Impulse control disorders in Parkinson's disease: don't set your mind at rest by self-assessments.

BACKGROUND AND PURPOSE: Impulse control disorders (ICDs) and related conditions in Parkinson's disease (PD) patients are frequent, disabling and sometimes devastating neuropsychiatric behaviors. Current knowledge on the prevalence of ICDs in PD is mainly based on assessments with questionnaires or patient interviews. This study was designed to evaluate the reliability of self-assessed ICDs and related conditions in PD by exploring the agreement between self-assessment of ICDs and related conditions in PD patients on the one hand and the estimation of their caregivers on the other hand. METHODS: After a short validation study of a novel ICD screening questionnaire, a cross-sectional study in 150 PD patients was performed. All patients filled out the self-assessment version of a screening questionnaire for ICDs, and caregivers completed an adapted version (n = 64). RESULTS: When comparing self-assessments of PD patients and ratings by their caregivers, significant differences with regard to the estimated prevalence of hypersexuality (55% vs. 17%), dopamine dysregulation syndrome (31% vs. 3%) and punding (22% vs. 9%) were found. CONCLUSIONS: Patients underestimate the presence and severity of some ICDs and related conditions, which shows how important assessments with caregivers are. After all, ICDs are probably much more frequent in PD than previously reported.

Transdermal rotigotine causes impulse control disorders in patients with restless legs syndrome.

INTRODUCTION: Dopaminergic drugs are the mainstay of treatment for restless legs syndrome (RLS). We analyzed the frequency and clinical characteristics of impulse control disorders (ICD) in patients with RLS on transdermal rotigotine treatment. METHODS: Retrospective case series at a university movement disorder clinic (n = 28, 17 women). Symptoms of ICD were assessed via detailed history taking and scoring with the Zurich Screening Questionnaire for ICD (ZICD) prior to and after initiation of treatment. RESULTS: None of the patients had a history of ICD prior to treatment. Baseline mean scores for patients who did (8.0 ± 2.5) and did not (6.2 ± 2.7) develop ICD under treatment did not differ. Six male patients (21%) developed various symptoms of ICD (mean ZICD scores 20.7 ± 10.2) on rotigotine treatment (mean dose: 3.8 mg/d), including binge eating, hypersexuality, compulsive shopping, pathological gambling, and punding, equaling a prevalence rate of 21%. Also in the non-ICD group, ZICD scores increased (7.5 ± 2.8). CONCLUSION: This is the first report of ICD in patients treated with transdermal rotigotine for RLS. In contrast to literature, even low doses of rotigotine (mean 3.8 mg/d) can cause ICD. Therefore every prescribing physician should be aware that ICD may emerge in both RLS and PD patients on any dopaminergic treatment, and should actively ask for such symptoms. The ZICD questionnaire not only replicated the findings of detailed history taking but also showed an increased tendency towards impulsive behaviour in subjects that did not develop ICD.

Evaluación de la coagulopatía por consumo asociada con las hemorragias obstétricas graves / Evaluation of consumptive coagulopathy associated to severe obstetrics hemorrhagies

Objetivo Evaluar la frecuencia, las complicaciones y el pronóstico de la coagulopatía por consumo (CC) en un grupo de pacientes con hemorragias obstétricas graves en el periodo periparto. Material y métodos Estudio retrospectivo y descriptivo, efectuado en 91 enfermas con CC sobre 247 pacientes con hemorragias obstétricas graves en el periodo periparto, ingresadas entre 1991 y 2008 en la División de Cuidados Intensivos de la Clínica y Maternidad Suizo Argentina. Resultados El shock se presentó en 110 enfermas y afectó a más de la mitad de los casos con desgarros cervicovaginales y rupturas uterinas. 61 gestantes con shock presentaron CC, 12 de ellas con sangrado múltiple, confirmando el diagnóstico de coagulación intravascular diseminada. En el grupo sin shock (n=137) el número de casos con CC (n=30) fue menor (p<0,05). El fallo multiorgánico se vinculó con la presencia de shock hemorrágico y CC, resultando las complicaciones más frecuentes el distrés pulmonar y la insuficiencia renal aguda. Todas las puérperas sobrevivieron sin secuelas. Conclusiones La prevalencia de la CC en las pacientes con hemorragias obstétricas graves resultó mayor que la observada en la población general de enfermos en estado crítico. La presencia de shock en el curso de una hemorragia obstétrica grave origina CC en más de la mitad de los casos y, en ocasiones, se asocia con daño orgánico. La prevención del shock hemorrágico no evitó la CC en el 21% de las enfermas. La supervivencia materna fue óptima (AU)

