Impact of joint consultation by a clinical pharmacist and a clinical geriatrician to improve inappropriate prescribing for elderly patients.

OBJECTIVE: Appropriate prescribing is a key quality element in medication safety. It is unclear if therapeutic interventions resulting from medication review lead to clinically relevant improvements. The effect of medication review on prescribing appropriateness was evaluated in the setting of an outpatient consultation team, consisting of a clinical pharmacist and a clinical geriatrician, in a large non-academic teaching hospital in the Netherlands. METHOD: A group of 49 elderly patients with polypharmacy was included after referral by their general practitioner for drug related problems. After a regular assessment by a clinical geriatrician and medication record review by a clinical pharmacist, a treatment plan was implemented based on the recommended interventions. The main outcome measure was the change in the Medication Appropriateness Index (MAI) before and 3 months after primary consultation. RESULTS: Overall 82% of the recommended interventions of the pharmacist were implemented by the geriatrician of which 63% persisted up to the last visit. Per patient an average of 6.6 interventions were carried out. The interventions showed a reduction of the MAI per patient of 50%. The number of drugs per patient was reduced from 12.1 to 11.0. The number of medications listed on the Beers list decreased from 2.3 to 1.5 and the number of drugs listed on the Hospital Admissions Related to Medication (HARM) Trigger list decreased from 2.1 to 1.5. CONCLUSIONS: Interventions from a multidisciplinary outpatient consultation team were effective in improving appropriate prescribing in elderly outpatients with polypharmacy.

Performance of Abusign drugs-of-abuse slide tests with particluar emphasis on concentrations near the cutoff: comparison with FPIA-ADx and confirmation of results with GC-MS.

The objective of the present study was to evaluate the performance of Abusign test slides in comparison with fluorescence polarization immunoassay (FPIA)-ADx and gas chromatography-mass spectrometry (GC-MS) confirmation with special emphasis on concentrations near the cutoff. Analysis was performed on 35 individual slide tests for cocaine (cutoff, 300 ng/mL), cannabinoids (cutoff, 100 ng/mL), and opiates (cutoff, 300 ng/mL); 104 tests for cannabinoids (cutoff, 50 ng/mL); and 34 panel slides (amphetamine cutoff 1000 ng/mL, cocaine cutoff 300 ng/mL, opiates cutoff 300 ng/mL, and cannabinoids cutoff 100 ng/mL). Urine samples that had a concentration measured with FPIA-ADx within +/-25% of the Abusign cutoff were selected. Inter- and intra-individual agreement were assessed from the readings of the slides (positive or negative) by four persons at t = 3, 5, and 10 min after sample incubation. In addition, the sensitivity and specificity of the cannabinoids slide test (50 ng/mL) were compared with those of FPIA-ADx using GC-MS as the gold standard. There was a considerable variation in the reading of the slides between different persons. In addition, for the same observer the reading could depend upon the time of incubation. In comparison with FPIA-ADx, the Abusign test slides showed a high sensitivity (46% vs. 87%) and a low specificity (95% vs. 51%). We concluded that the Abusign slide test is unsuitable for situations in which a reliable test result is desired because of the low interindividual agreement, the dependency of the test result upon time, and the low specificity. However, the test slides may be of value in toxicological screening.

Poppy seeds: differences in morphine and codeine content and variation in inter- and intra-individual excretion.

Poppy seeds from seven different origins (Dutch, Australian, Hungarian, Spanish, Czech, and two Turkish) were analyzed for the amount of opiates present. Four grams of each kind of seeds, equivalent to the amount of seeds on two bagels, were ingested by volunteers. One volunteer also ingested four times the same amount of poppy seeds from the same origin (Spanish). During 24 hours urine samples were obtained and screened for the presence of morphine and codeine using the FPIA technique (cut-off = 200 ng/mL) and a GC/MS confirmation with a limit of detection (LOD) of 25 ng/mL for codeine and morphine. Poppy seeds from different origins contain a wide variation of morphine (2-251 micro g/g) and codeine (0.4-57.1 micro g/g) content. No other opiate could be detected. After ingestion a large interindividual variation of excretion of opiates exists. The testing results from the same kind of seeds ingested four times with a one week interval by the same volunteer also show a poor reproduceability. Several kinds of poppy seeds can give positive testing results (Australian, Hungarian, Spanish and one kind of Turkish seeds). Within 24 hours all testing results became negative.

