bluuebunny/crossref_metadata_2025_split huggingface dataset:
Pyloric Channel Stricture Secondary to High-Dose Ibuprofen Therapy in a Patient with Cystic Fibrosis
Authors: Bell Edward A , Grothe Rayna , Zivkovich Veljko , Foote Jan M , Wellendorf Joyce 
Published: March 2004

OBJECTIVE: To describe a case of pyloric channel stricture secondary to high-dose ibuprofen therapy in a pediatric patient with cystic fibrosis. CASE SUMMARY: A 12-year-old white girl started taking high-dose ibuprofen to treat the pulmonary manifestations of cystic fibrosis. The peak plasma concentration at dose initiation was within the accepted therapeutic range. Approximately one month later, the patient developed emesis and intolerance of solid foods, which persisted for several months and resulted in a weight loss of seven kilograms. The patient was referred to a pediatric gastroenterologist, who performed an upper endoscopy and subsequently diagnosed a pyloric channel stricture. The patient's pyloric channel was successfully dilated with two balloons. It is felt that the pyloric stricture developed from healing antral/pyloric channel ulcers. Ibuprofen was discontinued and omeprazole therapy was begun. Over the course of the following year, the patient was asymptomatic. Follow-up upper gastrointestinal barium swallows were normal. DISCUSSION: When used for analgesia and fever in the pediatric population, ibuprofen has been shown to be a relatively safe drug. While it is known that ibuprofen may cause gastrointestinal adverse effects, the pediatric population is at lower risk; however, large doses of ibuprofen increase the risk of gastrointestinal adverse effects. The use of large doses of ibuprofen in the treatment of cystic fibrosis is a relatively new therapy. Limited data thus far in cystic fibrosis patients do not suggest increased risk of gastrointestinal complications. CONCLUSIONS: Limited data to date indicate that ibuprofen, when used in large doses to treat the pulmonary manifestations of cystic fibrosis, is relatively safe. However, because of the potential risks to the gastrointestinal tract of high-dose ibuprofen therapy, clinicians should be aware of its possible complications.
Hydrochlorothiazide-Induced Pulmonary Edema and Associated Immunologic Changes
Authors: Bernal Carlos , Patarca Roberto 
Published: March 2004

OBJECTIVE: To describe a patient with noncardiogenic acute pulmonary edema induced by hydrochlorothiazide and to investigate the possible involvement of an immunologic mechanism in this adverse reaction. CASE SUMMARY: A 66-year-old Hispanic woman developed acute pulmonary edema 30 minutes after the ingestion of one tablet of triamterene 75 mg/hydrochlorothiazide 50 mg. The reaction was associated with hemoconcentration; a decreased white blood cell count with a shift to a predominance of polymorphonuclear cells; decreased serum immunoglobulin (Ig) G, IgG1, and IgG4; and increased serum IgM and complement 3 concentrations. DISCUSSION: Although there have been 35 reports of cases of hydrochlorothiazide-induced pulmonary edema, the etiology of this adverse reaction remains unknown. The observations presented in this case report, along with commonalities with previously reported cases, suggest that granulocytic infiltration into the lungs and IgG deposition in alveolar membranes may play a role in hydrochlorothiazide-induced pulmonary edema. CONCLUSIONS: Noncardiogenic pulmonary edema may be an immunologically mediated rare idiosyncratic reaction to hydrochlorothiazide.
Treatment of Obsessive-Compulsive Disorder Using Clomipramine in a Very Old Patient
Authors: Trappler Brian 
Published: March 2004

OBJECTIVE: To describe the effect of the tricyclic drug clomipramine in a very old patient with obsessive–compulsive disorder and Alzheimer dementia. CASE SUMMARY: A 93-year-old woman had a history of obsessive–compulsive disorder since early adulthood. The obsession consisted of remembering names of famous people and the compulsion consisted of excessive list making. With the onset of memory loss secondary to Alzheimer disease, she became increasingly anxious and compulsive as a result of a failure to remember. After nine weeks on fluoxetine she became jittery and more confused. After a two-week washout period, she was given a nine-week course of clomipramine that was carefully titrated up to a therapeutic concentration. RESULTS: At the completion of clomipramine treatment, the patient no longer felt driven to recall the names of famous people. Her score from the Yale–Brown Obsessive–Compulsive Scale dropped from 29 to 3. Her Folstein Mini-Mental State Examination score increased from 21 to 23. CONCLUSIONS: Clomipramine appeared much more effective and better tolerated than fluoxetine in this very old patient despite its potential anticholinergic effect and the coexistence of Alzheimer disease.
Contemporary Utilization of Digoxin in Patients with Atrial Fibrillation
Authors: McAlister Finlay A , Ackman Margaret L , Tsuyuki Ross T , Kimber Shane , Teo Koon K 
Published: March 2004

