Annals of Pharmacotherapy

Cryptococcus neoformans infections of the central nervous system affect up to ten percent of AIDS patients. Standard therapy with amphotericin B with or without 5-flucytosine has a high rate of failure, relapse, and toxicity. Fluconazole is a new triazole antifungal agent available in both oral and intravenous forms that has shown efficacy in the primary and maintenance treatment of cryptococcal meningitis in AIDS patients. In this open, noncomparative trial, we evaluated the safety and efficacy of intravenous fluconazole followed by oral fluconazole in the treatment of acute cryptococcal meningitis in AIDS patients.

Thirteen AIDS patients with acute cryptococcal meningitis, or relapse after successful primary therapy, received 400 mg of intravenous fluconazole daily for 12–16 days followed by oral fluconazole 400 mg/d for the duration of primary therapy. If cerebrospinal fluid (CSF) cultures converted to negative within 32 weeks of treatment, the fluconazole dose was decreased to 200 mg/d as maintenance therapy.

Fluconazole therapy was successful in six patients (46 percent) and unsuccessful in seven (54 percent). Of the seven patients considered unsuccessful, one demonstrated clinical improvement but remained CSF-culture positive, five were clinical failures and were switched to amphotericin B therapy, and one died after two weeks secondary to cryptococcal meningitis. No patient experienced any adverse reactions necessitating discontinuation of therapy.

In this small group of patients, moderate doses of parenteral and oral fluconazole for acute cryptococcal meningitis in AIDS patients demonstrated failure rates similar to those reported in other studies with fluconazole and with amphotericin B. As there was no difference in initial Karnofsky scores or the severity of disease in treatment successes versus failures, it is difficult to determine who might respond to fluconazole as initial therapy or who should be treated initially with another agent. Further studies and clinical experience are needed.

To determine if there is any association between glycemia and blood pressure in black patients with hypertension and diabetes mellitus whose antihypertensive medications had been unchanged for six months.

Retrospective, from March 1990 through February 1991.

Internal medicine ambulatory clinic at Detroit Receiving Hospital/University Health Center.

Patients seen during this period with hypertension and type II diabetes. Of the 639 possible subjects, 124 met the following criteria: (1) no change in antihypertensive medications for six months, (2) absence of secondary hypertension, and (3) weight change (if any) was less than five percent. Changes in antihypertensive medication(s) excluded 388 patients, secondary hypertension excluded 3, weight changes of more than five percent excluded 94, and lack of matching postprandial capillary blood glucose (PCBG) values excluded 30. The mean age of the subjects was 66.8 years, mean diabetes duration was 12.0 years, mean PCBG was 10.7 mmol, mean systolic blood pressure (SBP) was 154.3 mm Hg, mean diastolic blood pressure (DBP) was 90.1 mm Hg. There were 28 men in the study and 96 women; 90 were obese (body mass index >25 kg/m²) and 34 were nonobese. The diabetes was managed with insulin in 67 patients, with sulfonylureas in 50, and with diet in 7. intervention: None

SBP and DBP versus PCBG at matching times both at baseline and at six months.

There was a positive association between blood pressure measurements and glycemia. Overall change in SBP was strongly correlated with PCBG changes (r=0.745, p<0.0001). Improved glycemia correlated with improved SBP control (r=0.330, p<0.0024). Deterioration of glycemia correlated with a worsening of SBP control (r=0.445, p<0.0053). The method of blood glucose control had no statistically significant effect (ANOVA) on these results.

Glycemia is positively associated with blood pressure.

To assess the level of physician acceptance and perceived usefulness of a pharmacy-prepared, physician-edited pharmacy and therapeutics (P&T) committee newsletter.

Two separate surveys conducted after 7 and 24 months of publication, respectively.

500-bed, university-affiliated, tertiary-care hospital.

The initial survey was mailed to physicians after 7 months of publication and they were requested to rate various aspects of the newsletter, including timeliness of articles, usefulness of articles, quality of writing and design, and overall value of the publication on a scale of 1–4: (1 = excellent, 2 = good, 3 = fair, 4 = poor). Physicians were also asked to rank different categories of articles (articles on new drugs, drug-class reviews, topical reviews, formulary news, and articles providing P&T committee information) and were encouraged to provide comments. A separate follow-up survey conducted at 24 months asked physicians to indicate whether they (1) regularly received the newsletter, (2) regularly read the newsletter, (3) found the information in the newsletter to be useful, and (4) desired to continue receiving the newsletter.