[Biliary drainage in the diagnosis of acute idiopathic pancreatitis]. / El sondaje biliar en el diagnóstico de las pancreatitis agudas idiopáticas.

The identification of a casual agent in the so-called "idiopatic acute pancreatitis" is of great interest in relationship with the prognosis and the election of correct therapy. We have performed a duodenal drainage for the microscopic study of the bile, looking for cholesterol crystals and bilirrubinate's in a group of 19 patients with idiopatic acute pancreatitis. The results have been compared with a control group composed by 45 assymptomatic individuals. In the patients group drainage results were abnormal in 11 cases (57.9%) vs. 11.2% in the control group (difference statistically significant). In 4 of the 11 cases, a cholecystectomy was performed showing biliary pathology. Patients at follow-up were assymptomatic. Duodenal drainage is an easy method without risks that must be used always in idiopatic acute pancreatitis. It allows the diagnosis of microlithiasis and may help in the therapeutic indication of cholecystectomy.

[Liver involvement in Q fever and Mediterranean boutonneuse fever. Comparative study]. / Afectación hepática en la fiebre Q y la fiebre botonosa del Mediterráneo. Estudio comparativo.

Rickettsia spp. infections produce hepatic damage with transaminases elevation and biological signs of cholostasis. Classical biochemical tests of hepatic function were analyzed and compared in 8 patients with Q Fever (QF) and 7 with Boutonneuse Mediterranean Fever (BMF). Liver enlargement was detected in 75% of the QF group of patients as compared with the 57% of the BMF group. Transaminases were raised in 75% of the patients of the QF group and in 85, 7% of the BMF patients. Only one patient in the QF group showed manifest clinical jaundice. Statistically significant differences were found between the values of AST, ALT, alkaline phosphatase and GGT, which were higher in the QF group. Liver involvement is more important in patients with QF than in FBM. There is a large percentage of clinically silent involvement in both diseases. Liver function tests should be carried out in infections by Rickettsia spp.

[Poisoning with amitraz, an agricultural anti-ectoparasitic agent]. / Een intoxicatie met amitraz, een agrarisch anti-ectoparasiticum.

A mentally handicapped male aged 22 years ingested 25-100 ml of the agricultural anti-ectoparasite product amitraz (Taktic) (at most 12.5 g amitraz), and went into coma approx. one hour later (Glasgow coma score: 3). Gastric lavage was performed and activated charcoal and sodium sulphate deposited in the stomach. Product information could be obtained from the manufacturers in the United Kingdom with some trouble, 1.5 hours after admission. It was striking how little information is available concerning the toxicity of agricultural products. Patient had recovered the next day; he was discharged three days after admission. Blood assay 1.5 hours after ingestion revealed a concentration of amitraz plus metabolites of 3.7 micrograms/ml; when the patient came out of coma it was < 0.67 microgram/ml.

[Cholecystectomy: a choice technique in biliary microlithiasis]. / La colecistectomía: técnica de elección en la microlitiasis biliar.

The purpose of our study is to show results obtained after a cholecystectomy on 25 patients in order to present a suggestive clinic of bile origin and a positive result for determination of microcrystals in the bile probe even in the case of negative radiologic diagnoses (echography, cholecystography). Out of 25 patients operated on the following results were obtained: microscopic cholelithiasis in 12, granular cholelithiasis in 3, acute cholecystitis in 2, cholesterolosis in 2 and without pathologic findings in 6 patients after an observation period of 24 months following the operation it was demonstrated that almost all the patients (96%) had no symptoms. On the other hand, the above mentioned results are compared to the findings obtained during an observation period of a group of 34 patients with positive probe results with the same clinic characteristics and not having been operated on refusing the operation suggested.