Objective To evaluate the frequency, complications and outcomes of consumptive coagulopathy (CC) in patients with severe obstetric hemorrhage in the peripartum period.Material and methods Of 247 patients with severe obstetric hemorrhage in the peripartum period admitted to the Intensive Care Division of Clínica y Maternidad Suizo, Argentina, between 1991 and 2008, we performed a retrospective and descriptive study of 91 patients with CC.Results Shock occurred in 110 patients and affected more than half of the patients with cervical and vaginal tears and uterine rupture. Shock developed in 61 pregnant women with CC. Of these, 12 showed multiple bleeding, confirming the diagnosis of disseminated intravascular coagulation. In the group without shock (n=137), the number of patient with CC (n=30) was lower (p<0.05). Multiple organ failure was associated with the presence of hemorrhagic shock and CC, the most frequent complications being respiratory distress and acute renal failure. All the puerperal women survived without sequelae.Conclusions The prevalence of CC in patients with severe obstetric hemorrhage was higher than that observed in the general population of critically ill patients. The presence of shock in the course of a severe obstetric hemorrhage causes CC in more than half of affected patients and sometimes is associated with organ failure. Prevention of hemorrhagic shock did not prevent CC in 21% of the patients. Maternal survival was optimal (AU)

Significance of self-reported sleep quality (SQ) in chronic kidney disease (CKD): the Renal Research Institute (RRI)-CKD study.

BACKGROUND: There has been limited research on sleep quality (SQ) in CKD. METHODS: This prospective cohort study of adults with CKD Stages 3 - 5 at four US centers collected self-reported SQ information from the Kidney Disease Quality of Life (KDQOL) instrument, including an estimated SQ score (0 - 100), and 3 SQ-related questions. "Poor" SQ was defined as SQ score < or = 60. Logistic and multiple linear regression assessed associations between SQ and its potential predictors. Times to death and end stage renal disease (ESRD) were examined using Cox regression. A comparison with SQ in ESRD patients from the Dialysis Outcomes and Practice Patterns Study (DOPPS), was additionally performed. RESULTS: Mean SQ score was 59.4 +/- 23.6 (n = 689), and "poor" SQ was reported by 57%. Mean estimated glomerular filtration rate (eGFR) was 24.9 +/- 10.6 ml/min/1.73 m2. Higher SQ significantly correlated with KDQOL mental and physical component summary scales. Significant predictors of lower SQ score included--younger age, presence of dyspnea, self-reported depression, pain, and itchness. There were no significant pairwise differences in SQ from CKD Stage 3 through ESRD. Self-reported daytime sleepiness was significantly associated with higher risk of mortality prior to ESRD (HR = 1.85, p = 0.02). CONCLUSION: Self-reported "poor" SQ was common in a CKD cohort (Stages 3 - 5) and was not only associated with lower quality of life scores and several modifiable symptoms, but also with higher risk of pre-ESRD mortality. Greater attention to this clinical problem is highly recommended in this high-risk population.

