Evaluation of Bleeding in Orthopedic Surgery With Perioperative Use of Serotonergic Antidepressants.

BACKGROUND: The use of serotonergic antidepressants (SADs) is associated with an increase in bleeding, and their exposure during the perioperative period increases the potential bleeding risk in patients undergoing surgical operations. OBJECTIVE: The purpose of this study was to compare the rates of bleeding between patients on perioperative SADs and those not on SADs in patients undergoing orthopedic surgical procedures. METHODS: A retrospective cohort study was conducted with patients who were admitted to a single tertiary care county teaching hospital for orthopedic surgery. Outcomes evaluated were requirements of ≥ 2 units of packed red blood cells (PRBCs) and length of hospital stay for those requiring ≥ 2 units of PRBCs. RESULTS: Of 273 patients, a significantly higher percentage of patients who received SADs required ≥ 2 units of PRBCs (19.3% vs 6.9%; P = 0.0049). Patients who required transfusion had a higher median (interquartile range [IQR]) age (79 [64-84.6] vs 65 [59-75]; P < 0.0001). The risk of requiring ≥ 2 units of PRBCs transfusion was greater for individuals having an anemia comorbidity (odds ratio [OR], 4.55; 95% CI, 1.95-10.62, P = 0.0004). Patients who required ≥ 2 units of PRBCs had a longer median hospital stay than those who did not receive ≥ 2 units of PRBCs (8 [5-10.1] vs 4 [3-5]; P < 0.0001). CONCLUSION AND RELEVANCE: Receiving SADs in the perioperative period is associated with a higher transfusion requirement in patients undergoing orthopedic surgery. Clinicians should be aware of this increased risk for patients who are taking SADs while undergoing surgical procedures.

An Evaluation of Interprofessional Patient Navigation Services in High Utilizers at a County Tertiary Teaching Health System.

EXECUTIVE SUMMARY: The Affordable Care Act holds health systems accountable for patient outcomes. Patients with low socioeconomic status are at highest risk of lacking a primary care provider, receiving lower quality of care, and being readmitted. These patients also have elevated risks of all-cause readmissions and death after discharge. The purpose of this study was to determine if an interprofessional patient navigation program (PNP) decreases emergency department (ED) visits and hospital admissions for these high utilizers of care, thus promoting the implementation of PNPs in other healthcare settings. We performed a retrospective, single-centered, chart review of patients who were enrolled in the PNP. We compared utilization, including ED visits and hospital admissions, for patients two years prior to enrollment to their utilization after enrollment. We found significant reductions in hospital utilization through patient navigation in the predominantly indigent, culturally diverse population of high utilizers of the healthcare system. In addition, our investigation of costs associated with implementing a PNP indicates the potential for cost avoidance.

A retrospective analysis of clinical acuity markers on hospital length of stay in patients with febrile neutropenia.

OBJECTIVE: The primary objective of this study was to identify factors that have predictive value in determining total hospital length of stay in patients with febrile neutropenia, particularly time to first antibiotic dose. METHODS: This study was a retrospective chart review analyzing patients admitted to a 443 bed tertiary county teaching hospital from 1 November 2010 through 1 November 2015. Patients were eligible for enrollment into the study if they met Infectious Diseases Society of America accepted criteria for febrile neutropenia. RESULTS: Ninety-three patients were included for analysis. Time to first antibiotic dose, first empirically appropriate antibiotic dose, and time to first isolate-appropriate antibiotic did not show a significant correlation to total hospital length of stay (p = 0.71, p = 0.342, and p = 0.77, respectively). Subject's Multinational Association for Supportive Care in Cancer and Simplified Acute Physiology II scores were significantly correlated with hospital lengths of stay (p = 0.0052, rs = -0.243 and p = 0.0001, rs = 0.344, respectively). Higher median (interquartile ranges) Simplified Acute Physiology II scores were also associated with hospital mortality [dead = 46 (34.8-51.7) vs. alive = 34 (28-43.3), p = 0.0173]. CONCLUSIONS: Measures of patient acuity, such as the Multinational Association for Supportive Care in Cancer and Simplified Acute Physiology II scores, did show a correlation to clinical outcomes in patients with febrile neutropenia. Timing of initial antibiotics between 2.32 and 6.27 hours after presentation in patients with febrile neutropenia did not correlate with clinical outcomes.