OBJECTIVE: To define the contemporary practice patterns of digoxin utilization for the management of patients with atrial fibrillation (AF). METHODS: A retrospective medical records audit of 2490 patients with documented AF, from 12 Canadian hospitals and six outpatient clinics, during fiscal year 1993–1994, was conducted. RESULTS: There were 1158 women and 1332 men, with a mean age of 72 years; 956 patients were <70 years of age and 1534 were ≥70 years old. The majority of patients had nonvalvular AF (75% of those with a documented etiology). Paroxysmal AF (PAF) was documented in 800 patients, 936 had chronic AF, and 754 had new-onset AF. While the prescribing patterns were heterogeneous, the predominant strategy pursued in all subgroups appeared to be that of achieving rate control. Digoxin was the most commonly prescribed medication (79%) and was prescribed for the majority of patients in all subgroups, including patients with PAF (74%) and patients with a history of chronic AF who were currently in sinus rhythm (83%). Only 10% of the patients with PAF who were prescribed digoxin had congestive heart failure. Similarly, less than 25% of the patients with chronic AF who were prescribed digoxin after conversion to sinus rhythm had evidence of heart failure. CONCLUSIONS: In the absence of clinical trial evidence supporting either a strategy of antiarrhythmic therapy or rate control with anticoagulation, the appropriateness of the observed prescribing practices cannot be judged. However, digoxin is not the best rate-controlling agent for all patients and may be overused in certain subgroups of patients, such as those with PAF and those successfully converted to sinus rhythm.
Compliance with Sulfonylureas in a Health Maintenance Organization: A Pharmacy Record–Based Study
Authors: Venturini Francesca , Nichol Michael B , Sung Jennifer CY , Bailey Karen L , Cody Marisue , McCombs Jeffrey S 
Published: March 2004

OBJECTIVE: To determine which factors affect compliance with sulfonylureas in a population served by a health maintenance organization in Southern California. METHODS: Retrospective analysis of pharmacy records and healthcare utilization data for two years (April 1993–March 1995), and a survey mailed to patients. Patients treated with sulfonylureas were selected for analysis on the basis of their prescription profile. Compliance was measured from the pharmacy records as the proportion of days the patient was in possession of the prescribed medications. Patient compliance with sulfonylureas was modeled as a function of four clusters of determinants: patient-related attributes, drug regimen characteristics and complexity, health status and disease-related variables, and characteristics of the interaction with healthcare providers. RESULTS: 786 patients were identified for analysis (49.1% women, mean age 59 y). The mean compliance rate was 83% ± 22% SD. Compliance was significantly positively related with age and self-reported level of medication-taking compliance at baseline. Factors shown to have an inverse relationship with compliance were treatment complexity, perception of general health, and being a newly treated patient (adjusted R2 for the final model = 0.148). CONCLUSIONS: Our results suggest that factors found to be associated with noncompliant behavior (e.g., being a newly treated patient, self-reported compliance, regimen complexity) can be assessed by physicians and pharmacists as a routine practice.
Adverse Effects in a Newborn Infant Breast-Fed by a Mother Treated with Doxepin
Authors: Frey Otto R , Scheidt Peter , von Brenndorff Alexis I 
Published: March 2004