Hemorragias obstétricas exanguinantes / Exsanguinating obstetric haemorrhages

Objetivo evaluar la etiología, el tratamiento y la morbilidad en un grupo de gestantes con hemorragias obstétricas exanguinantes, así como proponer medidas para su prevención. Material y método estudio retrospectivo y descriptivo efectuado sobre 25 gestantes con edad de 35±5 años que ingresaron desde marzo de 1991 hasta febrero de 2008 en la División de Cuidados Intensivos por presentar hemorragias de origen obstétrico (con un monto estimado superior a 4.000ml) y que requirieron transfusiones iguales o mayores de 10 U de glóbulos rojos. Resultados hubo 11 desgarros cervicovaginales y roturas uterinas. El 88% de los casos presentó shock hemorrágico. El promedio de hematíes sedimentados transfundidos fue de 14,8±5,1U, y el hematocrito alcanzado al cabo de las siguientes 24h fue del 20,6±6,2%. En el caso de 20 enfermas se recurrió a la histerectomía como última medida para controlar la hemorragia masiva. Siete de las mujeres histerectomizadas presentaron hemorragia retroperitoneal o intraperitoneal, y hubo que reintervenirlas quirúrgicamente por hemorragias persistentes. Veintidós enfermas presentaron coagulopatía por consumo; 6 de ellas, coagulación intravascular diseminada. En la mitad de las puérperas se presentaron complicaciones graves. Cinco mujeres sufrieron lesiones quirúrgicas: 2 mujeres sufrieron lesiones rectosigmoideas, 2 mujeres sufrieron lesiones vasculares y una mujer sufrió lesión vesical. Ocho mujeres presentaron distrés pulmonar; 2 de ellas, disfunción multiorgánica. Las 25 puérperas sobrevivieron sin secuelas. Conclusiones a) Los desgarros cervicovaginales y las roturas uterinas representaron las causas más frecuentes de hemorragias exanguinantes; b) la histerectomía, aunque necesaria, no resolvió la hemorragia en el 40% de los casos; c) hubo un elevado índice de complicaciones, y d) la supervivencia materna fue óptima (AU)

Objective: To evaluate etiology, treatment and morbidity in a group of pregnant women with exsanguinating obstetric haemorrhage and to propose measures for its prevention. Material and methods: We performed a retrospective, descriptive study of 25 pregnant women, aged 3575 years, admitted to the Intensive Care Division from March 1991 to February 2008 with obstetric haemorrhage exceeding 4000 ml and transfusion requirement equal to or greater than 10 units of red blood cells. Results: There were 11 cervico-vaginal lacerations and uterine ruptures. Haemorrhagic shock occurred in 88% of the patients. The mean red cell transfusion requirement was14.875.1 units, and the hematocrit after 24 h was 20.676.2%. Hysterectomy wasperformed as the last option to stop massive bleeding in 20 patients. Retro and/or intraperitoneal bleeding occurred in seven patients with hysterectomy, who underwent reintervention for persistent bleeding. Coagulation factor defects were found in 22 patients, of whom six had disseminated intravascular coagulation. Serious complications occurred in 50% of the patients. Five patients had recto sigmoid(2), vascular (2) and bladder (1) surgical lesions. Eight had respiratory distress; of these, two had multiple organ dysfunction. The 25 puerperal women survived without recurrences. Conclusions: a). The most frequent causes of exsanguinating bleeding were cervicovaginal lacerations and uterine ruptures. b). Hysterectomy, although necessary, did not resolve the bleeding in 40% of the patients. c). There was a high rate of maternal complications d). Survival was optimal (AU)

The emergency department care of hemodialysis patients.

