Showing papers by "American Pharmacists Association published in 2011"

ASHP guidelines on emergency medicine pharmacist services.

Abstract: Emergency medicine (EM) is an ever-changing, rapidly evolving practice specialty. The formal emergency department (ED) has its roots in the 1950s, when full-time emergency services were established in the United States.[1][1] Since then, the rate of mortality from accidental and traumatic injuries

High-Dose Dexmedetomidine for Sedation in the Intensive Care Unit: An Evaluation of Clinical Efficacy and Safety

Abstract: BACKGROUND:Dexmedetomidine is an α2-receptor agonist used for sedation in the intensive care unit (ICU). Although dexmedetomidine is labeled for sedation in critically ill patients at doses up to 0.7 μg/kg/h, recent studies have used more liberal dosing regimens. However, to our knowledge, no study has assessed the clinical impact of doses greater than 0.7 μg/kg/h when compared to doses within the Food and Drug Administration-approved labeling.OBJECTIVE:To compare the clinical efficacy and safety of high (HD) and low (LD) dses of dexmedetomidine for sedation in the ICU.METHODS:This retrospective study included a sample of patients who received dexmedetomidine in medical, surgical, medical/surgical, and cardiothoracic ICUs between January 1, 2008, and December 1, 2009. Patients were included in the LD group if their maximum dose was less than 0.7 μg/kg/h or in the HD group if any dose was more than 0.7 μg/kg/h. Efficacy was determined by the percentage of Richmond Agitation and Sedation Scale (RASS) scores...

How can we teach EBM in clinical practice? An analysis of barriers to implementation of on-the-job EBM teaching and learning.

Abstract: Introduction: Evidence-based medicine (EBM) improves the quality of health care. Courses on how to teach EBM in practice are available, but knowledge does not automatically imply its application in teaching. We aimed to identify and compare barriers and facilitators for teaching EBM in clinical practice in various European countries. Methods: A questionnaire was constructed listing potential barriers and facilitators for EBM teaching in clinical practice. Answers were reported on a 7-point Likert scale ranging from not at all being a barrier to being an insurmountable barrier. Results: The questionnaire was completed by 120 clinical EBM teachers from 11 countries. Lack of time was the strongest barrier for teaching EBM in practice (median 5). Moderate barriers were the lack of requirements for EBM skills and a pyramid hierarchy in health care management structure (median 4). In Germany, Hungary and Poland, reading and understanding articles in English was a higher barrier than in the other countries. Conclusion: Incorporation of teaching EBM in practice faces several barriers to implementation. Teaching EBM in clinical settings is most successful where EBM principles are culturally embedded and form part and parcel of everyday clinical decisions and medical practice.

Integrating medication therapy management in the primary care medical home: A review of randomized controlled trials.

Abstract: Purpose Randomized controlled trials (RCTs) that evaluated the effect of medication therapy management (MTM) on patient outcomes in the primary care medical home were reviewed to determine how these services may be integrated into the primary care medical home. Methods A literature search was conducted to identify RCTS published between 1989 and 2009 that evaluated the impact of MTM services on patient outcomes. To qualify as MTM services, the interventions had to include both a review of medication therapy and patient interactions, including educating patients about drug therapy, identifying potential barriers to medication adherence, and helping patients manage their diseases. The internal validity of the studies was evaluated using previously published criteria. The description, specification, and appropriateness of study objectives, study population, intervention, randomization, blinding, outcome measures, statistical analysis, and conclusions were evaluated. Results A total of 1795 publications were identified, but only 8 met the inclusion criteria. These studies targeted patients with specific medical conditions or patients with multiple medications without specifying a medical condition. The interventions varied in intensity (i.e., frequency and length of patient contact), ranging from a single patient contact in a community pharmacy setting to multiple visits with an ambulatory care pharmacist practicing in a collaborative care model. Two of the 8 studies obtained expected results. These studies targeted patients with unrealized therapeutic goals, and the interventions involved collaboration between pharmacists and physicians and extensive patient follow-up. Conclusion Of 1795 publications identified, 8 were RCTs meeting selection criteria for evaluation of the effect of MTM services on patient outcomes. Two service elements that benefit patient care were identified: (1) selecting patients with specific therapeutic problems and (2) implementing MTM services that involve timely communication with primary care providers to discuss therapeutic problems, along with routine patient follow-up to support medication adherence to changes in therapy.

