Health care outcomes case study: anemia in end-stage renal disease.

Outcomes goals in managing anemia in end-stage renal disease (ESRD) with epoetin alfa and other therapies are illustrated with a case study. Anemia is common in patients with ESRD undergoing hemodialysis; the cause is primarily a reduction in the secretion of erythropoietin. Multiple coexisting factors, such as iron deficiency and blood loss, also contribute. Outcomes goals include decreasing blood transfusions, increasing physical performance, improving cardiovascular and cognitive function, enhancing overall well-being, and achieving self-sufficiency. The potential to achieve these goals has been linked to the attainment of an optima, hematocrit and hemoglobin concentration with epoetin alfa therapy. Once epoetin alfa is begun, safety and effectiveness should be monitored and attainment of outcomes goals assessed. Supplemental iron, folate, and cyanocobalamin may be necessary, as may management of the underlying inflammatory process. The pharmacist can help optimize outcomes by conducting drug-use evaluations, monitoring laboratory test values and drug dosages, assessing drug effectiveness, and counseling patients. A case study of a 67-year-old woman with diabetes mellitus and ESRD who was placed on hemodialysis is presented as an example of how the pharmacist can help optimize outcomes. Opportunities for pharmacists in outcomes management in patients with ESRD-associated anemia include monitoring epoetin alfa therapy, counseling patients, and working with the renal team.

Current concepts in clinical therapeutics: Parkinson's disease.

The etiology, pathophysiology, diagnosis and clinical presentation, and clinical management of Parkinson's disease are reviewed. The cause of Parkinson's disease, a progressive, degenerative neurologic motor disorder, is unknown. Both endogenous and environmental factors appear to play a role. The clinical features of parkinsonism result from a depletion in dopaminergic transmission in the corpus striatum; the dopamine deficiency is caused by a loss of melanin-containing nerve cells within the substantia nigra and locus ceruleus. In the remaining neurons, hyalin-like masses called Lewy bodies increase in number, but the importance of this is unclear. The diagnosis of Parkinson's disease is based on the clinical presentation of the patient, which initially includes sensory complaints of aching pains, paresthesias, numbness, and coldness. As the disease progresses, the four classic symptoms become prominent: tremor, rigidity, bradykinesia, and postural difficulties. Drug therapy is the cornerstone of clinical management of Parkinson's disease, but no treatment has been found that will retard or reverse the disease. Therapy is usually initiated with anticholinergic agents such as biperiden hydrochloride or trihexyphenidyl hydrochloride with or without amantadine. The mainstay of therapy is levodopa, which is used in combination with dopa decarboxylase inhibitors to decrease the peripheral conversion of levodopa to dopamine. Bromocriptine is a dopamine agonist useful in treating Parkinson's disease. Therapy, which must continue for life, eventually becomes less effective or completely ineffective in all patients. Drug therapy has improved greatly the functional ability of patients with Parkinson's disease, but new agents that can extend the length of effective treatment or reverse the disease are needed.

Vancomycin intermediate-resistant Staphylococcus aureus.

OBJECTIVE: To describe further details about the third reported case of vancomycin intermediate-resistant Staphylococcus aureus (VISA). CASE SUMMARY: A patient with a history of recurrent methicillin-resistant S. aureus (MRSA) bacteremia was treated with several courses of vancomycin for 18 of 23 possible weeks on an inpatient/outpatient basis. After 6 months of repeated courses, an isolate of MRSA showed a minimum inhibitory concentration of 8 micrograms/mL, indicating intermediate resistance to vancomycin. The patient continued to receive a vancomycin/aminoglycoside/rifampin regimen and, when he was hospitalized several weeks later, no further MRSA or VISA was detected. DISCUSSION: Prolonged, intermittent vancomycin use (18 of 23 possible weeks) for MRSA bacteremia on an inpatient/outpatient basis most likely contributed to the development of VISA. Infection control measures prevented the spread of VISA among patients and healthcare workers. CONCLUSIONS: Infection control measures and evaluation of antimicrobial prescribing need to be strongly enforced to further prevent the spread and development of resistant organisms.

Treatment of radiation-induced proctitis with sucralfate enemas.

OBJECTIVE: To report a case of radiation-induced proctitis treated with sucralfate enemas. CASE SUMMARY: A 77-year-old white woman was transferred from an acute care institution to our inpatient rehabilitation unit with impaired mobility and reduced activities of daily living. Her condition was secondary to myopathy and peripheral neuropathy associated with postradiation chemotherapy and metastatic ovarian carcinoma. During her stay, she developed hematochezia and pain secondary to a diagnosis of radiation-induced proctitis. Her hemoglobin had reached a nadir of 7.3 g/dL. The patient received blood transfusions and was started on 10% w/v sucralfate retention enemas 2 g/20 mL daily for 12 consecutive days. She was symptom-free at discharge, with a stable hemoglobin of approximately 10 g/dL. DISCUSSION: Proctitis is a common adverse effect of radiotherapy to the lower abdomen and pelvic area. Sucralfate is an aluminum complex that acts as a local cytoprotective agent against ulceration of the gastrointestinal mucosal lining. Rectal administration of sucralfate, as described in our patient and reported in published case studies, may provide an alternative therapy for patients with radiation-induced proctitis. CONCLUSIONS: Sucralfate suspension enemas provide a viable treatment option in patients who are intolerant of, refractory to, or not candidates for standard therapy for radiation-induced proctitis.