AIMS: To describe the emergency department (ED) presentation, evaluation and disposition of maintenance hemodialysis (HD) patients. MATERIALS AND METHODS: A retrospective review of adult HD patients seen 1/1-12/31/97. The following was collected: demographics, mode of arrival, chief complaint, etiology of renal failure, evaluation, treatment, disposition, length of stay and facility charges. During the study period, this tertiary care ED had an annual adult census of 45,000. No clinical pathways were in place. RESULTS: 143 patients made 355 visits: 351 charts were available. Mean patient age was 51 (range 20-86), 62% were male, 51% were white. 70% presented from home, 26% from dialysis. EMS transported 32%. Medicare insured 78%. Etiologies of renal failure included hypertension (33%), diabetes (27%), HIV (7%) and glomerulonephritis (8%). Complaints were related to infection (18%), dyspnea (17%), vascular access (16%). chest pain or dysrhythmia (15%) and gastrointestinal complaints (12%). ED evaluation included CBC (79%), electrolytes (75%), CXR (57%) and EKG (48%). Antibiotics were administered to 21%. HD was performed earlier than scheduled in 14%. Two hundred and eighteen patients (62%) were admitted (ICU 11%, telemetry 22%), 19 (5%) refused admission and 2 expired in the ED. The average hospital length of stay was 7.8 days (range 1-59), with 29% hospitalized more than 1 week, compared to 6.54 days for non-HD patients. The mean facility charge for admitted subjects was $14,758, while the average cost for non-HD admissions was $7,152. Of the 133 patients (38%) who were discharged directly from the ED, the mean length stay was 223 minutes (range 30 to 750) and the mean charge was $658. The mean length of stay for non-HD patients was 124 minutes. CONCLUSION: The ED evaluation of adult HD patients involves multiple diagnostic modalities, and patients are usually admitted. The admit rate, ED length of stay for discharged patients and hospital charges for care were substantially higher in the HD patients than in the general population. Further research in the ED care of these complex patients should be undertaken.

End-stage renal disease: factors affecting referral decisions by family physicians in Canada, the United States, and Britain.

The objective of this study is to determine how patient age, sex, creatinine level, and comorbidity affect referral decisions for the treatment of end-stage renal disease (ESRD) and whether these decisions are affected by physician characteristics in three countries: Canada, the United States, and Britain. A vignette-based questionnaire was mailed to a random sample of family physicians in Ontario, Canada (1,818 physicians); all family physicians in the state of New York (1,814 physicians); and a sample of general practitioners from the south of England (2,228 physicians) in 1996. Physicians were presented with clinical scenarios involving a patient with varying degrees of renal insufficiency and a complicating comorbidity, including angina, diabetes, cancer, mental illness, or socioeconomic circumstances. They were asked to indicate the likelihood of referral. Half the physicians received a questionnaire describing a male patient, and half, a female patient. Mean creatinine levels at which physicians would refer were 260 micromol/L for British physicians, 297 micromol/L for Canadian physicians, and 340 micromol/L for American physicians. No difference in referral rates was found based on the sex of the patient or physician. Sixty-five percent of American and Canadian physicians would refer regardless of patient age, but only 49% of British physicians would do so. Family physicians in the United States, Canada, and Britain function as gatekeepers for patients with ESRD. They are less likely to refer based on increasing severity of comorbid conditions. They also discriminate based on age, but not sex.

A pharmacokinetic drug-drug interaction study of venlafaxine and indinavir.

Depression is a common occurrence in the human immunodeficiency virus (HIV)-infected population. Complications in treating depressed HIV-infected individuals include the use of multiple medications, additive side effects, and potentially significant drug-drug interactions. Based on the pharmacologic characteristics of venlafaxine and indinavir, we hypothesized that significant pharmacokinetic drug-drug interactions would not occur when these drugs where taken concurrently. Nine healthy adult subjects were given a single 800 mg oral dose of indinavir and serial blood samples were collected for measurement of plasma drug concentrations. Over the next 9 days, venlafaxine was administered at a dosage of 50 mg every 8 hours following a brief titration. A venlafaxine trough plasma concentration and serial concentrations following venlafaxine administration were obtained on day 10. On day 11, venlafaxine and indinavir were administered together and serial blood sampling was repeated. Indinavir had no effect on venlafaxine plasma concentrations but resulted in a 7% decrease in plasma concentrations of O-desmethyl-venlafaxine (ODV)(P = 0.028). This effect is unlikely to be clinically significant. Venlafaxine coadministration resulted in a 28% decrease in the area under the concentration time curve (AUC) of plasma indinavir (P = 0.016) and a 36% decrease in its maximum plasma concentration (Cmax; P = 0.038). As the plasma concentration of protease inhibitors is a critical factor in maintaining efficacy and minimizing the potential for viral resistance, the decrease in both AUC and Cmax of indinavir from coadministration of venlafaxine is of concern. The clinical significance of these results obtained from a small number of healthy volunteers is unknown. Further studies are needed to substantiate or refute this apparent drug-drug interaction. Until such time, venlafaxine should be used cautiously in patients receiving indinavir.

