Prescription drug overdoses: a review.

Context Many treatments for pressure ulcers are promoted, but their relative efficacy is unclear. Objective To systematically review published randomized controlled trials (RCTs) evaluating therapies for pressure ulcers. Data Sources and Study Selection The databases of MEDLINE, EMBASE, and CINAHL were searched (from inception through August 23, 2008) to identify relevant RCTs published in the English language. Data Extraction Methodological characteristics and outcomes were extracted by 3 investigators. Data Synthesis A total of 103 RCTs met inclusion criteria. Of these, 83 did not provide sufficient information about authors' potential financial conflicts of interest. Methodological quality was variable. Most trials were conducted in acute care (38 [37%]), mixed care (25 [24%]), or long-term care (22 [21%]) settings. Among 12 RCTs evaluating support surfaces, no clear evidence favored one support surface over another. No trials compared a specialized support surface with a standard mattress and repositioning. Among 7 RCTs evaluating nutritional supplements, 1 higher-quality trial found that protein supplementation of long-term care residents improved wound healing compared with placebo (improvement in Pressure Ulcer Scale for Healing mean [SD] score of 3.55 [4.66] vs 3.22 [4.11], respectively; P  2 vs 0.27 cm 2 , respectively; P Conclusions Little evidence supports the use of a specific support surface or dressing over other alternatives. Similarly, there is little evidence to support routine nutritional supplementation or adjunctive therapies compared with standard care.

https://jamanetwork.com/journals/jama/articlepdf/183029/jcr80006_2647_2662.pdf

Treatment of Pressure Ulcers: A Systematic Review

Proton pump inhibitors (PPI) are one of the most widely used classes of drugs. PPIs have a very favorable safety profile, and it is unusual for a patient to stop them because of side effects. However, with increasing numbers of patients chronically taking PPIs for gastroesophageal reflux disease and other common, persistent conditions, the long-term potential adverse effects are receiving increasing attention. An insufficiently studied area receiving much attention is the long-term effect of chronic acid suppression on the absorption of vitamins and nutrients. This increased attention results from the reported potential adverse effect of chronic PPI treatment leading to an increased occurrence of bone fractures. Interest in this area has led to examination of the effects of PPIs on calcium absorption/metabolism and numerous cohort, case-control, and prospective studies of their ability to affect bone density and cause bone fractures. In this article, these studies are systematically examined, as are studies of the effects of chronic PPI use on absorption of VB12, iron, and magnesium. Studies in each area have led to differing conclusions, but when examined systematically, consistent results of several studies support the conclusion that long-term adverse effects on these processes can have important clinical implications.

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Association of Long-Term Proton Pump Inhibitor Therapy with Bone Fractures and Effects on Absorption of Calcium, Vitamin B12, Iron, and Magnesium

Vitamin B12 is important to DNA synthesis and may affect bone formation. We examined the association between this vitamin and BMD in 2576 adults. Men with plasma B12 < 148 pM had significantly lower BMD at the hip, and women at the spine, relative to those with higher B12, and trends were similar for both at all sites. Low vitamin B12 may be a risk factor for low BMD.



Introduction: Vitamin B12 is important to DNA synthesis and may affect bone formation. It has been linked to osteoblastic activity in clinical studies and cell culture.



Materials and Methods: We examined the relationship between plasma vitamin B12 status and BMD in 2576 adult participants in the Framingham Offspring Osteoporosis Study (1996–2001). BMD was measured by DXA at the hip and spine. Plasma vitamin B12 was measured by radioassay. Mean BMD measures were estimated for four categories of vitamin B12 concentration, based on commonly used cut-offs, using analysis of covariance, adjusted for age, BMI, physical activity score for the elderly (PASE), alcohol use, smoking status, total calcium and vitamin D intake, season of bone measurement, and for women, menopause status and current estrogen use. Further adjustment for protein intake and total homocysteine concentration was also performed.



Results: Both men and women with vitamin B12 concentrations <148 pM had lower average BMD than those with vitamin B12 above this cut-off. These differences were significant (p < 0.05) for men at most hip sites and for women at the spine. Significance remained after further adjustment for protein intake and plasma homocysteine.



Conclusions: Vitamin B12 deficiency may be an important modifiable risk factor for osteoporosis.

Low plasma vitamin B12 is associated with lower BMD: the Framingham Osteoporosis Study.

Overutilization of Proton Pump Inhibitors: A Review of Cost-Effectiveness and Risk in PPI

OBJECTIVE:To compare the healing of stage II decubitus ulcers with topically applied phenytoin sodium with two other standard topical treatment procedures in a long-term care setting; and to assess the extent of systemic absorption after topical application in the phenytoin group.METHODS:Forty-seven nursing home patients with stage II decubitus ulcers were chosen for this study. The patients were matched for age, gender, and size and severity of wounds, and randomly assigned to each treatment group. Clinical assessment of decubitus ulcers was performed at the beginning of treatment and at each dressing change. Ulcers were examined for the presence of healthy granulation tissue, reduction in surface dimensions, and time to healing. Two phenytoin sodium plasma concentrations were to be obtained on all patients in the phenytoin group.RESULTS:Topical phenytoin therapy resulted in a shorter time to complete healing and formation of granulation tissue when compared with DuoDerm dressings or triple antibiotic oi...