Oral Ferrous Sulfate Does Not Increase Preoperative Hemoglobin in Patients Scheduled for Hip or Knee Arthroplasty

Abstract: BACKGROUND:Low hemoglobin (Hb) concentrations before lower limb joint replacement are associated with the need for blood transfusions and increased mortality. To optimize preoperative Hb, blood conservation protocols often recommend oral iron supplements, even in nonanemic patients.OBJECTIVE:To investigate the impact of ferrous sulfate on the change in Hb prior to hip or knee arthroplasty and evaluate the effect of oral iron on hematocrit, mean corpuscular volume (MCV), ferritin, and transferrin saturation, as well as its tolerability and treatment adherence.METHODS:We conducted a prospective, observational cohort study of adults with Hb concentrations between 10 and 15 g/dL who received iron supplementation prior to hip or knee arthroplasty. Systemic inflammatory diseases, vitamin B12 or folate deficiency, and current use of iron supplements, intravenous iron, or erythropoietin were exclusion criteria. All participants were prescribed ferrous sulfate 300 mg 3 times daily for a minimum of 3 weeks. Complet...

Pregabalin-Induced Hepatotoxicity:

Abstract: OBJECTIVE:To report a case of acute elevation of hepatic enzyme levels as a probable adverse reaction associated with pregabalin.CASE SUMMARY:A 59-year-old man with a history of mantle cell lymphoma developed neuropathic pain and was treated with pregabalin 25 mg daily. Fourteen days after beginning pregabalin therapy, he developed left ankle edema and elevation of liver enzyme levels. Peak values were aspartate transaminase 907 U/L, alanine transaminase 1582 U/L, and γ-glutamyltransferase 510 U/L. Pregabalin was discontinued and hepatic enzyme levels returned gradually (over 4 months) to baseline levels.DISCUSSION:Many medications are commonly associated with liver injury; few cases of pregabalin-associated hepatotoxicity have been documented. A MEDLINE search (1966-November 2010) revealed 2 reports of acute liver injury with the initiation of pregabalin. In our patient, with hemosiderosis after hematopoietic cell transplantation, pregabalin worsened the underlying liver injury. The low pregabalin dosage...

Dental prescribing in Wales and associated public health issues.

Abstract: Dental prescribing data in Wales have not been studied in detail previously. The analysis of national data available from Health Solutions Wales showed that dental prescribing in Wales accounted for 9% of total antibacterial prescribing in primary care in 2008. Penicillin and metronidazole constituted the bulk of antibiotics prescribed by dentists. Since the publication of National Institute for Health and Clinical Excellence (NICE) guidance (March 2008) on prophylaxis against infective endocarditis, dental prescriptions for amoxicillin 3g sachets and clindamycin capsules have decreased. Dental prescriptions for fluoride preparations increased in number from 2007 to 2008. Dental prescribing of controlled drugs raises no concern. The figure for antibiotic prescribing in Wales is similar to that of England. Nevertheless, the figure seems a little high, indicating potential inappropriate prescribing behaviour among dentists. Antibiotic resistance is a major public health issue and many patients each year die from infections from bacterial strains that are resistant to one or more antibiotics. Inappropriate use of antibiotics is a major cause of antibiotic resistance and every effort should be made to reduce the number of inappropriate antibiotic prescriptions in dental practice.

Treatment of Alternaria Keratitis with Intrastromal and Topical Caspofungin in Combination with Intrastromal, Topical, and Oral Voriconazole

Abstract: Objective:To report a case of refractory atypical Alternaria keratitis that was treated with intrastromal and topical caspofungin 0.5% in combination with topical, oral, and intrastromal voriconazole.Case Summary:A 67-year-old female with a history of bilateral intraocular lens exchange and left pseudophakic bullous keratopathy was referred to the emergency department of the Royal Victorian Eye and Ear Hospital, Melbourne, Australia. Visual acuity of her left eye was limited to counting fingers. A fine branching pattern was noted throughout the anterior stroma of her left corneal graft. The anterior chamber was deep and quiet. Hourly topical voriconazole 1% was initiated, with limited response. One week later, Alternaria spp. was cultured from the corneal scraping. Subsequently, topical caspofungin 0.5% was added, with concomitant use of topical, oral, and intrastromal voriconazole. Despite gradual symptomatic improvement, topical voriconazole was increased to 2% and intrastromal caspofungin was added. Th...