OBJECTIVE: To report adverse effects in a newborn infant whose mother had been treated with doxepin during pregnancy and while breast-feeding. CASE SUMMARY: The nine-day-old white boy was admitted because of poor sucking and swallowing, with muscle hypotonia and vomiting. He was drowsy and had lost 150 g. At the time of admission, he was breast-fed by his mother who was being treated with doxepin 35 mg/d. Samples of plasma and breast milk were taken and analyzed by HPLC and fluorescence polarization immunoassay. The amount of doxepin and N-desmethyldoxepin (DDP) ingested via breast-feeding was approximately 10–20 μg/kg/d (i.e., only 2.5% of the weight-adjusted dose of the mother). Doxepin was detectable in small amounts in the infant's plasma (∼10 μg/L); DDP was below the lower limit of detection of 10 μg/L. All adverse effects subsided within 48 hours after breast-feeding was stopped. DISCUSSION: Despite the small doses of doxepin and its active metabolite ingested by breast-fed babies, there is a risk of accumulation and resultant adverse effects. In newborns, the metabolic activity is considerably decreased and may be further reduced by hyperbilirubinemia. CONCLUSIONS: Available data suggest that women treated with doxepin should breast-feed their infants with great caution, if at all, although much larger databases are needed to confirm this.
Rhabdomyolysis Associated with Naltrexone
Authors: Zaim Sina , Wiley David B , Albano Shirley A 
Published: March 2004

OBJECTIVE: To report a possible association between naltrexone therapy and the development of rhabdomyolysis in one patient. CASE SUMMARY: A 28-year-old white man in good physical health was started on naltrexone 50 mg/d for inpatient treatment of alcohol dependence and depression. A routine serum chemistry panel obtained on day 9 of naltrexone therapy showed marked new elevations in creatine kinase and aspartate aminotransferase. The patient remained asymptomatic and did not develop renal insufficiency. The serum enzyme concentrations returned to normal within eight days of naltrexone discontinuation. DISCUSSION: Rhabdomyolysis has not been previously reported to occur in patients during treatment with naltrexone. Alcoholism may result in a reversible acute muscle syndrome, but our patient did not fit the appropriate clinical profile for such a syndrome. Additionally, the other prescribed medications could not be implicated as possible causative agents. CONCLUSIONS: This case report illustrates a possible association between naltrexone therapy and rhabdomyolysis.
Indirect Modulation of Dopamine D2 Receptors as Potential Pharmacotherapy for Schizophrenia: I. Adenosine Agonists
Authors: Dixon Domeeka A , Fenix Lori A , Kim Denise M , Raffa Robert B 
Published: March 2004

OBJECTIVE: To review preclinical and clinical information related to pharmacologic modulation of dopamine D2 receptors as potential novel antipsychotic therapy. Specifically, to summarize the data that suggest a modulatory action of adenosine A2A receptors on dopamine D2 receptors and, therefore, a possible rational role of adenosine A2A agonists as novel antipsychotic agents. DATA SOURCES: Primary and review articles were identified by MEDLINE search (from 1966 to May 1998) and through secondary sources. STUDY SELECTION AND DATA EXTRACTION: All of the articles identified from the data sources were evaluated and all information deemed relevant was included in this review. DATA SYNTHESIS: For all of the older and many of the newer antipsychotic agents, there is a strong correlation between clinical antipsychotic activity and affinity for dopamine D2 receptors. Unfortunately, dopamine D2 receptors are believed to also be involved in the adverse effect profile of these agents. The indirect modulation of dopamine D2 receptors, rather than direct block, might produce antipsychotic effects without the usual adverse reactions. Several lines of evidence from animal studies suggest that the use of selective A2A agonists might represent a novel approach to the treatment of psychoses. CONCLUSIONS: Dopamine receptor modulation might represent a novel antipsychotic approach or adjunct therapy. The data regarding adenosine agonists (particularly selective A2A receptor agonists) are inconclusive at the present time. Direct clinical demonstration of effectiveness is required.
Economic Impact of a Drug Information Service
Authors: Kinky Denise E , Erush Sarah C , Laskin Mitchell S , Gibson Gene A 
Published: March 2004