Topical Phenytoin Treatment of Stage II Decubitus Ulcers in the Elderly

BACKGROUND:Assimilation of vitamin B12 from dietary sources requires gastric acid. By decreasing acid production, the proton pump inhibitors (PPIs) and histamine2 (H2)-blockers may reduce vitamin B12 absorption.OBJECTIVE:To determine whether chronic acid suppression therapy is associated with the initiation of vitamin B12 supplementation, we conducted a retrospective case–control study using a state-wide Medicaid population.METHODS:Case patients were identified as those who initiated vitamin B12 supplementation during the study period. Four control patients were age-and gender-matched to each case. Patients (n = 109 844) with a paid claim between September 27, 1995, and September 27, 1997, were eligible for inclusion. Chronic acid suppression therapy was defined as treatment with H2-blockers or PPIs for ≥10 of the 12 months prior to the first vitamin B12 injection. Comparisons were made between the case and control groups regarding exposure to chronic acid suppression therapy.RESULTS:One hundred twenty-fi...

Increased Vitamin B12 Requirement Associated with Chronic Acid Suppression Therapy

This descriptive report illustrates the philosophy and curricular design of the Idaho State University College of Pharmacy problem-based learning (PBL) methodology. A four semester course sequence was initiated in the spring of 1993. The model, originally developed for use in medical education, features use of an illstructured problem format and parallels a well established critical thinking process. The curricular objectives are to: (i) emphasize fundamental basic science concepts; (ii) develop a systematic process for identifying drug-related problems, termed pharmaceutical diagnosis; (iii) facilitate development of clinical problemsolving skills prior to clerkship entry; (iv) foster development of team-oriented interactive communication skills; and (v) inculcate a process for life-long learning. An abbreviated case example is presented to summarize the PBL stages and clinical problem-solving process.

Problem-Based Learning: A Tutorial Model Incorporating Pharmaceutical Diagnosis.

Objective To estimate frequencies of potential errors involving similarly named drugs using a retrospective claims database and measure the association between frequencies of potential errors and two measures of drug name similarity, edit distance (minimum number of insertions, substitutions, or deletions of characters required to change a given word into another target word) and normalized edit distance (proportion of letters that must be changed to commute one word to another, and ranges from 0 to 1, with 0 indicating identical words, and 1 indicating a pair of words with no common letters). Design Retrospective database analysis. Setting Idaho Medicaid claims data from 1993 to 2000. Patients Not applicable. Intervention Potential errors were detected using adjacent claims generated by dispensing of one drug followed by dispensing of the other drug with a similar name. In all, four potential error criteria were developed: two for detecting potential refill errors and two for detecting potential initial errors. A total of 10 drug pairs were randomly selected from the Idaho Medicaid claims database for each value of edit distance, which ranged from 1 to 30 (n=300). Main Outcome Measures Frequencies of potential medication errors in claims sequences for initial and refill claims, edit distance, and normalized edit distance. Results Of 300 drug pairs studied, 106 (35.33%) were involved in at least one potential error. A total of 1,138 dispensing episodes satisfied the criteria for potential errors. Frequencies of potential errors per drug pair were negatively associated with edit distance ( r =–0.133, P r =–0.226, P r =–0.126, P r =–0.222, P r =–0.134, P r =–0.226, P Conclusion Error criteria were successfully applied to a retrospective claims database to detect potential initial and refill errors that involved similarly named drugs.

https://www.japha.org/article/S1544-3191(15)31643-5/pdf

Retrospective Detection of Potential Medication Errors Involving Drugs with Similar Names

Objectives. To evaluate early predictors of advanced pharmacy practice experience (APPE) performance using either timed pharmaceutical care plan (TPCP) reports of 4 case histories or traditional lecture-based pharmacotherapy course examinations. Methods. Statistical process control (SPC) methods were used to identify a group of third-year pharmacy students “at risk” for poor APPE performance (defined as an APPE grade point average of < 3.0). Examination scores from an integrated lecture-based pharmacotherapy sequence were used for comparison. Results. TPCP scores but not lecture-based examination scores successfully identified 6 of 10 students who ultimately performed poorly in their APPEs. Conclusion. Adaptation of SPC methods to assess student performance during problem-based learning (PBL) case reports is a useful technique for identifying students “at risk” for poor APPE performance.

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Vaughn L. Culbertson

Papers

Topical Phenytoin Treatment of Stage II Decubitus Ulcers in the Elderly

Increased Vitamin B12 Requirement Associated with Chronic Acid Suppression Therapy

Problem-Based Learning: A Tutorial Model Incorporating Pharmaceutical Diagnosis.

Retrospective Detection of Potential Medication Errors Involving Drugs with Similar Names

Pharmaceutical Care Plan Examinations to Identify Students at Risk for Poor Performance in Advanced Pharmacy Practice Experiences