Exploring community pharmacists' perceptions of their professional relationships with physicians, in Canada and The Netherlands.

Abstract: Objective — To explore community pharmacists' levels of interaction with, and perceptions of, physicians in primary care in Canada and the Netherlands Method — Interviews with community pharmacists Setting — Thirty-six community pharmacies in Vancouver, Canada, and 36 in the Nijmegen and Arnhem areas of the Netherlands Key findings — Dutch pharmacists were more likely to have “face-to-face contacts with the physician in the pharmacy setting” (P=0.008) and structured professional meetings with physicians (P<0.001). Canadian pharmacists were more likely to agree that “interaction with physicians is mainly limited to phone/fax” (P<0.001) and “the concept of pharmaceutical care is difficult to implement” (P=0.006). Qualitative analysis revealed that in both countries pharmacists had concerns about the attitudes of physicians and issues concerning territoriality. There were also many constructive comments and these enabled consideration of actions to enhance patient care Conclusion — The findings of the study suggest four areas which could contribute to improved patient care: (1) Increasing levels of professional interaction; (2) developing a mutual understanding of roles; (3) participating in joint initiatives to benefit patients through the extended role of pharmacists; (4) conducting structured meetings between professionals with an emphasis on the care of individual patients

The impact of an aged care pharmacist in a department of emergency medicine

Abstract: Rationale, aims and objectives Departments of Emergency Medicine (DEM) have experienced increased demand largely because of the aging population. This project aimed to assess the impact of a specialist aged care pharmacist (ACP) on the efficiency and effectiveness of care of older patients seeking emergency treatment. Method Eligible patients presenting to the DEM of Bundaberg Hospital (Australia), aged ≥65 years with a chronic condition, or ≥70 years without a chronic condition, and an Australian Triage Category score of ≥2, were alternately allocated to either the ACP (for medication reconciliation and medication review roles, along with patient education and referrals where warranted), or continued management by the DEM doctor (control group). Results A total of 199 patients were included (intervention, n = 101; control, n = 98), with no significant difference in mean age or gender distribution. While the ACP-managed group demonstrated a significantly greater length of stay than the control group, some confounding was likely. The ACP demonstrated greater vigilance than usual care in ensuring completeness and accuracy in charted medication orders. The ACP also provided timely clinical review for medication-related problems, with 81 issues identified for 73 admitted patients, and 24 issues among the 28 discharged patients. Qualitative data were strongly supportive, valuing and accepting of the ACP role. Conclusions This study provides evidence, on balance, supporting the integration of an ACP in the DEM assessing elderly patients. Further research of this role using longer sampling, in multiple sites and with economic analysis is recommended.

Rapid Onset of Iatrogenic Adrenal Insufficiency in a Patient with Cystic Fibrosis-Related Liver Disease Treated with Inhaled Corticosteroids and a Moderate CYP3A4 Inhibitor

Abstract: Objective To report the rapid onset of adrenal insufficiency and subsequent development of Cushing syndrome precipitated by a CYP3A4-mediated drug-drug interaction that may have been enhanced by the presence of cystic fibrosis (CF)-related liver disease. Case summary A 9-year-old girl with CF and cirrhosis experienced a decline in lung function that led to a diagnosis of asthma. After initiation of asthma therapy with inhaled fluticasone 110 μg/actuation, the patient experienced improvement in lung function to baseline. Seven weeks after the initiation of inhaled fluticasone, she developed vaginal candidiasis and was prescribed fluconazole 100 mg/day, a CYP3A4 inhibitor. Three days after starting fluconazole, she developed polyuria and polydipsia and was found to have severe hyperglycemia, which led to the diagnosis of Cushing syndrome. Fluticasone was discontinued, and the patient's adrenal function normalized. Discussion Patients with CF are commonly prescribed complex medication regimens that may affect drug metabolism. CYP3A4 inhibitors may significantly decrease metabolic clearance in patients using chronic inhaled corticosteroids. Iatrogenic Cushing syndrome has been reported in patients with CF treated concomitantly, and for extended duration, with inhaled corticosteroids and CYP3A4 inhibitors. This case highlights rapid onset of adrenal insufficiency in a patient with CF-related liver disease treated briefly with a moderate CYP3A4 inhibitor. Use of the Horn drug interaction probability scale indicates that the interaction between fluticasone and fluconazole was probable. Conclusions CYP3A4-mediated drug interactions represent a significant risk in patients treated with long-term inhaled corticosteroids. The presence of clinically significant CF-related liver disease may enhance this risk.