Initial survey results yielded mean newsletter quality scores ranging from 1.54 to 1.66. Respondents preferred, in descending order, articles on new drugs, drug-class reviews, topical reviews, formulary news, and P&T committee information. The 24-month survey revealed that 96 percent of the physicians regularly receiving and reading the newsletter found the information useful and 97 percent felt that the newsletter should continue to be published. Favorable comments were also received from several prominent physicians.

The results indicate strong physician acceptance of a pharmacy-prepared, physician-edited newsletter and provide information about the types of articles preferred by physicians in a university hospital setting.

To develop a comprehensive list of symptoms categorized by body system as part of a questionnaire for detecting potential adverse drug reactions.

A preliminary list of symptoms in lay terminology was extracted from the “Side Effects” section of all drug monographs contained in the United States Pharmacopeia Dispensing Information (USP DI) computerized database (Volume II, Advice for the Patient) using natural language processing software. The list was sorted alphabetically and duplicate terms were eliminated. Symptoms were then categorized by body system or anatomic region. A preferred term for each symptom was selected when multiple synonyms and related words were listed. Finally, all of the symptom terms were incorporated into a thesaurus from which the questionnaire was derived.

The questionnaire will be used as part of a computer-assisted interview, developed to solicit information from patients regarding their medication regimens and to systematically query them regarding the presence of salient symptoms or complaints. The computer system will eventually interface with the USP DI database to identify drugs from a patient's regimen that may be associated with adverse symptoms. The symptom thesaurus will provide the link to the USP DI database. Preliminary experience with the questionnaire in a limited number of patients has been encouraging.

The questionnaire can assist clinicians in identifying drug-related symptoms including unreported adverse clinical effects of newly marketed or investigational therapeutic agents. When the questionnaire is computerized and linked to a comprehensive database, it can be more widely used to alert healthcare providers of potential adverse drug reactions that may otherwise go undetected.

To determine the causes and frequency of overdoses associated with the administration of opioid analgesics in hospitalized patients.

Case series.

Two acute care teaching hospitals.

Eighty-one hospitalized patients who received naloxone for a clinically suspected narcotic overdose.

Three investigators reviewed each patient who received naloxone during a 12-month period. The patients were judged to have a narcotic overdose if caregivers documented an immediate improvement in mental status, respiratory rate, or blood pressure after naloxone administration.

The number and causes of narcotic overdoses were determined. The frequency of morphine and meperidine overdoses was calculated. The number of incidents reported using incident or adverse drug reaction reports or the appropriate International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code.

In the 22 overdoses that occurred, 14 (64 percent) were caused by medication prescribing, compounding, or administration errors and potentially were preventable. The remaining eight patients experienced an overdose despite receiving appropriate amounts of opioids. The frequency of overdoses was 0.4 and 0.2 percent of total patients receiving morphine or meperidine, respectively, at the two hospitals. Nonreporting of these narcotic overdoses was frequent. In one hospital, 1 incident report and 3 adverse drug reactions were reported for 17 overdoses. At the second hospital, 1 incident report and 1 adverse drug reaction were reported for 6 overdoses. None of the patient charts included an ICD-9-CM code that documented the problem.

The causes of overdoses are not limited to prescribing and administration errors. Some patients, despite proper execution of appropriate orders, develop a narcotic overdose. Caregivers must be aware of this problem and monitor patients for a decrease in mental status and respiratory rate. In addition, we conclude that an important number of hospitalized patients develop an overdose even though the frequency is low related to the number of patients receiving narcotics.

This research was performed to examine community pharmacists' interactions with prescribers and to determine if these interactions are related to payment method.

Randomly selected pharmacists (47 in chain pharmacies and 26 in independent pharmacies) collected data concerning prescriber interactions for a 40-hour period. These interactions were analyzed in terms of payment methods, prescriber acceptance, and types of information discussed.

