiating the drug (600-mg dose) the patient began to sneeze and his eyes began to tear and itch. Within 10 minutes, his lips and nasal passages began to swell. By the end of the infusion (approximately 20 min), the patient's lips were severely swollen and his nasal passages were completely closed off secondary to the swelling. The patient did not have difficulty breathing through his mouth and denied any shortness of breath. He did not develop a rash. His vital signs remained stable and no pharmacologic agents were administered for this reaction. No subsequent doses of clindamycin were given and complete resolution of all symptoms occurred within 24 hours. CONCLUSIONS: Severe lip and nasal passage swelling is an uncommon adverse reaction associated with the use of intravenous clindamycin. We believe this to be the first published case of nasal passage swelling and only the second case reporting lip edema associated with the intravenous form of this agent. Clinicians should be aware of this uncommon but potentially severe reaction.
Effect of Heat Treatment of Potentially Infected Blood Samples on Therapeutic Drug Monitoring of Selected Drugs
Authors: Burger David M. , van Dijk Elisabeth A. , van Gijn Roel , Beijnen Jos H. 
Published: January 2017

OBJECTIVE: To investigate the effect of heat treatment on the outcome of drug analysis in whole blood and serum for eight drugs routinely assayed for therapeutic monitoring. DESIGN: All blood and serum samples (n=373) received at the pharmacy laboratory for therapeutic monitoring of carbamazepine, digoxin, gentamicin, kanamycin, phenobarbital, phenytoin, theophylline, and valproic acid were heated at 60°C for 30 minutes. Serum was subsequently assayed by fluorescence polarization immunoassay (TDx). SETTING: The study was conducted at the analytical laboratory of the pharmacy, using standard laboratory procedures. MAIN OUTCOME MEASURES: Analyses of heated samples were compared with analyses of untreated samples using a paired Wilcoxon signed-rank test. RESULTS: Serum concentrations of phenytoin from treated whole blood, and of gentamicin in treated serum, were significantly lower than in untreated samples. These differences, however, were small, clinically irrelevant, and lie within assay variation intervals. Heat treatment did not influence the outcome of analyses for carbamazepine, digoxin, kanamycin, phenobarbital, theophylline, and valproic acid. CONCLUSIONS: Heat treatment of whole blood and serum samples of the investigated drugs does not influence the outcome of drug analysis, although drug instability cannot be fully excluded. Heat treatment can protect laboratory technicians from HIV infection without influencing therapeutic monitoring of these drugs.
Current Issues Surrounding Women and Minorities in Drug Trials
Authors: Wermeling Daniel P. , Selwitz Ada Sue 
Published: January 2017

OBJECTIVE: Our principal objective is to make readers aware of conflicting demands placed on investigators and the pharmaceutical industry regarding inclusion of women and minorities in clinical research. Tremendous pressures have been placed to expedite the drug approval process. Moreover, during the last decade certain segments of society, particularly women and minorities, have demanded greater participation in clinical drug trials and earlier access to investigational drug therapies. Regulations that have served the clinical research community (pharmaceutical industry, investigators, institutional review boards) as guidelines for safe conduct of human clinical trials are being challenged by social and political change. This article provides an overview of some of the controversy relative to federal regulations governing clinical trials; scientific concerns; social, political and legal trends; and ethical principles applied to human clinical research. DATA SOURCES: Literature for this paper was retrieved from a variety of sources including the nonmedical press, editorials, peer-reviewed journals, Department of Health and Human Services regulations, National Institutes of Health policy, the Belmont Report, and regulations of the Food and Drug Administration. DATA SYNTHESIS: Scientists evaluating new therapeutic agents ask specific research questions to assess safety, efficacy, and the mechanism(s) of action. Because of concerns for scientific validity, safety, liability, and convenience, many early evaluations of new drugs involve patient populations that may not represent the ultimate users of a new drug. Federal regulations and ethical principles allow certain groups of people to be excluded from early research proposals because they are thought to be putting themselves at greater risk by participating than are other groups. However, women, minorities, and other populations are demanding greater access to investigational drugs. The focus has changed from protection from research risks and burdens to the potential benefits a person or class of people may obtain by participating in a study. CONCLUSIONS: Scientists, the pharmaceutical industry, regulators, and society must agree on a safe and efficient mechanism for new drug development that permits more equitable participation of subjects in the various phases of research.
Assessment of Patient Acceptance and Inhalation Technique of a Pressurized Aerosol Inhaler and Two Breath-Actuated Devices
Authors: Nimmo Cindy J. Reesor , Chen Daniel N.M. , Martinusen Shelagh M. , Ustad Tina L. , Ostrow David N. 
Published: January 2017