Ciprofloxacin vs. levofloxacin for prophylaxis in recipients of hematopoietic stem cell transplantation.

BACKGROUND: Infection is the most common cause of morbidity and mortality in patients undergoing myleosuppressive therapy with the risk of infection being heightened during the neutropenic phase. Fluoroquinolones are most often utilized as prophylaxis, specifically levofloxacin or ciprofloxacin; however, there is increasing resistance among these agents. The objective of this study is to compare the efficacy of ciprofloxacin and levofloxacin when used prophylactically in hematopoietic stem cell transplantation patients. STUDY DESIGN: A retrospective cohort study conducted at a 443-bed tertiary teaching county hospital from 1 January 2005 to 31 September 2016. METHODS: Patients aged 18-89 who were admitted and received levofloxacin or ciprofloxacin post hematopoietic stem cell transplantation were evaluated. RESULTS: The patient population (N = 151) was predominantly male (93 vs. 58) and the median (IQR) age was 57 (20.1) years. There were 108 patients undergoing autologous hematopoietic stem cell transplantation compared to 43 undergoing allogenic hematopoietic stem cell transplantation. Significantly fewer patients who received levofloxacin (11/43, 25.6%) developed neutropenic fever compared to patients who received ciprofloxacin (61/108, 56.5%, p = 0.0006). Also there were significantly more positive blood cultures in the ciprofloxacin group (36/108, 33.3%) compared to the levofloxacin group (4/43, 9.3%); the majority of which were Gram-positive organisms (p = 0.0025). CONCLUSION: Prophylaxis with levofloxacin was associated with a lower incidence of febrile neutropenia and bacteremia when compared to ciprofloxacin in hematopoietic stem cell transplantation patients.

Rate of patients at elevated risk of opioid overdose visiting the emergency department.

OBJECTIVE: To determine the rate of patients visiting the emergency department who are at risk of opioid overdose. METHODS: The electronic records of a 412 bed tertiary care county teaching hospital were searched for emergency department (ED) visits from January 1, 2013 to October 31, 2016 to find patients on at least 100mg morphine equivalents (MME) of oral opioid therapy, or an opioid in combination with a benzodiazepine. Records were also searched for patients with a positive urinalysis for opioids when no opioid was present on their home medication list. Medication reconciliations were searched for patients at risk of opioid overdose who were subsequently discharged on naloxone. RESULTS: An analysis of 2521 patients visiting the ED was performed, and the overall rate of risk of opioid overdose increased from 25.84% to 47.41% (p<0.0001) in patients meeting inclusion criteria from 2013 to 2016. For patients on opioids, the rate of patients on 100 MME daily or greater increased from 9.72% to 28.24% (p<0.0001) from 2013 to 2016. The rate of patients on opioid therapy in combination with benzodiazepine therapy did not change significantly from 2013 to 2016. When comparing patients at risk of opioid overdose to total emergency department visits, we found the rate of at risk patients increased significantly from 0.12% to 0.56% (p<0.0001) from 2013 to 2016. CONCLUSIONS: The rate of patients visiting the emergency department at risk of opioid overdose increased significantly from 2013 to 2016. Naloxone was not routinely prescribed to this patient cohort.

Risk of Bleeding in Patients on Full-Dose Enoxaparin With Venous Thromboembolism and Selective Serotonin Reuptake Inhibitors.