Information concerning 730 interactions by 72 pharmacists was obtained. Payment methods were related to the frequency of interactions per pharmacist (p<0.01). There were higher percentages of interactions for self-pay (median 2.2 percent) and Medicaid (median 1.8 percent) prescriptions than for third-party fee-for-service (mode 0 percent) or capitation prescriptions (mode 0 percent). Type of information discussed was related to payment method. The vast majority of information provided by pharmacists (91 percent) was accepted by prescribers. The rate of acceptance was 97 percent for prescriber-initiated interactions versus 88 percent for pharmacist- or patient-initiated interactions (p<0.01).

Relationships between payment method and interactions were identified. These findings may be attributable to prescribing policies and reimbursement policies. Prescribing policies that restrict prescribers to a formulary may help make them become more adept at using those products; thus, they will make fewer prescribing errors. Reimbursement policies that require patients to consistently use a specific pharmacy (i.e., capitation) may help pharmacists become more familiar with the patient's prescription history. Therefore, interactions with prescribers are needed less frequently for these patients' prescriptions.

To report a case of mercaptopurine-induced fever.

A patient with Crohn's disease was treated with mercaptopurine (6-MP) for an exacerbation of his illness. The patient developed fever and chills. After thorough diagnostic examinations and failure to respond to antimicrobial therapy, symptoms were attributed to an allergic-type reaction to 6-MP. The patient defervesced after 6-MP withdrawal. Fever and chills, along with arthralgias, recurred upon rechallenge with a single dose of 6-MR

Adverse effects attributable to 6-MP therapy in inflammatory bowel disease were reviewed in the literature. Drug-induced fever has been previously reported; however, it is an uncommon adverse effect and is difficult to diagnose. It is also difficult to predict which patients will have the reaction. It is a diagnosis of exclusion requiring a thorough investigation.

Drug-induced fever should be considered when confronted with fever and chills in patients with inflammatory bowel disease being treated with 6-MP. This case report shows the difficulty in differentiating between an infectious process and an adverse reaction to a medication.

To describe the clinical features of serum sickness-like diseases (SSLD) in cefaclor-treated patients.

Analysis of a case series spontaneously reported to Lyons Pharmacovigilance Center.

General and hospital practitioners and the French Network of Regional Pharmacovigilance Centers (FNRPC).

All reported cases with a possible causative relationship between cefaclor treatment and SSLD.

Eight cases of SSLD following cefaclor treatment are described. The clinical features included cutaneous reactions, arthralgias, and moderate hyperthermia. In 50 percent of the patients, hospitalization was required because of incapacitating symptoms. The outcome was benign in all cases following discontinuation of the offending drug. All eight cases were reported in children under five years of age. Among 137 cefaclor-associated drug reactions collected by FNRPC, 27 cases of SSLD have been reported; 23 of these patients were younger than five years of age. A literature survey confirmed the higher reporting of SSLD in children with cefaclor compared with other antibiotics and suggested an incidence of 0.024–0.2 percent of SSLD per drug course of cefaclor.

The case reports and epidemiologic studies confirmed the presumed role of age (patients under five years of age) in cefaclor-induced SSLD and the benign outcome despite severe clinical presentations in some reports.

To document the termination of nightmares brought about by an alteration in the ophthalmic administration of beta-blocking and cholinergic agents.

A 75-year-old man residing in a long-term care facility experienced nightly nightmares of approximately one-year duration.

Other potential causes for the nightmares were eliminated. The administration of the ophthalmic agents was evaluated and the resident was then instructed to alter administration to include closure of his eyes for one to two minutes after administration.

Following the alteration in administration the nightmares were not present and have not reappeared in the ensuing year.

Ophthalmic application of beta-blocking and cholinergic agents is used for the treatment of glaucoma and has been reported to cause a wide variety of central nervous system effects. Researchers have documented reduced systemic absorption and enhanced ocular retention time with specific modifications in the administration of the ophthalmic products. Based on this research the suggestion has been made that systemic adverse effects may be reduced by altering administration through use of lid closure and lacrimal occlusion. This case validates this hypothesis and provides strong evidence for the need to counsel all patients receiving ophthalmic agents on proper administration, including techniques to reduce absorption in order to avoid undesirable systemic effects.

To characterize reports to poison centers involving liquid medication errors associated with the use of dispensing cups. design: Case series reported by 16 US poison centers over an eight-day period.

Calls to poison control centers, predominantly but not exclusively from homes.

Children and adults.