Occupational medical program alcohol screening. Utility of the CAGE and BMAST.

Alcohol consumption is a primary or secondary factor in many work-related accidents, suicides, homicides, violent crimes, and motor vehicle accidents. The absentee rate in alcoholics is 3.8 to 8. 3 times greater than that for nonalcoholic workers. The purpose of this research was to evaluate the effectiveness of two interview questionnaires-the Brief Michigan Alcoholism Screening Test (BMAST) and the CAGE (cut down, annoyed by criticism, guilty about drinking, and eye-opener drinks). The validity of the BMAST and the CAGE as screening tools for alcohol problems has been verified in a number of nonworkplace settings. If they prove to be as effective for screening workers in an occupational medical setting, follow-up definitive diagnoses could result in earlier detection of alcohol problems and allow prompt intervention. Positive outcomes could include a safer workplace, less absenteeism, improved worker productivity, and a reduction in personal and family problems caused by drinking.

Indinavir-induced nephropathy.

We report the case of a 38-year-old male who developed renal insufficiency while on the protease inhibitor, indinavir. This patient had an increase in serum creatinine over a period of approximately one year, along with persistently abnormal urinalysis. A renal biopsy was performed and showed marked tubular crystal deposition. The indinavir was discontinued, and after two months the patient's serum creatinine and urinalysis returned to normal. To our knowledge this is the second case of indinavir associated nephropathy.

Pharmacokinetics of intermittent intraperitoneal cefazolin in continuous ambulatory peritoneal dialysis patients.

OBJECTIVE: To investigate the pharmacokinetic parameters of intermittent intraperitoneal (IP) cefazolin, and recommend a cefazolin dosing regimen in continuous ambulatory peritoneal dialysis (CAPD) patients. DESIGN: Prospective nonrandomized open study. SETTING: CAPD outpatient clinic in Albany, New York. PATIENTS: Seven volunteer CAPD patients without peritonitis. Three of the patients were nonanuric while 4 were anuric. INTERVENTIONS: Cefazolin (15 mg/kg total body weight) was given to each patient during the first peritoneal exchange. Blood and dialysate samples were collected at times 0, 0.5, 1,2,3,6 (end of the first antibiotic-containing dwell), 24, and 48 hours after the administration of IP cefazolin. Urine samples were collected in nonanuric patients over the study period. RESULTS: The mean+/-SD amount of cefazolin dose absorbed from the dialysate after the 6-hour dwell was 69.7%+/-8.0% of the administered dose. The cefazolin absorption rate constant from dialysate to serum was 0.21+/-0.1/hr (absorption half-life 3.5+/-0.8 hr). The mean serum concentrations reached at 24 and 48 hours were 52.4+/-3.7 mg/L and 30.3+/-5.9 mg/L, respectively. The mean dialysate cefazolin concentrations reached at 24 and 48 hours were 15.1+/-3.4 mg/L and 7.9+/-1.4 mg/L, respectively. The cefazolin serum elimination rate constant was 0.02+/-0.01/hr (elimination half-life 31.5+/-8.8 hr). The total cefazolin body clearance was 3.4+/-0.6 ml/min. In the 3 nonanuric patients the mean renal clearance of cefazolin was 0.6+/-0.4 ml/min. The peritoneal clearance of cefazolin was 1.0+/-0.3 mL/min. The systemic volume of distribution of cefazolin was 0.2+/-0.05 L/kg. No statistical difference was detected in pharmacokinetic parameters between anuric and nonanuric patients, although this may be due to the small number of patients in each group. CONCLUSION: A single daily dose of cefazolin dosed at 15 mg/kg actual body weight in CAPD patients is effective in achieving serum concentration levels greater than the minimum inhibitory concentration for sensitive organisms over 48 hours, and dialysate concentration levels over 24 hours. Caution is warranted in extrapolation of dosing recommendations to patients who maintain a significant degree of residual renal function.