BACKGROUND: Selective serotonin reuptake inhibitors (SSRIs) are very commonly prescribed agents that are also potent antiplatelet agents. OBJECTIVE: This study was designed compare the rate of major bleeding events between patients who were treated with low-molecular-weight heparin (LMWH) for venous thromboembolism (VTE) on SSRIs and those not on chronic SSRI therapy. METHODS: This was a retrospective cohort study of 575 patients with a primary or secondary diagnosis of an acute VTE initiated on full-dose enoxaparin with or without an SSRI between October 1, 2009, and October 1, 2014, in a 443-bed, single tertiary care referral county teaching hospital. RESULTS: No significant difference was found in the incidence of major bleeding in the SSRI versus non-SSRI group (19.6% vs 17.0%, P = 0.548). Ad hoc analysis demonstrated an elevated risk of major bleeding in patients on escitalopram compared with those on any of the other SSRIs (46.2% vs 15.2%, P = 0.018). Multivariate analysis demonstrated that escitalopram use-OR (95% CI) = 18.85 (1.84-193.6)-was associated with increased major bleeding, and acid suppressive therapy-0.24 (0.07-0.90); P = 0.014-was associated with decreased major bleeding in patients reporting alcohol use. CONCLUSION: No difference was found in the incidence of major bleeding in patients on LMWH and SSRIs versus those on LMWH but not on SSRIs. However, ad hoc findings showed a significantly higher rate of major bleeding events in patients who received escitalopram and alcohol among patients on full-dose enoxaparin for VTE. These findings merit further exploration.

Acid Suppressive Therapy for Stress Ulcer Prophylaxis in Noncritically Ill Patients.

BACKGROUND: The current literature discourages the use of acid suppressive therapy (AST) for stress ulcer prophylaxis (SUP) in noncritically ill patients. However, several sources indicate that the majority of noncritically ill patients are given AST for SUP while there may only be a small proportion of high-risk patients who need SUP therapy. There is a new scoring system to aid practitioners in stratifying the risk of stress ulcer-related gastrointestinal bleeding in noncritically ill patients developed by Herzig et al and appropriately prescribe AST for SUP in this population. OBJECTIVE: Our primary objective was to determine the current usage of AST in noncritically ill patients at a tertiary teaching hospital and use the new scoring system to identify non-intensive care unit patients who were inappropriately given AST. METHODS: We retrospectively determined the percentage of noncritically ill patients who were given AST on medical floors between January 2010 and December 2012. After identifying these patients, we randomly selected a sample and retrospectively collected data from their medical record to determine the gastrointestinal bleeding risk score to determine if the patient was appropriately given AST. RESULTS: Of the 42 600 admissions, 22 949 (53.7%) noncritically ill patients were given AST. A total of 442 patients were randomly selected for data collection and 156 patients were excluded. Gastrointestinal bleeding risk score was calculated in 286 patients. This new risk stratification tool identified 253 (88.5%) patients to have a low (≤7) and low-medium risk score (8-9). CONCLUSIONS: A large percentage of noncritically ill patients were given AST during their hospital stay; 88.5% of these medications were given inappropriately to patients who were at extremely low risk of gastrointestinal bleeding. Using the above information and the AST prescribing patterns at our institution, we estimate a potential inpatient medication cost savings of $114 622 for the study period.

Timing and appropriateness of initial antibiotic therapy in newly presenting septic patients.

OBJECTIVE: To determine the effectiveness of antibiotic regimens and time to antibiotics in septic patients admitted to an intensive care unit from the emergency department. METHODS: A retrospective case-control study of patients with sepsis syndromes admitted from the emergency department between August 2010 and July 2011 was conducted. Standard demographic information, time frames for written antibiotic orders and administration, and information regarding site of culture, organisms identified, sensitivities, and antibiotic effectiveness were documented. RESULTS: Four hundred medical records were reviewed; 184 patients met the study inclusion criteria and were included in the final analysis. Simplified Acute Physiology Scores II and Sequential Organ Failure Assessment scores were 49 and 6, respectively, and overall in-hospital mortality was 20.7%. Patients with positive blood cultures had higher Simplified Acute Physiology Scores II scores (56.0 vs 46.0, P = .0125). Serum lactate levels were also significantly higher in the in-hospital mortality group (3.2 vs 2.1, P = .0068). Computerized physician order entry dramatically decreased the median times to the last appropriate antibiotic administration (3.183 hours vs 6.992 hours, P < .0001) but did not alter mortality (20.6% vs 20.8%). Appropriateness of empiric antibiotic regimens was similar between patients surviving and those who died during their hospital stay (63.5% vs 68.8%, P = .58). CONCLUSIONS: Median times to the first antibiotic administration and last needed appropriate antibiotic administration were less than 3 and 5 hours, respectively; these times were similar between patients who survived and those who died during their hospital stay. Patients with a serum lactate level higher than 2.5 mmol/L were associated with a 2.5-times increased risk of mortality.