Of 34 reported cases, most (79 percent) involved a two- to threefold dosing error, and most (94 percent) involved an error in a single dose of medication. Cough and cold preparations were implicated in 65 percent; acetaminophen elixirs in 18 percent. Three major causes of dosing errors were identified, including teaspoon/tablespoon confusion, assumption that the dispensing cup was the unit of measure, and assumption that the full dispensing cup was the actual dose.

Dispensing cup markings should use a single unit of measure, and a uniform labeling system should be implemented. Teaspoon/tablespoon abbreviations should be avoided, and dispensing cup lettering should be more legible. Consumer education is essential to correct the misimpression that the full cup is always the recommended dose.

To identify problems with medication knowledge, self-estimated compliance, and recall of medication education in a group of elderly patients.

Survey.

Medicine and geriatric clinics at a county hospital.

Patients ≥60 years old and taking at least one prescription medication.

Medication knowledge, self-estimated compliance, and recall of medication education.

The percent of geriatric patients correctly stating 76–100 percent of their medication doses, uses, and frequencies was 30, 64, and 66 percent, respectively. Fifteen patients (34 percent) stated they never missed a medication dose and 27 (61 percent) remembered to take their medications by memory alone. Sixteen and 86 percent, respectively, of the patients from the medicine and geriatric clinics could not recall receiving verbal or written educational material. Only 27 percent of patients recalled having been told about possible adverse reactions. The most frequently cited providers of medication information were physicians.

Specially designed multidisciplinary medication education programs with repeated written and verbal reinforcement for elderly patients may improve patients' knowledge about their medications, recognition and management of adverse reactions, and compliance.

Because the analgesic effects of ketorolac are equivalent to those of narcotic analgesics, we investigated the possibility that this non-steroidal antiinflammatory drug might also exhibit anesthetic-sparing properties similar to those described for narcotic agents.

A nonrandomized, double-blind convenience sample. The treatment group received a preoperative dose of ketorolac 60 mg im 45 minutes prior to the induction of anesthesia. All other preoperative medications were identical.

Brooke Army Medical Center, a primary care setting.

Six women requiring vaginal hysterectomies from American Society of Anesthesiologists class I/II, all of similar age, weight, and body surface area.

End-tidal concentrations of the anesthetic gas were measured at five-minute intervals using a gas analyzer. A mean percent end-tidal concentration versus time curve was generated for each group.

The area under the concentration curves for the anesthetic gas in the ketorolac and control group were 15.9 ± 5.1 and 52.3 ± 13.4, respectively (p=0.006).

Ketorolac exhibits an anesthetic-sparing quality similar to that observed with narcotic analgesics.

To assess lymphocyte reactivity to dilevalol and to serum containing putative ex vivo dilevalol antigens or metabolites in a case of dilevalol-induced liver injury.

A 58-year-old woman with a clinical diagnosis of dilevalol-induced liver injury.

Peripheral blood mononuclear cells collected from the patient were cultured in the presence of a solution of dilevalol and also with sera collected from a volunteer before and after dilevalol intake. A similar protocol was performed with lymphocytes from a healthy subject.

No lymphocyte proliferation was observed either in the patient or in the healthy volunteer in the presence of dilevalol solutions. A significant proliferative response to serum collected after dilevalol intake was observed in the case of the patient compared with the proliferative response to the serum collected before the drug intake. No reactivity was found when lymphocytes from the healthy subject were tested under similar conditions.

The methodology used allowed the detection of lymphocyte sensitization to sera containing ex vivo-prepared dilevalol antigens, suggesting the involvement of an immunologic mechanism in dilevalol-induced liver injury.

To describe propafenone-induced liver injury.

Retrospective case report.

Referred care in a large tertiary care center. Laboratory tests were performed at the auxiliary site and the tertiary care center.

A 71-year-old woman with atrial fibrillation developed elevations of greater than two times the upper limit of normal in alkaline phosphatase (ALK), alanine aminotransferase (ALT), aspartate aminotransferase (AST), and gamma glutamyltransferase (GGT) after initiation of propafenone therapy.

Studies included serial measurements of ALK, ALT, AST, and GGT.