Comparison of the white-coat effect in community pharmacy versus the physician's office: the Palmera study.

Abstract: The aim of this study was to measure the community pharmacy white-coat effect (CPWCE) in treated hypertensive patients and to compare its magnitude with the WCE in the physician's office (POWCE). This cross-sectional study attempted to cover the treated hypertensive population, of more than 18 years of age and users of a rural CP located in Palmera (Valencia, Spain). Blood pressure (BP) was measured at three different settings, according to clinical guidelines: CP (three visits), PO (three visits), and home (4 consecutive days). The WCE was defined as the difference between the average CPBP or the average PO BP and the average home BP: CPWCE and POWCE, respectively. Differences between BP measurements were assessed by paired t-tests. The study sample consisted of 70 patients. The CPWCE was not significant, both for systolic BP (SBP) and for diastolic BP (DBP): 1.4 mmHg [standard deviation (SD): 11.3; 95% confidence interval (CI): -1.3 to 4.1] and -1.1 mmHg (SD: 7.5; 95% CI: -2.9 to 0.7), respectively. The POWCE was positive and statistically greater than 0 for SBP [13.3 mmHg (SD: 11.5); 95% CI: 10.5-16.0] and for DBP [2.4 mmHg (SD: 9.3); 95% CI: 0.2-4.6]. Finally, the POWCE was greater than the CPWCE both for SBP and for DBP (P<0.001). In this sample of treated hypertensive patients, the CPWCE was not statistically significant and was statistically lower than the POWCE.

High Unbound Fraction of Valproic Acid in a Hypoalbuminemic Critically Ill Patient on Renal Replacement Therapy

Abstract: Objective To describe a hypoalbuminemic critically ill patient with subtherapeutic total valproic acid serum concentrations but unbound valproic acid concentrations within normal limits. Case summary During an intensive care unit admission, a 61-year-old woman with urosepsis and multiorgan dysfunction syndrome developed tonic-clonic seizures with respiratory failure, and tracheal intubation was performed. An intravenous loading dose of valproic acid 1500 mg (25 mg/kg) was administered and therapy was continued with valproic acid 750 mg (12.5 mg/kg) twice daily. Because of progressive renal failure, continuous venovenous hemofiltration was started on day 3 of valproic acid therapy. On day 7 of valproic acid therapy, routine testing of serum valproic acid trough concentration returned as undetectable. Subsequent determinations of trough serum concentrations of total valproic acid showed values below the therapeutic range. Data from a full pharmacokinetic curve (multiple blood samples during a dosing interval) showed that the free fraction of valproic acid was >60%. Although total valproic acid concentrations were still low, the unbound concentrations were considered therapeutic. Serum albumin was 1.2 g/dL on the multiple sampling day. Discussion The patient's hypoalbuminemia probably explains the remarkably high free fraction of valproic acid. Our hypothesis is that the low albumin level was associated with high plasma clearance of valproic acid, leading to extremely low total drug concentrations. To our knowledge, this high percentage of free valproic acid has not been previously described. Conclusions Health-care professionals should be aware of the need of early determination of both total and free fraction valproic acid serum concentrations in hypoalbuminemic critically ill patients. Increasing the dose of valproic acid purely based on total valproic acid serum concentrations in this patient population should be avoided.

