Antifungal prophylaxis in chemotherapy-associated neutropenia: a retrospective, observational study.

BACKGROUND: In August 2002, the antifungal prophylaxis algorithm for neutropenic hematology/oncology (NHO) patients at the Medical Center was changed from conventional amphotericin (AMB) to an azole (AZ) based regimen (fluconazole [FLU] in low-risk and voriconazole [VOR] in high-risk patients). The aim of our study was to compare outcomes associated with the two regimens, including breakthrough fungal infection, adverse drug events, and costs. METHODS: Adult, non-febrile, NHO patients who received prophylactic AMB from 01 August 2001-30 July 2002 or AZ from 01 August 2002-30 July 2003 were retrospectively evaluated. RESULTS: A total of 370 patients (AMB: n = 181; AZ: n = 216) associated with 580 hospitalizations (AMB: n = 259; AZ: n = 321) were included. The incidence of probable/definite breakthrough Aspergillus infections was similar among regimens (AMB: 1.9% vs AZ: 0.6%; p=0.19). A greater incidence of mild/moderate (24.7% vs. 5.3%; p < 0.0001) and severe renal dysfunction (13.5% vs. 4.4%; p < 0.0012) was observed with AMB. In contrast, patients treated with VOR were found to have an increased rate of severe hepatic toxicity (32.5%) compared with patients treated with either AMB (22.6%) or FLU (21.4%) (p = 0.05). While the AZ period was associated with a >$9,000 increase in mean total costs/hospitalization, the mean acquisition cost associated with AZ was only $947/hospitalization more than AMB. CONCLUSION: While an AZ-based regimen is associated with increased cost, the reduced rate of nephrotoxicity and availability of oral dosage forms, suggests that azoles be used preferentially over AMB. However, an increased rate of severe hepatic toxicity may be associated with VOR.

Assessing the utility of a community pharmacy refill record as a measure of adherence and viral load response in patients infected with human immunodeficiency virus.

STUDY OBJECTIVE: To assess the utility of a community pharmacy refill record as a measure of adherence to antiretroviral agents and as a predictor of viral load response. DESIGN: Retrospective review of laboratory and community pharmacy records. SETTING: University-based human immunodeficiency virus (HIV) clinic and local community pharmacy. PATIENTS: Ninety-four patients with HIV or the acquired immunodeficiency syndrome (AIDS) who visited both settings and had retrievable pharmacy and laboratory records. MEASUREMENTS AND MAIN RESULTS: Community pharmacy records were compiled and screened for antiretroviral agent refill histories. The continuous, multiple-interval measure of medication gaps (CMG), a measure of drug nonadherence, was calculated for each antiretroviral agent. Viral load information was retrieved from the clinic records of patients who had a community pharmacy refill record documenting the previous 2 years. As refill nonadherence increased, viral load response increased, following an approximately sigmoid relationship. When the CMG score was less than 0.10, the viral load response did not change appreciably. The steepest rise in viral load response occurred with a CMG score ranging from 0.10-0.19. For values of 0.20 or greater, the viral load response was less sensitive to adherence performance. The probability (i.e., sensitivity) of having at least a 10% nonadherence record given a viral load greater than 1000 copies/ml was 80%. CONCLUSION: The community pharmacy refill record is a convenient, accessible, and useful tool for assessing adherence and predicting viral load outcomes in patients with HIV and AIDS.

Using correspondence analysis in pharmacy practice.