[Visceral and cutaneous Kaposi sarcoma in a patient with rheumatoid arthritis under steroid treatment]. / Sarcoma de Kaposi visceral y cutáneo en paciente con artritis reumatoide en tratamiento esteroideo.

We present the case of a patient under corticosteroid therapy (Deflazacort) developing a cutaneous Kaposi's Sarcoma. In a latter study performed due to the presence of digestive syndrome, a gastric Kaposi's sarcoma was detected. We review the cases published in the literature of patients with rheumatoid pathology under corticosteroid therapy.

Pentamidine aerosols and environmental contamination: health-care workers at risk.

In our hospital safety guidelines are available for the handling of pentamidine in the day-care department, but no safety ventilation cabin is used because only one patient a day has been treated, The number of patients to be treated, however, is growing, resulting in the need to treat more than one patient a day. To determine the environmental contamination and exposure of health-care workers during and after aerosolised pentamidine treatment of more than one patient with the acquired immunodeficiency syndrome a day a high-performance liquid chromatographic method is used for the detection and quantification of pentamidine. High volume air samples were taken before, immediately after and the day after a treatment session of up to three patients. Also, sediment samples and personal air samples close to the mouth of the health-care workers were taken. Immediately after a treatment session the air in the room contains 1.0-99.7 micrograms pentamidine per m3 of air. Before and the morning after treatment no pentamidine could be detected in the air. Sediment samples vary in detectable amounts of pentamidine from < 5 to 1165 micrograms. pentamidine/cm2. The personal air samples also show a large variation in quantities of pentamidine: < 5-170 ng a filter. When large amounts of pentamidine in the high volume air samples are found high amounts of pentamidine on the sediment samples and the personal air samples are found as well. This means that the patients treated should be instructed well on how to use the nebulizer correctly and be monitored during treatment. Additional safety measures (for example the use of a safety ventilation cabin) should be taken when more than one patient is treated a day.

A case of positive doping associated with a botanical food supplement.

In this manuscript the chemical and pharmacokinetic evaluation of a doping case associated with the use of an Ephedra-labelled dietary supplement is reported. The urine of a Dutch professional cyclist was found to be positive for norpseudoephedrine at a doping control. An inquiry revealed that the cyclist had consumed a liquid herbal food supplement with Ephedra as one of its 15 declared ingredients. Chemical analysis revealed concentrations of 6.8-8.2 mg/ml of norpseudoephedrine and 0.02-0.03 mg/ml of ephedrine in several batches, which could have caused the positive doping test. Since the International Olympic Committee (IOC) list of doping substances comprises several substances which occur naturally in botanicals, doping agents like ephedrines and/or caffeine may be taken unwittingly in the form of herbal food supplements. In this case, the predominance of norpseudoephedrine over ephedrine was explained by spiking with norpseudoephedrine, showing that adulteration of herbal food supplements with undeclared agents also have to be taken into account. Our report demonstrates a need for improved quality control of herbal food supplements.

Submandibular salivary gland hypertrophy induced by phenytoin.

A 16-year-old boy with epilepsy developed hypertrophy of the submandibular salivary glands, with high phenytoin (PHT) serum levels. The submandibular salivary glands became normal in 12 days after discontinuation of PHT. Other causes of salivary gland hypertrophy were excluded and we suggest that the hypertrophy was due to PHT.

In vitro and in vivo comparison of creams containing dithranol 0.5%.

In an in vitro model, the release and penetration through a silicon membrane of different cream formulations and ointments containing 0.5% dithranol were studied. The results indicated that the method is not suitable for predicting in vivo release and penetration. Experiments with rabbits showed that the degree of skin irritation produced by a hospital-prepared product containing 0.5% dithranol was comparable to that of of a commercial product. Clinical efficacy and side-effects of these two products were investigated in a double-blind left-right comparative study in 35 patients with chronic plaque psoriasis. The two creams proved to be equally effective and showed the same incidence of side-effects.