Cholestatic jaundice as a result of combination designer supplement ingestion.

OBJECTIVE: To report a case of cholestatic jaundice as a result of combination herbal and designer supplement use. CASE SUMMARY: A 50-year-old Hispanic male presented to the hospital with a 1-week history of significant painless jaundice; total bilirubin on admission was 29.4 mg/dL. He reported use of both herbal (creatine and whey protein) and designer (Incredible Bulk and Spartan 45) supplements concurrently for approximately 2 months. Upon admission, all supplements were discontinued and multiple laboratory and diagnostic tests were ordered. On day 6 of his hospital admission, a liver biopsy was performed, the results of which indicated drug-induced hepa to toxicity. On day 9 he was discharged with prescriptions for ursodeoxycholic acid and hydroxyzine. Three months post hospital discharge, the patient continued to be supplement-free and bilirubin had decreased substantially. DISCUSSION: Anabolic-androgenic steroids are capable of causing hepatotoxicity, and multiple cases reported in the literature support this. A case report described hepato toxicity secondary to both creatine and whey protein consumption, and several reports have described liver damage secondary to designer supplement use. To our knowledge, this is the first case to describe hepatotoxicity as a result of combination herbal and designer supplement use. The Roussel Uclaf Causality Assess ment Method (RUCAM) score for drug-induced hepatotoxicity indicated a highly probable correlation between the use of combination supplements and cholestatic jaundice. CONCLUSIONS: Health care professionals need to be aware of complications associated with designer supplement use and should be able to identify patients who would benefit from education on herbal and designer supplement use.

An Evaluation of Nonacademic Predictors of Success in a Doctor of Pharmacy Program.

Objective. Pharmacy programs have struggled to predict who will be successful in their programs based solely on cognitive skills. The primary objective of this study was to determine which, if any, nonacademic factors are associated with on-time progression within the school of pharmacy curriculum.Methods. A survey was developed and offered to all Texas Tech University Health Sciences Center Jerry H. Hodge School of Pharmacy students in fall 2020. This survey included questions to collect demographic data and incorporated four validated questionnaires: the Grit-Grid, the Academic Pharmacy Resilience Scale (APRS-16), the Cohen Perceived Stress Scale (CPSS), and the Turkish Time Management Questionnaire (TTMQ).Results. Completed surveys were submitted by 213 students out of 569 (37.4% response rate). On-time progression rate was calculated separately for each class. Through binary logistic regression, we found that on-time progression was significantly associated with prepharmacy grade point average >3.20, high school Grit-Grid score >0.9, APRS-16 score >35, and CPSS score >34. Pharmacy College Admission Test (PCAT) composite scores and admissions committee rubric scores were not associated with on-time progression.Conclusion. Based on the results of this study, it may be reasonable to implement the Grit-Grid, APRS-16, and the CPSS in the admissions process to help determine the most appropriate candidates for our program or use them as screening tools for incoming students to identify who may be at academic risk. However, these factors need to be validated in pharmacy programs in other private and public universities before widespread adoption can be condoned.

A model to predict NAPLEX outcomes and identify students needing additional preparation.

