The 11th edition of Harrison's Principles of Internal Medicine welcomes Anthony Fauci to its editorial staff, in addition to more than 85 new contributors. While the organization of the book is similar to previous editions, major emphasis has been placed on disorders that affect multiple organ systems. Important advances in genetics, immunology, and oncology are emphasized. Many chapters of the book have been rewritten and describe major advances in internal medicine. Subjects that received only a paragraph or two of attention in previous editions are now covered in entire chapters. Among the chapters that have been extensively revised are the chapters on infections in the compromised host, on skin rashes in infections, on many of the viral infections, including cytomegalovirus and Epstein-Barr virus, on sexually transmitted diseases, on diabetes mellitus, on disorders of bone and mineral metabolism, and on lymphadenopathy and splenomegaly. The major revisions in these chapters and many

Harrison's Principles of Internal Medicine

admission. This proportion could already be greater in some parts of the country and may increase if referrals of cases of self-poisoning increase faster than the facilities for their assessment and management. The provision of social work and psychiatric expertise in casualty departments may be one means of preventing unnecessary medical admissions without risk to the patients. Dr Blake's and Dr Bramble's figures do not demonstrate, however, that any advantage would attach to medical teams taking over assessment from psychiatrists except that, by implication, assessments would be completed sooner by staff working on the ward full time. What the figures actually suggest is that if assessment of overdoses were left to house doctors there would be an increase in admissions to psychiatric units (by 19°U), outpatients (by 5O°'), and referrals to social services (by 140o). So for house doctors to assess overdoses would provide no economy for the psychiatric or social services. The study does not tell us what the consequences would have been for the six patients who the psychiatrists would have admitted but to whom the house doctors would have offered outpatient appointments. E J SALTER

Vitamin D deficiency.

High-dose methotrexate (HDMTX), defined as a dose higher than 500 mg/m2, is used to treat a range of adult and childhood cancers. Although HDMTX is safely administered to most patients, it can cause significant toxicity, including acute kidney injury (AKI) in 2%-12% of patients. Nephrotoxicity results from crystallization of methotrexate in the renal tubular lumen, leading to tubular toxicity. AKI and other toxicities of high-dose methotrexate can lead to significant morbidity, treatment delays, and diminished renal function. Risk factors for methotrexate-associated toxicity include a history of renal dysfunction, volume depletion, acidic urine, and drug interactions. Renal toxicity leads to impaired methotrexate clearance and prolonged exposure to toxic concentrations, which further worsen renal function and exacerbate nonrenal adverse events, including myelosuppression, mucositis, dermatologic toxicity, and hepatotoxicity. Serum creatinine, urine output, and serum methotrexate concentration are monitored to assess renal clearance, with concurrent hydration, urinary alkalinization, and leucovorin rescue to prevent and mitigate AKI and subsequent toxicity. When delayed methotrexate excretion or AKI occurs despite preventive strategies, increased hydration, high-dose leucovorin, and glucarpidase are usually sufficient to allow renal recovery without the need for dialysis. Prompt recognition and effective treatment of AKI and associated toxicities mitigate further toxicity, facilitate renal recovery, and permit patients to receive other chemotherapy or resume HDMTX therapy when additional courses are indicated. Implications for practice High-dose methotrexate (HDMTX), defined as a dose higher than 500 mg/m2, is used for a range of cancers. Although HDMTX is safely administered to most patients, it can cause significant toxicity, including acute kidney injury (AKI), attributable to crystallization of methotrexate in the renal tubular lumen, leading to tubular toxicity. When AKI occurs despite preventive strategies, increased hydration, high-dose leucovorin, and glucarpidase allow renal recovery without the need for dialysis. This article, based on a review of the current associated literature, provides comprehensive recommendations for prevention of toxicity and, when necessary, detailed treatment guidance to mitigate AKI and subsequent toxicity.

Preventing and Managing Toxicities of High-Dose Methotrexate

How to investigate drug use in health facilities : selected drug use indicators

PURPOSETo update the ASCO guideline on the recommended prevention and treatment approaches in the management of chemotherapy-induced peripheral neuropathy (CIPN) in adult cancer survivors.METHODSAn...

https://ascopubs.org/doi/pdfdirect/10.1200/JCO.20.01399

Prevention and management of chemotherapy-induced peripheral neuropathy in survivors of adult cancers: ASCO guideline update

To determine the incidence of self-medication among Sharjah university students and the impact of medical knowledge on such practice. A pre-validated questionnaire was distributed to 200 pharmacy students during May, 2012. Data were analyzed using SPSS and results expressed as counts and percentages. The overall response rate was 85% with 98% of respondents being Arabs. Females comprised about 91% of students and the mean age (SD) was 19.5(2.4). Practicing self-medication in the past year was high as145 (86%) used drugs without medical consultation. Most respondents (128, 76%) obtained their medication from pharmacies and used the medication for one week (106, 63%). Antibiotics were used by 54(32%) of students despite the fact that slightly more than 50% of students were aware of the possibility of emergence of bacterial resistance and were also aware of the concept of rational drug use in general. Main reasons for self-medication were non-serious health problem, illness is minor, seeking quick relief and to avoid long waiting hours at clinics. Reasons against self-medication include risks of adverse effects, using the wrong medication, drug interaction, misdiagnosis and drug abuse and dependence. Medical consultation is mainly sought in case of presence of severe pain, worsening of symptoms, or persistence of the latter for more than a week. Headache or mild pain, eye and ear symptoms, gastric problems, cold, fever and allergy were the commonest symptoms for self-medication. Knowledge of responsible self medication is inadequate but the practice is high and common among pharmacy students. Interventions to promote responsible self-medication among university students are required.