Shake table tests on clutter levels of typical medicine shelves and contents subjected to earthquakes

Abstract: Overturned shelves and fallen objects scattered on floors are one of the most frequently observed forms of nonstructural damage after earthquakes. The term ‘clutter’ is adopted in this study to represent this type of damage. Clutter may cause obstructions and thus hinder the use of a room. Making a seismic evaluation of clutter is a daunting task, due to the diversity of the types of shelves and objects and the way the objects are stored. Nonetheless, in order to achieve performance-based seismic evaluation, especially for critical facilities such as hospitals, it is reasonable to undertake the estimation of clutter when examining the association between the performance of structural and nonstructural elements. Of particular interest in this paper is clutter caused by objects stored on medicine shelves in pharmacies, which are one of the critical departments for delivering post-earthquake emergency care. Shake table tests were conducted on three conventional types of medicine shelves. Sinusoidal waves and earthquake motions were input uniaxially. The results of the tests using the sinusoidal wave input indicated the relationship between the input excitation intensity and clutter level expressed in scattering distance from the front of the shelf. Tests using earthquake motion input were then conducted and the results were compared with those for sinusoidal waves. Based on a comparison of the results from these tests, criteria for the seismic evaluation of clutter caused by medicine shelves due to earthquakes were proposed. Copyright © 2011 John Wiley & Sons, Ltd.

Multivitamin Supplement Use and Risk of Breast Cancer: A Meta-Analysis:

Abstract: BackgroundThe association between consumption of multivitamins and breast cancer is inconsistent in epidemiologic studies.Objective:To perform a meta-analysis of cohort and case-control studies to evaluate multivitamin intake and its relationship with breast cancer risk.Methods:The published literature was systematically searched and reviewed using MEDLINE (1950 through July 2010), EMBASE (1980 through July 2010). and the Cochrane Central Register of Controlled Trials (The Cochrane Library 2010 issue 1). Studies that included specific risk estimates were pooled using a random-effects model. The bias and quality of these studies were assessed with REVMAN statistical software (version 5.0) and the GRADE method of the Cochrane Collaboration.Results:Eight of 27 studies that included 355,080 subjects were available for analysis. The total duration of multivitamin use in these trials ranged from 3 to 10 years. The frequency of current use in these studies ranged from 2 to 6 times/week. In analyses by duration o...

Collaboratively planning for medicines administration competency: a survey evaluation

Abstract: hemingway s., baxter h., smith g., burgess-dawson r. & dewhirst k. (2011) Journal of Nursing Management 19, 366–376 Collaboratively planning for medicines administration competency: a survey evaluation Aims This survey evaluated the experiences of mental health nurses who had undergone assessment of their competence in the administration of medicines using established assessment frameworks. Background Medicines management activities have at times been widely criticized. Joint collaborations between Higher Education Authorities and the National Health Service in education and training can start to address some of these criticisms. Method A questionnaire using 22 closed and open response questions was distributed to 827 practising mental health nurses and 44 graduate mental health nurses. Results A total of 70 registered and 41 graduate mental health nurses who had completed the assessment of administration competency frameworks responded to the survey. Response rates were 24 and 96%, respectively. The assessment frameworks were received positively. Environmental factors were perceived as the main barrier to medicines safety; however, this was not reflected in how this aspect of the competency framework was perceived. Implications for nursing management The administration of medicines is an area of mental health and all fields of nursing practice that needs attention. The use of competency frameworks as outlined in the ‘Medicine with Respect Project’ is one strategy to achieve the improvement in this essential clinical skill.

A Self-Administration of Medications Program to Identify and Address Potential Barriers to Adherence in Elderly Patients

Abstract: BACKGROUND:Inpatient self-administration of medications programs (SAMPs) improve the medication knowledge and adherence of elderly patients after their discharge from the hospital. They may also identify patients who will have difficulties managing their medications after discharge; however, no previous study has evaluated the value of a SAMP for detecting and addressing barriers to adherence.OBJECTIVE:To evaluate the usefulness of a SAMP for detecting and addressing barriers to adherence in functionally impaired elderly hospital inpatients, and to identify predictors of patient performance in a SAMP.METHODS:A prospective cohort study was conducted on 2 subacute aged-care wards. Patients who were intending to independently manage their medications after discharge were recruited. Medications were dispensed and labeled with full directions, and the patients were educated about their medications. Each patient was required to request the medications from nursing staff when due, then select and administer them...