The patient developed elevations of greater than two times the upper limit of normal in ALK, ALT, and AST, one month after initiating propafenone therapy. The propafenone dose was decreased from 900 to 675 mg/d and, ten days later, the ALK, ALT, and AST were decreased slightly, but still above the upper limit of normal. One month later, serum transaminases had returned to baseline, but propafenone therapy was discontinued because of recurrent atrial fibrillation, persistent elevation in ALK, and elevation in GGT. Two months after discontinuing propafenone, serum aminotransaminase and ALK concentrations had normalized and GGT had decreased and remained only slightly elevated.

The occurrence of liver injury secondary to propafenone therapy is rare. Reported cases appear to be secondary to hepatocellular injury, cholestasis, or a combination of the two. In this case, the pattern demonstrated by elevations in liver enzymes may be classified as acute cholestatic liver injury. Because the reported incidence is 0.1–0.2 percent and there are no known fatalities secondary to propafenone liver injury, routine monitoring of liver function tests in all patients receiving propafenone cannot be recommended at this time. Baseline liver function tests prior to initiating propafenone therapy with follow-up laboratory studies one month later are recommended in patients with known liver dysfunction. If elevations are noted, a reduction in dose may result in lower liver enzyme concentrations, although discontinuation of therapy may be required in some cases.

To report four cases of cinnarizine-induced weight gain.

Case reports from a local obesity center and review articles.

Data were abstracted from spontaneous comments made by patients to one of the authors, who was a doctor at the clinic, and reviewed by the remaining authors.

We reviewed the cases of four women, aged 50–57 years without endocrine or metabolic pathologies, that showed weight gain associated with the intake of cinnarizine for one to two years. No other drugs usually were administered during the period in which the women gained weight, although in two cases cinnarizine was associated with dihydroergocristine in the same medicine (Clinadil). The mean weight increase was 6.25 kg (range 4–10). The increases do not appear to be related to whether the patients' initial weight was ideal or excessive. The weight gain was always associated with increased appetite and food intake. One patient discontinued cinnarizine treatment and her weight returned to its previous level.

Cinnarizine is a piperazine derivative used in the treatment of vertigo and in the prophylaxis of migraine. In contrast to related drugs, data about cinnarizine are scarce because randomized trials of cinnarizine have been inconclusive. Our observations indicate that cinnarizine may cause weight gain, as observed with other drugs in the same class.

To report a case of ciprofloxacin-induced psychosis and to discuss occurrence rates, risk factors, possible etiologies, preventive measures, and treatment courses for this adverse reaction.

Case reports and review articles identified by MEDLINE.

Data from pertinent published sources were reviewed and abstracted.

A 49-year-old man developed symptoms of severe psychosis concomitant with ciprofloxacin (250 mg bid) treatment. Central nervous system effects secondary to ciprofloxacin treatment are uncommon and usually consist only of minor dizziness or mild headache, although rare occurrences of seizures and hallucinations have been reported. The mechanism by which ciprofloxacin causes these adverse effects is not fully understood. It has been suggested that quinolones may produce an epileptogenic effect by inhibiting the binding of gamma-aminobutyric acid to its receptor sites in the brain. There is yet no explanation for the occurrence of hallucinations or psychosis.

Caution should be exercised when using ciprofloxacin in the treatment of patients with personality abnormalities or symptoms of psychosis.

To review the pharmacology, pharmacokinetics, adverse effects, and various dosage regimens of pentostatin, and to evaluate the role of pentostatin in the treatment of hairy cell leukemia (HCL).

Articles were identified via an English-language literature search of MEDLINE (1966–91) and an extensive search of bibliographies from identified articles.

Human clinical trials and case reports were selected for evaluation.

The literature was assessed for quality, methodology, and outcome information.

At dosages of 4 mg/m² administered every other week for 6–9 months, pentostatin has been shown to successfully induce a complete response in 58–90 percent of patients and to produce a partial response in up to 30 percent of patients with HCL. The median time to achieve a response is 4.7 months. Long-term remissions of at least 14 months' duration have occurred in some patients. Compared with interferon alfa alone, total response rates are not significantly different when pentostatin and interferon alfa are used in combination. When dosed appropriately, pentostatin is generally well tolerated. Common adverse effects include nausea, vomiting, myelosuppression, fever, and infection.