Evaluation of self-medication among pharmacy students

IntroductionRemote pharmacist interventions have achieved much more attention during the coronavirus disease 2019 (COVID-19) outbreak, since they reduce the risk of transmission and can potentially...

Role of telepharmacy in pharmacist counselling to coronavirus disease 2019 patients and medication dispensing errors.

Background: Telepharmacy services are expected to have an important role in increasing access of patients to pharmaceutical care and reducing potential dispensing errors in community pharmacies. Objective: To assess the predictors for effective telepharmacy services on increasing access of patients to care and reducing dispensing errors in community pharmacies. Method: This is a prospective study carried out for 4 months in 52 community pharmacies across the United Arab Emirates (UAE) using disguised direct observation. Multivariable logistic regression was used as a tool to predict factors associated with effective telepharmacy services in improving dispensing safety and increasing access of patients to pharmaceutical care. Data were entered and analyzed using the Statistical Package for Social Science (SPSS) software version 26. Results: Pharmacist recommendations related to COVID-19 at pharmacies with telepharmacy (n = 63,714) versus those without remote services (n = 15,539) were significantly more likely to be (1) contact the nearest testing center (adjusted odds ratio [AOR] = 7.93), (2) maintain home quarantine (AOR = 5.64), and (3) take paracetamol for fever (AOR = 3.53), all were significant results (p 0.05), respectively. However, pharmacies with telepharmacy were more likely to include wrong patient errors (AOR = 5.38, p < 0.05). Conclusions: Telepharmacy can be used as a tool to reduce the burden on the health care system and improve drug dispensing safety in community pharmacies.

Evaluation of Telepharmacy Services in Light of COVID-19.

The purpose of our study was to determine if a community pharmacist could affect total blood cholesterol (TBC) of ambulatory patients by a program of education, consultation cholesterol screening. Of 241 initially screened individuals, 57 patients with TBC 200 mg/dL) met the inclusion criteria of this six-month study. Of these, 51 completed the study. Outcome was determined by changes in TBC measured during the initial screening and after two follow-up visits. Pharmacist intervention included obtaining TBC concentrations and reporting the results to patients, teaching patients about the role of cholesterol in illness and health, explaining risk factors associated with cardiovascular disease providing follow-up communication with patients. Data were analyzed using ANOVA, Mann-Whitney chi-square. The mean TBC was 5.84 mmol/L (225.7 mg/dL) for the study group and 4.23 mmol/L (163.8 mg/dL) for participants with TBC <5.17 mmol/L (<200 mg/dL) (p<0.0001). There was a significant difference (p = 0....

Outcome of Cholesterol Screening in a Community Pharmacy

Background Contemporary pharmaceutical care requires sustained pharmacist competency through maintenance and improvement of knowledge, skills, and performance. Existing continuing education (CE) models reflect a wide spectrum of international approaches to life-long learning. Objective The objective of this study was to determine CE preferences of pharmacists in Egypt before implementing a plan for compulsory annual CE activities and events for licensure renewal. Setting A questionnaire containing questions about continuing education needs and preferences of Egyptian pharmacists was distributed to 400 pharmacies in Cairo. The sample was drawn randomly from the address list in yellow pages. The survey was conducted by personal interview. Method The questionnaire was designed and validated. Questions were divided into specific domains of interest including pharmacist demographics; access to internet resources; frequency and characteristics of past CE activities; preferences for delivery and content; motivation to participation; and plans for future CE activities. All data analyses were conducted using SPSS for Windows version 18.0. All statistical tests were 2-tailed and based on a significance level of p value ≤ 0.05. Results During the six months of questionnaire distribution, 400 pharmacists (one from each randomly selected pharmacies) were asked to complete the questionnaire. The response rate was 359 out of 400 pharmacists (89.75%). Twenty three percent of respondents had held their highest pharmacy degree to practice for less than 5 years and 19% had obtained their initial degree more than 15 years ago. More than half of the respondents were female (53.3%). Topics related to therapeutics were of highest interest to 85.3%, closely followed by clinical skills topics. Pharmacists working in community pharmacies had attended less CE events (15 vs. 28%, p = 0.034 within the past 2 years) when compared to their hospital-based counterparts. Conversely, hospital pharmacists generally reported less satisfaction with current CE (21 vs. 33%, p = 0.021). Conclusion Respondents of the survey expressed enthusiasm towards CE activity, but cited common barriers to participation, as well, such as employer-and technology-based obstacles. These results confirm that features of a successful CE program must be flexible to meet preferences and perceived needs of Egyptian pharmacists.

Osama Mohamed Ibrahim

Papers

Evaluation of self-medication among pharmacy students

Role of telepharmacy in pharmacist counselling to coronavirus disease 2019 patients and medication dispensing errors.

Evaluation of Telepharmacy Services in Light of COVID-19.

Outcome of Cholesterol Screening in a Community Pharmacy

Assessment of Egyptian pharmacists’ attitude, behaviors, and preferences related to continuing education