OBJECTIVE: A cost-avoidance model was developed to determine potential cost savings or “avoidance” that results from a drug information service (DIS) responding to drug information requests. DESIGN: Patient-specific questions received by the DIS were reviewed and evaluated. A panel determined whether a drug misadventure event may have occurred if the DIS had not been consulted. Potential outcomes from drug information requests were classified using a decision-tree model. A severity rating was then attached to each applicable request to predict potential cost savings of the DIS. RESULTS: Seventy-seven of the 570 drug information responses received in the six-week study period had assessable potential cost savings to the institution. During the study interval, potential cost savings were estimated to be $195 000. Projected to one year, potential cost savings reached $1.7 million. Of the savings noted, most were attributable to prevention of increased monitoring or additional treatment. Using a sensitivity analysis, annual potential cost savings ranged from $417 792 to $2 052 740 per year. Based on the estimated annual costs related to maintaining a DIS of $145 950, the resultant range of benefit/cost ratio is 2.9:1 to 13.2:1. CONCLUSIONS: This model demonstrates that the DIS at our institution provides potential cost savings. This model may be modified to evaluate potential cost savings in other areas of pharmacy practice.
Therapeutic Failure of Trimethoprim/Sulfamethoxazole in the Treatment of Pneumocystis Carinii Pneumonia
Authors: Al-Tawfiq Jaffar A , Sorensen Suellyn J , Cushing Herbert E 
Published: March 2004

OBJECTIVE: To report a case of failure of treatment of Pneumocystis carinii pneumonia (PCP) with trimethoprim/sulfamethoxazole (TMP/SMX) in a patient with HIV infection, despite an adequate serum SMX concentration. CASE SUMMARY: A 52-year-old white man was treated with TMP/SMX for PCP. After discharge he returned to the hospital with worsening of the PCP despite a serum SMX concentration of 60 μg/mL 18 hours after his last dose of TMP/SMX. DISCUSSION: PCP is one of the most common complications of HIV infection. TMP/SMX is the drug of choice for prophylaxis and treatment. The causes of therapeutic failure with this agent are not well documented. CONCLUSIONS: Alternative therapies to TMP/SMX should be seriously considered if the serum concentrations are therapeutic and the patient is not clinically improved.
Probable Antagonism of Warfarin by Green Tea
Authors: Taylor James R , Wilt Vickie M 
Published: March 2004

OBJECTIVE: To report a case of the inhibition of the effect of warfarin by green tea. CASE SUMMARY: A 44-year-old white man was receiving warfarin for thromboembolic prophylaxis secondary to a St. Jude mechanical valve replacement in the aortic position. The patient had an international normalized ratio (INR) of 3.20 approximately one month prior to entering our clinic, and an INR of 3.79 on entering our clinic. Twenty-two days later his INR was 1.37. One month later the patient's INR was 1.14. It was subsequently discovered that the patient began drinking one-half to one gallon of green tea per day about one week prior to the INR of 1.37. On discontinuation of the green tea, the patient's INR increased to 2.55. DISCUSSION: Warfarin produces anticoagulation by inhibiting production of the vitamin K–dependent clotting factors (i.e., factors II, VII, IX, X). The exogenous administration of vitamin K inhibits the effect of warfarin and reduces a patient's degree of anticoagulation. Green tea can be a significant source of vitamin K and thus antagonize the effect of warfarin. CONCLUSIONS: Warfarin is a highly effective oral anticoagulant, but it requires close monitoring to prevent complications. Patients receiving warfarin need to be routinely questioned about their intake of vitamin K–containing foods and beverages.
Significant Interactions with New Antiretrovirals and Psychotropic Drugs
Authors: Tseng Alice Lin-In , Foisy Michelle M 
Published: March 2004

OBJECTIVE: To provide an update on relevant antiretroviral interactions and psychotropic medications for healthcare practitioners managing complex HIV-related pharmacotherapy. DATA SOURCES: Information was retrieved via a MEDLINE search (January 1966–September 1998) using MeSH headings human immunodeficiency virus, drug interactions, psychiatry, psychotropics, psychiatric illness, and names of medications commonly prescribed for the management of HIV infection. Abstracts of international and national conferences (until February 1999), review articles, textbooks, and references of all articles also were searched. STUDY SELECTION AND DATA EXTRACTION: Literature on pharmacokinetic interactions was considered for inclusion. Pertinent information was selected and summarized for discussion. In the absence of specific data, pharmacokinetic and pharmacodynamic properties were considered in order to predict the likelihood of potential drug interactions. DATA SYNTHESIS: All protease inhibitors and nonnucleoside reverse transcriptase inhibitors are substrates of the cytochrome P450 system and possess enzyme-inhibiting and/or -inducing properties. Psychotropic medications also possess similar metabolic characteristics and may interact with antiretrovirals. Modifications in drug selection, dose, or dosing regimen may be needed to ensure adequate antiretroviral concentrations and thus minimize the risk of incomplete viral suppression and/or development of drug resistance. In the absence of specific data, consideration of metabolic characteristics may assist practitioners in predicting the likelihood of possible interactions. RESULTS: The incidence and implications of antiretroviral drug interactions are reviewed. Practical management strategies are also discussed. Comprehensive tables on clinically significant interactions with antiretroviral combinations and with psychiatric medications are provided. CONCLUSIONS: Given the increasing use of multiple-drug therapy, the potential for drug interactions is extremely high. Drug interactions may lead to undesirable outcomes including subtherapeutic drug concentrations and risk of antiretroviral resistance. Practitioners need to consider pharmacokinetic, pharmacologic, therapeutic, and adherence factors when managing interactions with complex antiretroviral therapy.
Physician Over-the-Counter Drug Prescribing Patterns: An Analysis of the National Ambulatory Medical Care Survey
Authors: Pradel Françoise G , Hartzema Abraham G , Mutran Elizabeth J , Hanson-Divers Christine 
Published: March 2004