Pharmacokinetics of intermittent intraperitoneal ceftazidime.

Ceftazidime is currently recommended as an alternative first-line agent in the treatment of peritonitis and for Pseudomonas peritonitis. The pharmacokinetics of intermittent intraperitoneal (i.p.) ceftazidime have been poorly characterized. This study was designed to characterize the pharmacokinetic disposition of a single dose of ceftazidime in anuric and non-anuric CAPD patients, over 48 hours. This was a prospective, open label, pharmacokinetic study. The study was conducted in an independent, outpatient dialysis center. Ten volunteer continuous ambulatory peritoneal dialysis (CAPD) patients with and without residual renal function, no peritonitis or antibiotics in the previous 4 weeks, and on CAPD for at least 2 months were recruited. Patients received a single dose of i.p. ceftazidime (15 mg/kg) in the first daytime exchange over a 6-hour dwell, after an overnight dwell. Serum, urine, and dialysate were collected over a 48-hour period. A high-pressure liquid chromatography (HPLC) assay was used to analyze ceftazidime in these samples. Pharmacokinetic parameters were calculated. Six of the 10 patients were non-anuric with a mean residual renal creatinine clearance of 2.9 +/- 1.6 mL/min. The mean +/- SD bioavailability was 72% +/- 14%, and the volume of distribution was 0.34 +/- 0.08 L/kg. The mean serum elimination half-life of 22 +/- 5 hours. The peritoneal clearance was 5.74 +/- 1.6 mL/min. No difference was detected between anuric and nonanuric patients. Mean plasma and dialysate concentrations at 24 hours were 24 +/- 6 microg/mL and 18 +/- 7 microg/mL, respectively, and were 12.0 +/- 3.6 microg/mL and 7.4 +/- 3.1 microg/mL at 48 hours, respectively. Once-daily i.p. dosing of ceftazidime achieves serum and dialysate levels greater than the MIC of sensitive organisms over 48 hours.

Effect of over-the-counter dosages of naproxen sodium and acetaminophen on plasma lithium concentrations in normal volunteers.

Prescription doses of nonsteroidal antiinflammatory agents have been shown to decrease clearance and increase plasma concentrations of lithium. This study was designed to evaluate whether over-the-counter (OTC) doses of naproxen sodium or acetaminophen have the same potential to affect lithium concentration. This was a prospective, crossover, 3-phase study conducted at the Clinical Pharmacology Studies Unit of the Albany Medical Center Hospital during July and August of 1995. The 3-phase study comprised the following: phase 1, lithium carbonate (300 mg every 12 hours) alone for 7 days; phase 2, lithium and either naproxen sodium (220 mg every 8 hours) or acetaminophen (650 mg every 6 hours) for 5 days; and phase 3, a 2-day washout period followed by a crossover to lithium with the alternate drug (acetaminophen or naproxen sodium) for 5 days. Twelve healthy male volunteers were recruited, nine of whom completed the study and were included in the statistical analysis. Mean (+/-SD) plasma lithium concentrations for subjects in treatment group 1 (lithium in phase 1, lithium and naproxen sodium in phase 2, lithium and acetaminophen in phase 3) were 0.38 (+/-0.11), 0.40 (+/-0.07), and 0.36 (+/-0.11) mEq/L, respectively. Mean plasma lithium concentrations for subjects in treatment group 2 (lithium in phase 1, lithium and acetaminophen in phase 2, lithium and naproxen sodium in phase 3) were 0.43 (+/-0.05), 0.48 (+/-0.10), and 0.48 (+/-0.05) mEq/L, respectively. One-way repeated-measures analysis of variance and paired t-test showed no statistically significant differences (p>0.05) in plasma lithium concentrations during any phase of the study. The results of this study demonstrated that OTC doses of naproxen sodium and acetaminophen did not increase plasma lithium concentrations in these volunteers when taken for short periods of time.