INTRODUCTION: Studies have been conducted to identify factors that may predict North American Pharmacist Licensure Examination (NAPLEX) outcomes, but there is no proposed single or combination of predictors that can be implemented reliably in academia. We aimed to develop a NAPLEX outcomes predictive model that could be practical, measurable, and reliable. METHODS: The study cohort consisted of students who graduated from 2012 to 2016 who had taken NAPLEX and whose first-attempt examination scores were available to the school of pharmacy. Students were considered to have poor performance on NAPLEX if they received an overall score of less than or equal to 82. Linear and logistic regression analysis were utilized to identify independent predictors. RESULTS: Seventy of 433 (16.2%) students were identified as poor performers. Independent factors that were associated with a poor outcome on NAPLEX were: age >28 years at graduation, Pharmacy College Admission Test scaled score <74, High Risk Drug Knowledge Assessment score <90, third-year Pharmacy Curriculum Outcome Assessment scaled score <349, and grades of <74 in more than three courses. These predictors were utilized to stratify students into four risk groups: Low, Intermediate-1, Intermediate-2, and High. Mean NAPLEX scores for these groups were 106.4, 97.4, 87.1, and 75.1, respectively. CONCLUSIONS: The model can be used as a practical tool to identify students who are at risk for poor performance on NAPLEX. Four of the five predictors in the model could be generalizable to other schools of pharmacy.

Quality of care of a pharmacist-managed diabetes service compared to usual care in an indigent clinic.

BACKGROUND: This study evaluates the quality of care of a pharmacist-managed diabetes clinic focused on an indigent population and compares that quality of care to usual care in the same health care setting. METHODS: Two groups of subjects were evaluated by retrospective review of medical records. The experimental group (n = 47) consisted of patients whose care was facilitated by a clinical pharmacist (medication initiation and modification, laboratory and physical assessment) in addition to routine physician care. A control group (n = 45) consisted of patients not referred to the pharmacy service whose care was provided solely by a physician. Changes in glycemic, blood pressure, and lipid control were assessed as were use of specific medications. RESULTS: After an average of 1.8 years of follow-up, a larger reduction in hemoglobin A1C was observed in the experimental group (2.0%) compared to the control group (1.2%), but the difference was not statistically different. Both groups experienced significant improvements in blood pressure control with a higher absolute increase from baseline in the experimental group compared to the control group (34% vs. 22% respectively, P < 0.001). Low-density lipoprotein-cholesterol levels in the control group fell by 2 mg/dL, while a 29 mg/dL reduction was observed in the experimental group (P < 0.001). While aspirin, angiotensin-converting enzyme inhibitor, and angiotensin receptor blocker therapies were not different between the two groups, statin therapy was significantly improved in the experimental group (from 23% to 68%) compared to the control group (from 33% to 44%) (P = 0.038). CONCLUSIONS: Many key diabetes quality of care outcomes in an indigent population were significantly improved in patients whose diabetes management was facilitated by a clinical pharmacist.

Evaluation of diabetes primary care and effects on health care charges in elderly patients with diabeties.

BACKGROUND: This study assessed diabetes out-patient care at a single institution in Medicare patients with significant health care expenditures and correlated the control of these patients with hospital admission rates and charges. METHODS: A retrospective review was performed at a university health sciences center's clinics and affiliated hospital. Medicare patients with Type 2 diabetes, >65 years, and hospitalized >1 in the past year with annual incurred Medicare charges of >$6,000 were included in the study. Data collected over a year period included: hospitalization and emergency department use and charges, and key out-patient diabetes-related quality of care outcomes. These outcomes were compared with national benchmark National Health and Nutrition Examination Survey (NHANES) data. RESULTS: Ninety-three patients were identified (median age of 72). More patients were at goal hemoglobin A1c, low-density lipoprotein cholesterol, and blood pressure than benchmark National Health and Nutrition Examination Survey data. There was a significant correlation between HbA1c and diabetes-related and all cause hospitalizations and ER visits per patient (P < 0.025) and diabetes-related charges (P = 0.0291). There were no differences between an endocrinologist and general practitioners in the quality of care except for documented microalbuminuria and aspirin use. CONCLUSIONS: Diabetes care at this institution was better than national benchmark data. HbA1c correlated with diabetes-related hospitalizations, all-cause combined hospitalizations and emergency department visits and charges. There were no major differences in the care of patients between the endocrinologist and general practitioners.

Evaluation of Factors which Influence Mortality in Gram-positive Bacteremia in Hemodialysis Patients.