Correspondence analysis (CA) and some of its uses in pharmacy practice are described. CA is a multivariate and graphic form of exploratory data analysis that reduces a multidimensional contingency table to a two-dimensional plot with minimal loss of information. An exploratory association between medication use and the number and severity of falls among the elderly living at home is used to illustrate the process of CA. Row profiles are constructed by dividing the count data in each cell by the total of the corresponding row, converting frequency data into relative frequencies. A graph of the data can be made by recalculating the frequencies to illustrate how the data might appear in a three-dimensional space with the axes defined by the three categories of falling (minimum, moderate, and major). For example, the number of patients using central nervous system (CNS) agents is plotted using the relative frequencies as vectors to locate a position in the three-dimensional space. All drug profiles and the average profile will lie exactly in a triangular plane defined by the terminal points of each axis. In this manner, data with three dimensions can be projected onto a two-dimensional space. Transferring the vectors named by pharmacologic class onto the plot requires creating two axes that cross at a common point or the origin. This point locates the average profile and defines an important reference for making comparisons. CA revealed that CNS agents may be associated with moderate to major falls, psychotherapeutic agents with moderate falls, and anticoagulants with moderate to minimum falls. CA has widespread uses in pharmacy practice. It can identify patients at risk for serious but preventable drug-related complications, enabling pharmacists to allocate pharmacy resources to the areas in most need and suggest hypotheses for future research. Clinicians can also use CA to analyze vast amounts of patient-related data to uncover hard-to-detect associations. The use of CA in pharmacy practice will allow new strategies for improved patient care to be more readily appreciated and implemented.

Exploring the prevalence of Ayurveda use among Asian Indians.

OBJECTIVE: Despite a growing body of literature on complementary and alternative medicine, there is still limited information on the use of Ayurveda in the United States. Because Ayurveda is one of the world's major traditional medical systems, knowledge of its use is important. In particular, information on utilization by Asian Indians living in the United States is needed due to increased immigration from India and related regions. Recent reports of heavy metal contamination of some imported Ayurveda products underscore this need. For this reason, an exploratory survey was conducted. DESIGN: A semistructured 21-item questionnaire was administered using face-to-face interviews. PARTICIPANTS AND SETTING: The study comprised a convenience sample of 64 Asian Indians living in Northern California. OUTCOME MEASURES: Main outcome measures included sociodemographic variables, questions on awareness, knowledge and use of Ayurvedic products or services, use of other nutritional/herbal products, and reasons for use. RESULTS: In the sample, 95% of the participants were aware of Ayurveda, 78% had knowledge of Ayurvedic products or treatments, and about 59% had used or were currently using Ayurveda. Only 18% of those using Ayurveda had informed their Western medical doctors. CONCLUSIONS: Given its common use in the United States by Asian Indians, its cultural relevance, potential therapeutic value, and possible safety concerns, physician and consumer education along with more empirical research is warranted.

Factors associated with uncontrolled hypertension in an affluent, elderly population.

OBJECTIVE: To explore demographic, economic, and treatment-related associations with uncontrolled hypertension in a relatively affluent, community-dwelling population. METHODS: Two home surveys of 655 and 432 subjects with a diagnosis of hypertension were completed in 1995 and 1999, respectively. Trained surveyors recorded medication history plus demographic and socioeconomic variables, as well as several measurements of blood pressure in the home. Uncontrolled hypertension was defined according to guidelines set forth by the Sixth Report of the Joint National Committee on prevention, detection, evaluation, and treatment of high blood pressure. Odds ratios for observing an elevated blood pressure given the patients' medication history, income, insurance coverage, demographic variables, and concomitant disease were estimated using multivariable logistic regression. RESULTS: On both occasions, >60% of the study population had an average blood pressure that was above recommended levels. Diuretic therapy alone (1995 survey) or in combination with an angiotensin-converting enzyme inhibitor (1999 survey) decreased the odds ratio for uncontrolled hypertension by 39% (p = 0.027) and 62% (p = 0.005), respectively. Lack of prescription drug insurance and a history of arthritis had negative effects, increasing the odds ratio for uncontrolled hypertension by more than twofold (p < 0.05). CONCLUSIONS: Uncontrolled hypertension occurs commonly among elderly patients notwithstanding a relatively high standard of living. The choice of medication, presence of concomitant disease, and availability of insurance may be important factors influencing blood pressure control.