Bilateral renal cortical necrosis associated with cefuroxime axetil.

Cefuroxime axetil has been associated with few reported adverse effects. We report a case of bilateral renal cortical necrosis in a female after receiving 7 doses over 4 treatment days. The patient presented with worsening symptoms consisting of arthralgias, pruritus, and abdominal pain. Laboratory data obtained was indicative of worsening renal failure and thrombocytopenia. The patient required hemodialysis by the third day. Kidney biopsy revealed cortical necrosis. The possible pathogenesis of cefuroxime axetil causing cortical necrosis in this case and a review of other reported cases of chemical induced renal cortical necrosis is discussed.

Workplace violence at government sites.

A government agency and its contractors employing nearly 96,000 workers throughout the country was surveyed for documented incidents of violence in the workplace. Thirty-five occupational medicine and related professionals (36% of those surveyed) from 27 locations returned the questionnaire. Of the responders, 20 individuals reported 74 incidents of workplace violence, with nearly 30% of these occurrences involving weapons, including 11 with guns. In a companion survey of human resource departments from 28 locations, there were 16 responders (57% of those surveyed) with 13 of them documenting 96 additional incidents. No duplicate reporting of the same event occurred between the two surveys. Approximately 70% of the agency workers were employed in locations covered by the 51 responders. Although the data are limited, the number of incidents and level of violence appear to be increasing over time. Of the 108 incidents for which time of occurrence was known, 32 were defined as "very serious," which included physical assault, threat or assault with a weapon, murder, suicide, or stalking. Verbal threats, verbal assaults, and vandalism were defined as "serious" incidents. A Cochran-Armitage trend test for an increasing proportion over time of "very serious" vs. "serious" events was statistically significant, with a P-value of 0.026.

Evaluation of drug-related problems in an outpatient hemodialysis unit and the impact of a clinical pharmacist.

PURPOSE: Drug-related morbidity and mortality are significant problems in the U.S. Recognition and resolution of drug-related problems (DRP) will decrease drug-related morbidity and mortality and promote optimal therapeutic outcomes. It was the objective of this study to identify DRP in hemodialysis outpatients by performing medication reviews; make appropriate recommendations and determine the significance of any interventions; and estimate outcome in terms of any changes in number of medications/patient or doses/day. METHODS: A thorough medication review was conducted with each patient after review of the computerized medication profiles and medical records. Each updated profile was assessed by a clinical pharmacist for the presence of any of the 8 classical DRP plus 2 additional categories (therapeutic duplication and other [specific for dialysis e.g., dry weight]). Appropriate recommendations were made to the physician. Accepted recommendations were deemed as interventions and assigned a significance rank on a published scale of 1 (adverse significance) to 6 (extremely significant) by each of the investigators. A final rank was assigned upon agreement between investigators. Changes in numbers of doses/day or medications/patient were determined. RESULTS: 49 patients were reviewed and 45 patients (21 women, 24 men) were included in the final analysis. Over one month 126 DRP were identified and 102 interventions were made. Drug interactions constituted the most common DRP (27.5%). The second most common DRP (26.5%) was in the dialysis-specific group. The number of interventions per significance rank were as follows: rank 1:0 (0%); rank 2: 7 (6.9%); rank 4: 80 (78%); rank 5: 5 (4.9%); rank 6: 1 (1%). Patients were taking a mean of 10.9 +/- 3.9 medications and a mean of 14.5 +/- 6 doses/day (range, 2-33) prior to the study and 10.7 +/- r and 14.4 +/- 5.8 by the end of the study period. CONCLUSIONS: With the addition of a clinical pharmacist in an hemodialysis unit numerous DRP were detected and interventions made. The majority of interventions were significant and possibly led to better therapeutic outcomes.