Pharmacy counter assistants and oral health promotion: an exploratory study

Abstract: Background The involvement of community pharmacists in oral health promotion is being increasingly recognised and studied. However, a large proportion of interactions in community pharmacies take place with pharmacy counter assistants rather than the pharmacist, and the role of pharmacy counter assistants in oral health promotion has received little or no attention until now. Aims To clarify the current state of affairs on pharmacy counter assistants' involvement with oral health promotion. Design and methods A postal-questionnaire-based survey of pharmacy counter assistants across East Yorkshire, North Lincolnshire and the Doncaster area. One hundred addresses were included and 35 responses were received. Results Pharmacy counter assistants are infrequently approached by the public for advice on matters of oral health and advice is not often volunteered despite a reasonable knowledge of the subject. Respondents identified a role for themselves in educating patients/customers, which they are keen to expand. Conclusions The expansion of the pharmacy counter assistant's role in oral health promotion would be of value to patients/customers. This should include increased opportunistic education and a more integrated position of pharmacy within a holistic health promotion strategy.

A medication reconciliation form and its impact on the medical record in a paediatric hospital.

Abstract: Objectives The objective of this study was to evaluate the quality of medication information available in medical charts before and after the implementation of a medication reconciliation form. Patients and methods This study is a retrospective chart review of patients under 18 years who were taking two medications or more at home and were admitted to a paediatric hospital for more than 24 hours and discharged from a general paediatrics, infectious disease, gastroenterology or pneumology ward over two 20-week periods (pre- and postimplementation). Each week, 10 medical records were randomly chosen and reviewed. The quality of the medication information was measured on admission (dose, route of administration and frequency) and on discharge (dose, route of administration, frequency and duration of treatment). The proportion of medications that fully met these criteria was compared between the groups using the chi-squared test. Results Information was analysed for a total of 3275 medications in the preimplementation group, vs. 3240 medications in the post-implementation group. Baseline characteristics were similar in both groups. On admission, the quality of medication information was comparable between the pre- and post-implementation groups (29.1 vs. 29.3%, respectively; P = 0.86). However, on discharge, an improvement in the quality of information was observed in the post-implementation group (51.7 vs. 65.2%; P < 0.001). Conclusion Our study demonstrated that the forms used in the reconciliation process, in particular the discharge prescription, could increase the quality of the information related to drug use in medical charts. We believe that medication reconciliation forms should be widely used by all the health care professional teams involved in the drug history or prescription process.

A comparison of low vs conventional‐dose heparin for minimal cardiopulmonary bypass in coronary artery bypass grafting surgery

Abstract: Summary The biocompatibility of minimal extracorporeal circuits has improved; however, anticoagulation is still required. We compared standard high-dose anticoagulation with a low-dose heparin regimen in a retrospective study of patients who underwent coronary bypass surgery using minimal cardiopulmonary bypass. One hundred patients who received 300 IU.kg−1 heparin were compared with 68 patients who received heparin according to an individually adjusted activated coagulation time target of 300 s, resulting in a mean (SD) heparin dose of 145 (30) IU.kg−1. There were no thromboembolic events in either group; however, patients in the low-dose group had lower 24-hour mean (SD) postoperative blood loss than the conventional group (545 (61) vs 680 (88) ml, p = 0.001) and a reduced rate of transfusion of allogeneic blood (15% patients transfused vs 32%, p = 0.01). An individually tailored low-dose heparin regimen for minimal cardiopulmonary bypass is safe and may be associated with reduced bleeding and lower transfusion requirements.

Patient-centered medical homes: primer for pharmacists.

Abstract: Objective To provide a patient-centered medical home (PCMH) primer for pharmacists, including basic background information, key terminology, and examples of success stories Data sources PCMH literature and resources obtained through search strategies by authors including but not limited to PubMed and Google Scholar Summary PCMHs are a potential means of achieving cost reduction in health care and providing collaborative and comprehensive care, and they represent a promising option for achieving health care reform Medication therapy management and collaborative drug therapy management are possible means for pharmacists to fulfill the goals of PCMHs Conclusion Pharmacists must become knowledgeable of standards of PCMH and their abilities to fulfill these standards Advocacy at local, state, and national levels is needed to achieve recognition of the value of pharmacists in PCMHs

Impact of a Pharmacist Intervention on Ambulatory Patients with Heart Failure: A Randomised Controlled Study