OBJECTIVE: To describe the prevalence of physician over-the-counter (OTC) drug prescribing in relation to selected physician, patient, and drug characteristics. DATA SOURCE AND METHODS: Data from the 1990 National Ambulatory Medical Care Survey, a multistage probability clustered sample, were analyzed. Physician drug utilization was expressed in drug mentions defined as “the physician's entry of a pharmaceutical agent ordered or provided, by any route of administration, for prevention, diagnosis, or treatment.” Sampling weights were used to obtain unbiased national estimates. Cross tabulations of the drug prescription status (OTC or prescription [Rx]) with independent variables were performed, overall and by therapeutic class. The overall OTC/Rx ratio (0.11) was used as the cutoff point for distinguishing high- from low-level OTC drug prescribing. RESULTS: In 1990, 9.7% of physician drug mentions were of OTC drugs. Women between 16 and 34 years, Asian/Pacific Islanders, white Hispanics, and African-Americans experienced high OTC drug mentions (OTC/Rx ≥ 0.11). After stratification by drug therapeutic class, physicians in general practice, family practice, internal medicine, obstetrics/gynecology, and pediatrics highly mentioned OTC drugs. CONCLUSIONS: OTC drug prescribing by physicians is substantial, and primary care specialties, patient gender, age, and race should be considered by those interested in evaluating OTC drug utilization in the ambulatory care setting.
Phenobarbital Dosing and Pharmacokinetics in a Neonate Receiving Extracorporeal Membrane Oxygenation
Authors: Elliott Ellie SR , Buck Marcia L 
Published: March 2004

OBJECTIVE: To describe the dosing and pharmacokinetics of phenobarbital in a neonate receiving extracorporeal membrane oxygenation (ECMO). CASE SUMMARY: The treatment of a 2.6 kg, 38-week gestational age boy with congenital diaphragmatic hernia who developed seizures while receiving ECMO support is described. A loading dose of 20 mg/kg resulted in concentrations of 16.4 and 12.9 μg/mL at 3 and 24 hours, respectively. A maintenance dose of 5 mg/kg/d provided a peak concentration of 19.7 μg/mL and trough concentration of 16.7 μg/mL after four doses. The calculated volume of distribution was 1.2 L/kg and the estimated elimination half-life was 92 hours. Serum concentrations decreased after circuit changes unless the new circuit was redosed. DISCUSSION: The reported incidence of seizures in neonates while receiving ECMO support is 18%. Despite this frequency, there are no clinical reports describing anticonvulsant use in this population. This case demonstrates the use of standard phenobarbital doses to achieve low, but therapeutic, serum concentrations. Pharmacokinetic analysis revealed a volume of distribution slightly larger than expected in neonates and an elimination half-life similar to published values. Altering circulating blood volumes resulted in significant reductions in serum concentrations. CONCLUSIONS: Neonates on ECMO may have a larger volume of distribution than neonates not receiving ECMO and may require larger phenobarbital doses to achieve desired serum concentrations. This may result from the presence of large exogenous blood volumes for priming, as well as loss of drug during circuit changes, extraction by the circuit, or hemofiltration. Further work is needed to better define the pharmacokinetics and pharmacodynamics of phenobarbital in the neonatal ECMO population.