OBJECTIVE: To assess inhalation technique in patients after written instruction alone, written and verbal instruction, and clinical use of two new inhalation devices. DESIGN: Randomized, crossover evaluation of the albuterol Diskhaler and the terbutaline Turbuhaler. SETTING: Canadian tertiary-care hospital. PATIENTS: Twenty hospitalized adults with asthma or chronic obstructive pulmonary disease currently using an albuterol metered-dose inhaler (MDI). Nineteen patients received Diskhaler, 16 received Turbuhaler, 15 received both inhalers, and 10 patients used both inhalers for three days each. INTERVENTIONS: Patients were randomized to receive either Diskhaler or Turbuhaler for three days. Inhaler technique was assessed after written instruction, written plus verbal instruction, at the first scheduled dose after instruction, and after three days of clinical use. Patients remaining in the hospital after three days crossed over to the other study inhaler and the same protocol was followed. MAIN OUTCOME MEASURES: Patient inhalation technique was assessed and compared for the MDI, Diskhaler, and Turbuhaler. RESULTS: Assessment of MDI technique revealed that 35 percent of patients used their MDI correctly on the first puff, and 42 percent used it correctly on the second puff. Following written instruction alone, correct technique was demonstrated by 32 percent of patients with Diskhaler and 6 percent with Turbuhaler. Technique significantly improved following verbal instruction, although 40 percent of the patients required up to three attempts to demonstrate correct technique on at least one of the study inhalers. After three days of clinical use, correct technique was demonstrated in only 54 percent of the Diskhaler and 64 percent of the Turbuhaler assessments. Performance at this assessment was, however, significantly better on the Turbuhaler than on the MDI (p=0.01). Performance on the Diskhaler was not significantly different from the performance on the other inhalers. CONCLUSIONS: Written instruction alone is inadequate in teaching correct inhalation technique. Verbal instruction and technique assessment are essential for patients to achieve proper technique. Patients may perform better on the Turbuhaler than on other inhalation devices.
Computerized Monitoring Protocols as a Pharmaceutical Care Practice Enhancement: A Conceptual Illustration Using Diabetes Mellitus
Authors: Boyd Alan F. , Hartzema Abraham G. 
Published: January 2017

OBJECTIVE: To illustrate how a computer system used in an ambulatory care pharmacy setting might enhance care of patients with diabetes by prospectively monitoring and prompting them to seek routine medical care. DATA SOURCES: A MEDLINE search to identify existing works on informatics was conducted. An epidemiology and general medical literature review of diabetes mellitus was also performed via MEDLINE. Additionally, known textbooks on the disease were consulted. CONCLUSIONS: Programming a computer system to prompt pharmacists to remind their patients of necessary medical interventions could save medical resources by warning chronically ill patients not to ignore routine medical care. Also, this would allow the pharmacist to prospectively monitor patient outcomes. By knowing when medical interventions are due and obtaining feedback from patients on the results of the medical contact, pharmacists increase their knowledge about patient outcomes and the rationale behind changes in pharmacotherapy. It is expected that such a system would prevent the inconspicuous development of chronic complications.
Nasal Absorption of Growth Hormone in Normal Subjects: Studies with Four Different Formulations
Authors: Laursen Torben , Ovesen Per , Grandjean Birgitte , Jensen Sigrid , Jørgensen Jens Otto L. , Illum Peter , Christiansen Jens Sandahl 
Published: January 2017