Abstract: Aim: To determine the impact of a pharmacist intervention on patient–guided diuretic dose adjustment in ambulatory patients with heart failure. Method: Patients with heart failure were randomised to usual care or usual care plus pharmacist intervention and followed for 3 months. Pharmacist intervention focused on patients improving self-care, recognising symptoms of fluid retention, measuring weight daily and self-adjusting diuretic dose using frusemide. The primary outcome was the number of appropriate weight-titrated frusemide dose adjustments. Secondary outcomes included the number of patients who correctly selfadjusted their frusemide dose, hospital readmissions due to fluid overload, heart failure-related knowledge and understanding, and quality of life (using validated tools). Results: 70 patients were recruited: 35 usual care (control) and 35 usual care plus pharmacist intervention. The average number of appropriate weight-titrated frusemide dose adjustments per patient per month in the control group was 0.32 ± 0.08 and in the intervention group was 0.85 ± 0.13 (p = 0.006). Hospital readmissions due to fluid overload was 31% in the control and 14% in the intervention groups (p = 0.04). There were significant differences between the groups regarding appropriate self-adjusted frusemide doses, heart failure-related knowledge and understanding, and quality of life. Conclusion: A pharmacist intervention improved the ability of heart failure patients to self-adjust their diuretic dose by using a flexible dosing regimen based on weight, resulting in quality of life improvement and a decrease in hospital readmissions due to fluid overload. J Pharm Pract Res 2011; 41: 126-31.

Esomeprazole but Not Pantoprazole is Associated with Lower Plasma Concentrations of Clopidogrel's Active Metabolite

Abstract: TOTHEEDITOR: Recently, the protonpumpinhibitor (PPI)omeprazole wasfoundto reducetheformation of theactivethiolmetabolite of c1opidogrel(AMC)by 45% and to increase on-treatment platelet reactivity to a similarextent.' Basedon thesefindings, the Foodand DrugAdministrationrecommends that the use of omeprazole and otherCYP2C19inhibitors, such as esomeprazole, should be avoided in patients treated withclopidogrel.' However, that recommendation has notbeensupported by pharmacokinetic data.Weinvestigated the effectof esomeprazole and pantoprazole on theplasmaconcentrations of the AMCandex vivo platelet reactivity. Methods. Forty-eight patientswith a historyof stent thrombosis receiveda 6OO-mg clopidogrelloading dose.Plasmaconcentrations of unchanged clopidogrel, the AMC,and the inactive carboxylic acidmetaboliteweredetermined withliquid chromatography and tandemmassspectrometryup to 6 hours after the administration of clopidogrel.' Plasma concentration versus timedataof eachpatient werefitby using a l-compartment first-order lag-time model. Platelet reactivity wasmeasured using 20 pmoVLof adenosine diphosphate (ADP)-induced lighttransmittance aggregometry6 hours after administrationof the clopidogrel loading dose. Twenty patients were given pantoprazole (40 mg/day) and6 weregivenesomeprazole (4 subjects, 40 mg/day and2 subjects, 20 mg/day) (Table I). Results. Esomeprazole usershada reduction of 45% in the maximal plasmaconcentration of AMC(C....(AMC» as comparedwith PPI nonusers (p = 0.005). Figure IA showsthat the C....(AMC)of esomeprazole was significantly lowerthan that ofpantoprazole (p = 0.001). Concentrations of the pantoprazoleand PPI nonuse group weresimilar. No significant differences in Cm.,(clopidogrel) and C....(inactivemetabolite) were foundbetween the3 groups. Participants whoreceived esomeprazole exhibited higherplatelet reactivity compared withthosewho did not receivea PPI(p =0.026); however, pantoprazole was not associated withsignificantly higherplatelet reactivity(Figure IB). Platelet reactivity did notdiffersignificantly betweenesomeprazoleand pantoprazole (Figure IB). All differences remained significant afteradjustment for the confounders bodymass index,recentclopidogrel intake, age, use of calcium channel blockers, and CYP2C19*2-carriage. Discussion.Contradictory resultsregarding the effect of coadministrationof CYP2C19-metabolized PPIs on platelet reactivity andclinicaloutcomein patients treated withclopidogrel havebeenreported.\"? Toourknowledge, this is the first studythat providespharmacokinetic data to support the assumption that concomitant use of esomeprazole decreases plasma concentrations of the AMC.The fact thatcoadministration of esomeprazole did notcausea decreasein theCms• of clopidogrel and its inactivemetabolite indicates thatthe lowerCma.(AMC) observed in the esomeprazole groupwas not the result of impaired clopidogrel absorption. The lack of influence of pantoprazole on Cm•.(AMC) is in line with the resultsof a recentplacebo-controlled pharmacokinetic study in healthy subjects}In that study,pantoprazolewas found to have much less impacton theexposure of theAMCandplatelet reactivity thanomeprazole (20% vs 45% decreasein AMC exposure and a 4.3% vs 8.0% increase in 5pmol/L ADP-induced platelet reactivity).' A limitationof our studyis the nonrandomized design.Althoughall significantdifferences remained significantafter adjustment for confounders, it is possible thatresidual confounding couldhaveaffected the results. Second,the samplesizemighthave beentoo smallto detectsignificant differences in platelet reactivity between esomeprazole and pantoprazole. In addition, the imbalances in baseline characteristics between treatment groups(eg,CYP2C19*2-carriers, different dosesof esomeprarole) mightlimit thegeneralizability of our findings. Finally, the impact of theconcomitant useof clopidogrel andesomeprazole or pantoprazole on clinical outcome cannotbe ascertained fromthe resultsof this study. In conclusion, esomeprazole use was associated with decreased C....(AMC)and increased plateletreactivity. On the other hand,panto-