Vascular access infection is one of the major contributors to hemodialysis (HD) patient morbidity and mortality. There is a paucity of consensus guidelines on vancomycin use in the HD population. The primary objective of this study was to determine if vancomycin serum concentrations were associated with positive outcomes in HD patients with Gram-positive bacteremia. A retrospective cohort study conducted at a 443-bed tertiary teaching county hospital from January 1, 2010 to January 1, 2016 was performed. Patients aged 18-89, with chronic renal failure on hemodialysis who presented with positive blood cultures with Gram-positive bacteria and received intravenous vancomycin for at least 24 hours were evaluated. A multivariate analysis was utilized comparing factors related to outcomes including Simplified Acute Physiology Score II (SAPS II), loading dose, 30-day mortality and vancomycin serum concentrations. A total of 139 patients were obtained, 90 of whom had documented pre-dialysis serum vancomycin concentrations. A multivariate analysis showed that a lower SAPS II score [OR 1.220 (95% CI: 1.086-1.370, p < 0.0001)], a higher loading dose/kg [OR 0.7911 (0.6302-0.9929, p = 0.0239)], and pre-dialysis concentrations between 15 and 20 mcg/mL [0.05437 (95% CI: 0.0033-0.8891, p = 0.0099)] were associated with decreased mortality (overall multivariate model, p < 0.0001). When patient acuity and loading dosing are taken into account, pre-dialysis vancomycin serum concentrations between 15 and 20 mcg/mL were associated with decreased mortality in Gram-positive bacteremic intermittent HD patients. Further prospective studies are needed to assess whether targeting a pre-dialysis serum vancomycin concentration of 15-20 mcg/mL can improve mortality.

Assessment of a didactic ambulatory care pharmacy elective on student perceptions and subsequent performance in an ambulatory care advanced pharmacy practice experience.

INTRODUCTION: This study assessed student perception in treating chronic disease states before and after taking an ambulatory care didactic elective and the impact on performance within a fourth-year ambulatory care advanced pharmacy practice experience (APPE). METHODS: Assessment of student perceptions was evaluated in students taking the Fall 2016 and Spring 2017 elective offering by completing an 11-item electronic survey prior to the first lecture of the course and after the last lecture of the course. A retrospective assessment of student performance in the APPE compared students that had taken the elective to those that had not over a two-and-one-half year period. Data collected included the students' final APPE experiential and required examination grade. RESULTS: In all but one survey question, student perceptions significantly improved upon completion of the elective. Student ambulatory care APPE final experiential grades were higher in students who had taken the elective compared to those that had not (90.3% vs. 88.9%, respectively, p = 0.04) as were APPE examination scores (78.0% vs. 74.0%, respectively, p = 0.01). DISCUSSION AND CONCLUSIONS: Student perception in key ambulatory care concepts, disease states, and drug knowledge improved after taking the ambulatory care elective. Student ambulatory care APPE performance was also mildly improved as a result of taking the elective compared to those who did not take the course. This is the first study to evaluate subsequent performance in an APPE as a result of taking an elective ambulatory care course and can serve as a template for other research in elective assessment.

Acetaminophen usage patterns and concentrations of glutathione and gamma-glutamyl transferase in alcoholic subjects.