OBJECTIVE: Current growth hormone (GH) therapy with daily subcutaneous injections results in elevated serum concentrations of GH lasting for several hours, whereas physiologic GH secretion is characterized by a short-duration peak and low basal concentrations. A closer imitation of this pattern might be achieved by administering GH nasally. We studied the effect on the absorption of nasally administered human GH of increasing concentrations of the enhancer didecanoyl-L-α-phosphatidylcholine (DDPC). DESIGN: Four formulations of nasal GH containing the enhancer DDPC in the relative concentrations 0, 4,8, and 16% w/w were administered in random order. SETTING: Participants were admitted to the hospital during the four study periods. INTERVENTIONS: On four occasions the subjects received GH 6 IU (2 mg) in each nostril. Blood was sampled frequently for four hours. Anterior rhinoscopy was performed at 0 and 4 h. During the study the subjects completed a questionnaire to record nasal symptoms. PATIENTS: Sixteen healthy subjects were examined at 0800 h after an overnight fast. MAIN OUTCOME MEASURES: Bioavailability of a nasal preparation of human GH: area under the curve (AUC), the maximum concentration(Cmax), and the time to reach maximum concentration (tmax). Scores for each nasal symptom were recorded as were the total scores. RESULTS: AUC, Cmax, and tmax,. were not significantly affected by increasing the DDPC concentration from 0 to 4 percent or from 8 to 16 percent. AUC and Cmax, however, increased significantly when the concentration of DDPC was changed from 4 to 8 percent. Mean (±SD) AUC (μg·h/L) increased from 20.51 ± 10.53(4 percent)to 46.14 ± 34.59 (8 percent), (p<0.005). Mean (±SD) of Cmax (μg.L) increased from 11.11 ± 5.02 (4 percent) to 28.22 ± 20.85 (8 percent), (p=0.OO2). Mean (±SD) of tmax (min) was not significantly different on the four occasions(range 40.6 ± 36.4 to 61.0 ± 45.2 min, p=0.13). The symptom scores (range 17.56–21.5, maximum 360) were not significantly different (p=0.59). CONCLUSIONS: Increasing the relative concentration of the enhancer DDPC increases the absorption of nasally administered GH.
Pharmacy-Perceived Barriers to Cancer Pain Control: Results of the North Carolina Cancer Pain Initiative Pharmacist Survey
Authors: Krick Stacie E. , Lindley Celeste M. , Bennett Michelle 
Published: January 2017

OBJECTIVE: To assess pharmacists' knowledge, attitudes, and beliefs regarding the use of narcotics in cancer pain management, identify pharmacist counseling activities for cancer pain patients, assess pharmacy-related barriers to cancer pain management, and evaluate the availability of narcotic analgesics. METHODS: Mailing of a six-page survey. SETTING: Five hundred randomly selected pharmacists registered in North Carolina. PARTICIPANTS: Of 500 pharmacists surveyed, 141 surveys were completed and returned for a response rate of 28.2 percent. RESULTS: Pharmacists surveyed were knowledgeable regarding the problem of undertreatment of cancer pain. More than 80 percent of respondents replied that most cancer patients experience pain at some time during their illness. Eighty-five percent of respondents agreed that the nurse must believe the patient's report of pain and that the patient is the best judge of the intensity of the pain. Conservative physician prescribing patterns and conservative administration patterns of nurses were identified as perceived barriers to adequate pain management by 51 and 44 percent of respondents, respectively. Less than 30 percent of respondents frequently counseled cancer pain patients and were unable to identify patients who have cancer pain as a major medical illness. Hospital pharmacists recommended adjunctive therapy more often than did community pharmacists (p=0.013). Interventions in pain management regimens were more often conducted by hospital pharmacists than by community pharmacists (p=0.049). Differences in availability of narcotics was noted among practice sites for some more potent narcotics. Of the pharmacists surveyed, only 43 percent had attended a continuing education program on cancer pain management. Ninety-six percent of respondents were interested in attending a continuing education program in the future. CONCLUSIONS: Pharmacists in North Carolina are aware that the undertreatment of cancer pain is a serious medical problem. Unfortunately, pharmacists appear to be unable to identify patients with cancer pain as a major medical problem; therefore, counseling activity is limited. Addiction is still perceived as a barrier by some pharmacists. Through organizations such as the North Carolina Pain Initiative, these problems can be addressed.