β-lactamase producing enterobacteria isolated from surveillance swabs of patients in a Cardiac Intensive Care Unit in Rio de Janeiro, Brazil

Abstract: There is a high incidence of infections caused by betalactamase-producing Gram-negative microorganisms in Brazil. These organisms are of clinical and epidemiological importance, since their mobile genetic elements facilitate cross-infection. The present study was conducted in sentinel rectal swabs from patients admitted to a cardiac surgery hospital in Rio de Janeiro, from January through December 2007, in a consecutive manner. The aim of the study was to characterize the genotype and phenotype of these isolates from colonized patients. Biochemical tests, antimicrobial susceptibility tests, a confirmatory test for the expression of extended spectrum betalactamase (ESBL) production and polymerase chain reaction for the blaTEM, blaSHV, CTX-M1, Toho-1 and AmpC genes were performed at the University Hospital of Universidade do Estado do Rio de Janeiro (UERJ). The most frequently isolated bacteria were Escherichia coli 9/41 (21.95%) and Klebsiella pneumoniae 14/41 (34.1%). In 24/41 (58%), the ESBL genotype was confirmed. The most prevalent genes in samples that expressed ESBL were blaTEM 13/24 (54%), AmpC 12/24 (50%), blaSHV 6/24 (25%), CTX-M1 7/24 (29%), and Toho-1 6/24 (25%). Of these, 14/24 (58%) presented more than one genotype for the tested primers. In nine (37%) samples other than E. coli, K. pneumoniae or Proteus spp., the phenotype for ESBL was found and confirmed by PCR. The most sensitive substrate in the approximation test in ESBL positive samples was ceftriaxone (83%). Fifty percent of the samples expressed AmpC were associated with other genes. Intermediate susceptibility to ertapenem was found in 2/41 (5%).

Dofetilide Dose Calculation Errors in Elderly Associated with Use of the Modification of Diet in Renal Disease Equation

Abstract: Objective:To report 2 cases of drug dosage calculation errors that occurred when the Modification of Diet in Renal Disease (MDRD) equation was used for initiating drug therapy with dofetilide in ei...

Stability of Azacitidine Suspensions

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The potential risk of infections during (prolonged) rituximab therapy in rheumatoid arthritis

Abstract: Introduction: Biologicals are a fast expanding group of new drugs and rituximab (RTX) is one of them. Long-term efficacy and safety constantly need addressing as little is known about these factors. In rheumatoid arthritis, RTX it is used for active disease that is not responding to other therapies. Since RTX acts by depleting B-cells, concerns regarding the long-term safety of this drug have been raised. Areas covered: This review covers 10 manuscripts on RTX safety in rheumatoid arthritis published between January 2004 and July 2010. Expert opinion: In present literature RTX appears to be safe for up to five courses. In this review, important drawbacks of current research are discussed. Longer follow-up time is needed to make relevant conclusions on RTX safety with regard to infectious complications. Prolonged RTX therapy causes subsequent B-cell depletion. Eventually, plasma cells disappear, causing hypogammaglobulinemias and subsequent problems in immunity. The formation of new plasma cells is halted ...