STUDY OBJECTIVES: To determine if subjects with chronic alcoholism are predisposed to acetaminophen-induced hepatotoxicity, and to determine the contributing factors. DESIGN: Prospective cohort study. SETTING: Community-based crisis intervention center. SUBJECTS: One hundred eighty-eight subjects who answered "yes" to at least one of the four questions on the CAGE (Cut down-Annoyed-Guilty-Eye-opener) questionnaire for identifying alcoholism, and 10 healthy volunteers (controls). INTERVENTION: A history, physical examination, urine toxicologic analysis, ethanol and drug therapy history, and venous blood samples were collected on all subjects. MEASUREMENTS AND MAIN RESULTS: Venous blood was analyzed for a liver profile, prothrombin time, and total and oxidized glutathione concentrations. A significantly higher proportion of daily drinkers were regular daily users (29.2% [45/154] vs 11.8% [4/34], p=0.0497) as well as abusers (35.7% [55/154] vs 14.7% [5/34], p=0.0237) of acetaminophen compared with non daily drinkers. Alcoholic subjects with elevated gamma-glutamyl transferase (GGT >or= 51 U/L) levels had significantly lower median plasma glutathione concentrations (2.33 micromol/L, 95% confidence interval [CI] 1.74-2.69 micromol/L) compared with those of alcoholic subjects with normal GGT concentrations (5.97 micromol/L, 95% CI 4.39-7.03 micromol/L, p<0.0001) and healthy volunteers (6.59 micromol/L, 95% CI 4.79-9.65 micromol/L, p=0.0002). A significant inverse correlation was also noted between the GGT concentration and the plasma total glutathione concentration (r = -0.62, p<0.0001). None of the 188 subjects met all preset criteria for hepatotoxicity. CONCLUSIONS: Daily drinkers were more than twice as likely as non daily drinkers to be regular daily acetaminophen users and abusers. Alcoholic subjects with elevated GGT concentrations had significantly lower plasma total glutathione concentrations, and plasma total glutathione concentrations inversely correlated with GGT concentrations. Elevated GGT concentrations may be a clinical marker of depleted glutathione in alcoholic subjects. Acetaminophen-induced hepatotoxicity appears to be uncommon in alcoholic subjects, despite the 31.9% (60/188 patients) who took doses that are potentially hepatotoxic.

Propoxyphene prescribing among populations older and younger than age 65 in a tertiary care hospital.

OBJECTIVE: To evaluate the proportion of patients aged 65 years and older who are prescribed propoxyphene (PP) versus those aged 65 and younger. DESIGN: Retrospective cross-sectional study. SETTING: Tertiary care facility. PARTICIPANTS: Adult patients admitted to the hospital between January 1, 2005, and June 30, 2005, and prescribed either hydrocodone (HC) or PP. MAIN OUTCOME MEASURE: The primary outcome measure was the proportion of PP orders prescribed for patients older versus younger than age 65. The secondary outcomes were to identify other variables occurring in higher proportions among patients who were prescribed PP versus HC. RESULTS: Of the 7,910 patients reviewed, 7,295 patients 92.2% were prescribed HC and 615 (7.8%) were prescribed PP. In a random sample of 1,065 patients, the prescribing pattern of PP for subjects > or =65 (221/615, 35.9%), was significantly higher than for HC (128/450, 28.4%), P = 0.0122. In a random selection of the larger sample, there were 44/108 (40.7%) in the PP group and 22/120 subjects (18.3%) > or =65 in the HC group (P = 0.0003). Among PP users, there was a higher percentage of females (P = 0.0150), more subjects with narcotic allergies (P < 0.0001), and more subjects with a history of fractures (P = 0.0232). CONCLUSIONS: Compared with nationally reported data, the rate of PP prescribing is relatively low. However, despite the recommendation to avoid the use of PP in elderly patients, its use occurs in a higher proportion of patients age 65 years or older than in younger patients. Studies evaluating the prescribing rates of potentially inappropriate medications should be put in context by comparing reported data with that of a younger cohort.

Lack of effect on coronary atherosclerotic disease biomarkers with modest dosing of an angiotensin-converting enzyme inhibitor, angiotensin II type-1 receptor blocker, and the combination.

