Use of neutrophil to lymphocyte ratio for predicting histopathological grade of canine mast cell tumours.

Canine mast cell tumours (MCTs) are variable in their biological behaviour and treatment decisions depend heavily on the histopathological grade. Biomarkers such as neutrophil to lymphocyte ratio (NLR) and albumin to globulin ratio are used to predict the biological behaviour of human neoplasms, but have not been widely studied in dogs. A retrospective analysis identified 62 cases of gross MCT (14 high-grade, 48 low-grade tumours). Median NLR was significantly different between high- and low-grade MCT and tumours at different locations. A multivariable model identified increasing NLR (OR 2.0) and age (OR 1.7) to be associated with an increased risk of high-grade MCT. Receiver operating characteristic curve analysis identified an NLR threshold value of 5.67 (sensitivity 85.7 per cent; specificity 54.2 per cent) for predicting a high-grade MCT. An NLR threshold of 5.67 could be useful alongside existing tools (appearance, location, etc.) to help to predict the grade of MCT. With further validation, this biomarker could be used to guide clinical decisions before obtaining a histopathological diagnosis.

Survey of clinical pharmacists' knowledge of appropriateness of antimicrobial therapy for upper respiratory infections and acute bronchitis.

We conducted a survey to assess clinical pharmacists' recommendation of antibiotics for upper respiratory infections (URIs) and acute bronchitis. A random sample of 752 members of the American College of Clinical Pharmacy were mailed a multiple-choice survey that presented four examples consistent with clinical symptoms of the two disorders. Respondents were asked what treatment they would recommend for each example. The response rate was 59%. Pharmacists recommended antibiotics for the treatment of both URIs and acute bronchitis significantly more if patients' symptoms included discolored discharge or sputum as opposed to clear discharge. Those who were board certified were less likely than nonboard-certified pharmacists to recommend antibiotics for URIs with discolored discharge. Pharmacists who specialized in either ambulatory care or infectious disease were less likely than those in other specialties to recommend antibiotics for acute bronchitis with discolored sputum. Clinical pharmacists are similar to patients and physicians in their belief that antibiotics are appropriate for URIs and acute bronchitis with discolored discharge. Considering the role that pharmacists play as clinical consultants to physicians, greater efforts should be made to educate them regarding appropriate prescription of antibiotics.

Medication cost information in a computer-based patient record system. Impact on prescribing in a family medicine clinical practice.

BACKGROUND: Medications account for 8% of national health care expenditures, and prescription drugs are a focus of cost containment measures. Physicians have limited knowledge about drug costs, and no method of providing this information has demonstrated sustained cost reductions. OBJECTIVE: To determine the impact of cost information in a computer-based patient record system on prescribing by family physicians. METHODS: A yearlong, controlled clinical trial was conducted at the Family Medicine Center, Medical University of South Carolina, Charleston, a group practice staffed by attending physicians and residents. Prescription cost information was included in the computer-based patient record system used at the center. During a 6-month period, cost information was not displayed; during the subsequent 6-month intervention period, costs were displayed at the time of prescribing. An intention-to-treat analysis was used to compare prescription costs between the control and intervention periods for all medications prescribed, and stratified analyses for several medication and physician factors were performed. RESULTS: A total of 22,883 prescriptions were written during the 1-year study period. The mean +/- SD cost per prescription in the control period was $21.83 +/- $27.00 (range, $0.01-$510.00), and in the intervention period was $22.03 +/- $28.12 (range, $0.01-$435.96) (P = .61, Student t test). Increases in mean prescription cost and proportion of total costs were identified in 4 medication classes: antibiotics, cardiovascular agents, headache therapies, and antithrombotic agents. Decreases in mean prescription cost and proportion of total costs were identified in 5 medication classes: nonsteroidal anti-inflammatory drugs, histamine type 2-receptor antagonists and proton pump inhibitors, ophthalmic preparations, vaginal preparations, and otic preparations. CONCLUSIONS: In this setting, the provision of real-time computerized drug cost information did not affect overall prescription drug costs to patients, although differences in individual medication classes were observed. The negative results of this study may reflect confounding due to the use of historical controls, suboptimal timing of the intervention in the prescribing process, susceptibility bias at the study site, or the insensitivity of prescribing habits to cost information.

Enhanced metabolism of levonorgestrel during phenobarbital treatment and resultant pregnancy.

Levonorgestrel implants (Norplant) are an alternative to oral contraceptives and medroxyprogesterone acetate intramuscular injections. An interaction may exist between levonorgestrel and agents that induce the hepatic microsomal enzyme system. A 21-year-old woman with a history of a seizure disorder, treated with phenobarbital, who received levonorgestrel implants became pregnant. After a normal delivery, she took oral contraceptives concomitantly with phenobarbital. Although she was educated about the importance of a backup method of contraception, the woman again became pregnant and delivered twins. A recent national survey of neurologists and obstetricians was conducted evaluating prescriber knowledge of interactions between oral contraceptives and anticonvulsants. Only 4% of neurologists and zero percent of obstetricians knew all the interactions between the six most commonly prescribed anticonvulsants and oral contraceptives. This case supports the importance of continued patient and prescriber education regarding the possibility of drug-drug interactions in women taking anticonvulsants and hormonal contraceptives.

An interdisciplinary effort to help patients with limited prescription drug benefits afford their medication.

BACKGROUND: Patients without prescription benefits present a significant challenge to health care providers. The inability of patients to afford medication may serve as a barrier to adherence and may ultimately result in poor patient outcomes. In this report, we describe the system used at a university-based adult internal medicine center to assist patients in affording medication. METHODS: Patients in need of prescription assistance are identified by any member of the interdisciplinary team, which consists of physicians, clinical pharmacists, nurses, a social worker, a financial counselor, and a dietitian. Medication profiles are reviewed to identify less expensive alternatives. State, federal, institutional, and pharmaceutical company assistance program eligibility is determined, and the appropriate program is accessed. RESULTS: The described approach is effective in assisting patients without prescription benefits with the procurement of medication. CONCLUSION: Use of this interdisciplinary approach is an innovative solution to a common problem encountered in the outpatient setting.

Concerns regarding universal varicella immunization. Time will tell.

The American Academy of Pediatrics, the Advisory Committee on Immunization Practices, and the American Academy of Family Physicians now recommend universal immunization for varicella for all susceptible children and adolescents. Although the varicella vaccine appears safe and efficacious, it is unknown how universal immunization will influence the epidemiology of varicella infections. The duration of immunity, both conferred and passive reinoculation, remains a concern and must continue to be evaluated in the population of vaccinees. As universal immunization is implemented, the cost-effectiveness of such a program will need to be evaluated. Physicians and parents must be educated about the risks and benefits of vaccination vs natural infection.

NSAIDs, antihypertensive agents and loss of blood pressure control.

It is common for patients seen by primary care physicians to be taking both nonsteroidal anti-inflammatory drugs (NSAIDs) and antihypertensive agents. If blood pressure control diminishes in these patients, the physician must evaluate the potential interaction between the two classes of medication. Although the increase in blood pressure secondary to NSAID use may be only 5 to 10 mm Hg, this increase may be enough to justify a change in medication. For this reason, it is important to evaluate the interaction between the two types of drugs and determine its clinical significance in specific patients.