BACKGROUND: Angiotensin-converting enzyme inhibitors and angiotensin II type 1 receptor blockers, used alone or in combination, have been shown to improve outcomes in certain populations, primarily when administered in high doses. For stable coronary atherosclerotic disease, however, the relative physiologic effect of these therapies is unclear. Furthermore, because of the notorious subtarget dosing of such agents in clinical practice, we explored the influence of a modest dosing of an angiotensin-converting enzyme inhibitor, angiotensin II type 1 receptor blockers, and the combination on common biologic markers of coronary atherosclerotic disease. METHODS: This randomized, cross-over study enrolled stable coronary atherosclerotic disease patients (n=20), each receiving three treatments: candesartan 16 mg daily, ramipril 5 mg daily, and candesartan 8 mg plus ramipril 2.5 mg daily. Treatments were administered for 2 weeks with a 2-week washout. Blood samples were collected before and after each treatment. Markers of endothelial function, fibrinolytic balance, and vascular inflammation were measured. RESULTS: No significant differences were observed in the pretreatment concentrations of angiotensin-converting enzyme or of any measured biologic marker. Relative to pretreatment levels, candesartan alone was the only therapy to exhibit an action on any measured biomarker--a trend toward increased nitric oxide concentrations (P=0.054). Otherwise, no effects on biologic markers were observed with the treatments. CONCLUSION: This study of various methods of the renin-angiotensin system inhibition in stable coronary atherosclerotic disease patients demonstrates negligible effects of a modest dosing of ramipril and the combination of ramipril plus candesartan on common biologic markers of coronary atherosclerotic disease. Candesartan at modest doses may favorably influence endothelial function. Overall, however, the results indicate that the commonly practiced subtarget dosing of such treatments provides little, if any, benefit pertaining to key physiologic components of coronary atherosclerotic disease.

Clinical Impact of Discordant Prescribing of Fluoroquinolones and Alternative Treatments in Escherichia coli Pyelonephritis.

INTRODUCTION: The emergence of resistant Escherichia coli to fluoroquinolones (FQs) is of growing concern, yet the latest guidelines for the treatment of pyelonephritis still recommend FQs as first-line treatment. Our primary objective was to determine the impact of discordant prescribing of FQs in E coli pyelonephritis on hospital length of stay (LOS) and early clinical response (ECR). METHODS: We retrospectively compared discordant and concordant prescribing of FQs for LOS and ECR. We also compared FQs, ceftriaxone, piperacillin/tazobactam, and carbapenems for these clinical outcomes. RESULTS: Forty-nine patients included in the comparison between discordant (n = 9) and concordant (n = 40) prescribing of FQs. There was significantly lower ECR in patients with discordant prescribing of FQs (38 of 40, 95% vs 5 of 9, 55.6%, P = .0074) and a trend toward longer LOS (4 [2.3] days vs 3 [2.0] days, P = .0571). Illness severity, estimated using Simplified Acute Physiology Score (SAPS II) score, was similar between groups (P = .717). CONCLUSION: There was a significantly decreased ECR and a trend toward increased LOS when FQs were used in FQ-resistant E coli. Regarding alternative treatment for E coli pyelonephritis, ceftriaxone was as effective as concordant FQs and significantly better than discordant FQs.

Unrecognized Interstitial Lung Disease as a Result of Chronic Nitrofurantoin Use.

Drug-induced interstitial lung disease is a rare condition attributed to several medications, including antimicrobial agents such as amphotericin B, anti-inflammatory agents such as methotrexate, biologic agents such as bevacizumab, and cardiovascular agents and chemotherapeutic agents. We describe the case of a 73-year-old female who developed interstitial lung disease following chronic use of nitrofurantoin for a urinary tract infection (UTI). The patient was taking nitrofurantoin 100 mg capsules twice daily for approximately 3 years. She presented to the hospital with complaints of a persistent dry cough that started 2 years previously. Her chest radiograph revealed bilateral reticular opacities and some atelectasis. Computed tomography of the chest demonstrated development of subpleural reticular opacities with minimal honeycombing. The patient had a severe restrictive defect on her pulmonary function tests, with a significant reduction in her carbon monoxide diffusion capacity. Multiple infectious disease and autoimmune tests were negative. Utilizing the algorithm of Naranjo (score of 9), it was determined that chronic use of nitrofurantoin was the definite cause of the patient's interstitial lung disease. Nitrofurantoin was discontinued and she was treated with oxygen and started on an oral steroid, both of which were continued permanently once discharged. Upon discharge, the patient was maintained on 5 L of oxygen at rest and 10 L of oxygen when ambulating. Unfortunately, her lung disease ultimately resulted in her demise several months after her diagnosis. This case report illustrates the importance of rapid recognition of drug-induced lung injuries and discontinuation of the offending agent.