Pentostatin is a purine analog that inhibits adenosine deaminase, a key enzyme necessary for purine salvage. Pentostatin has received labeling approval for the treatment of HCL refractory to a minimum of three to six months of treatment with interferon alfa. Based on current data, pentostatin will be a useful addition to the therapeutic agents presently available to patients with HCL. Ongoing trials are evaluating the effectiveness of pentostatin as first-line therapy for patients with HCL.

The objective of this review is to discuss the pathophysiology and potential etiologies of rhabdomyolysis in psychiatric patients, with an emphasis on psychotropic drug-induced rhabdomyolysis.

References were obtained through an on-line search of MEDLINE, using English-language and human literature only.

Because the topic is a potential drug-induced adverse effect, no controlled studies are available. Most of the literature are case reports and series of case reports.

The quality of case reports was assessed using the Food and Drug Administration guidelines for assessing the causality of a potential adverse drug reaction.

The results of this review are based on qualitative data and indicate that rhabdomyolysis in psychiatric patients can be from multiple etiologies, including agitation, dehydration, and intramuscular injections, as well as an adverse effect of psychotropic medications. Although the deficiencies of this type of data are recognized, it is the only type of data often available to assess the etiology and causality of an uncommon adverse event.

Rhabdomyolysis in psychiatric patients can be caused by many factors, both drug- and non—drug-related. Rhabdomyolysis is more likely to occur when patients are faced with a combination of risk factors. When combinations of factors are present (e.g., aggression and restraints, intramuscular injections, and extrapyramidal effects), or when muscle trauma from an individual factor is sufficiently traumatic, muscle necrosis may occur to the point that rhabdomyolysis ensues.

To discuss strategies available for the treatment of herpesvirus infections in individuals infected with HIV.

Information was obtained from controlled and uncontrolled clinical trials, abstracts, conference proceedings, and review articles.

Emphasis was placed on controlled investigations in subjects infected with HIV.

Data from human studies were extracted by the author and evaluated according to the patient population studied, sample size, dosage regimen, and therapeutic response.

Herpes group viruses are common opportunistic pathogens in HIV-infected individuals. Zoster, caused by varicella-zoster virus (VZV), is an early indication of the loss of cell-mediated immunity and HIV disease progression. Anorectal mucocutaneous disease is the most common manifestation caused by herpes simplex virus (HSV). Acyclovir is the drug of choice for treatment of both VZV and HSV infections. Cytomegalovirus (CMV) is the most common life-threatening viral infection in patients with AIDS; retinitis is the most frequent clinical manifestation. The response rate of CMV retinitis to initial treatment with either ganciclovir or foscarnet is equivalent, approximately 60–90 percent. Recent data suggest that the survival benefit may be greater with foscarnet.

Advances in the development and application of antiviral drugs for herpes group viruses have made treatment and, in some cases, prevention of infections possible. Future efforts, aimed at earlier intervention and suppression of latent virus, may offer additional improvement in quality of life for the HIV-infected individual.

To evaluate the benefits, risks, and costs of antimicrobial regimens used for selective decontamination of the digestive tract (SDD) in intensive care unit (ICU) patients.

Information was obtained from clinical trials, review articles, abstracts, and textbooks. Key indexing terms included antibiotics, selective decontamination, and infections.

Research articles describing controlled clinical trials of SDD in medical or surgical ICU patients were reviewed. Trials that investigated transplant, cirrhotic, leukemic, or oncology patient populations were excluded.

The details of studies that evaluated nosocomial infection or nosocomial pneumonia rates were extracted. These included study design, demographics, SDD regimens, severity of illness scores, and colonization, infection, and mortality rates.

The use of SDD in mechanically ventilated surgical or trauma ICU patients reduces the incidence of colonization, nosocomial pneumonia, and overall infection rates, but does not change the overall mortality rate. Administration of antibiotic and antifungal agents in a nasogastric suspension is required for SDD. The addition of systemic prophylactic antibiotics or oropharyngeal paste was not required to decrease nosocomial infections. The most frequently studied SDD regimen (colistin/amphotericin B/tobramycin) is not feasible for use in the US because of exorbitant drug costs. Less expensive alternatives include norfloxacin/nystatin, or colistin/nystatin/gentamicin.

Additional research is required before SDD regimens can be routinely recommended in surgical and trauma ICU patients. A multicenter study is warranted to determine the long-range benefits, potential for resistance, and cost-effectiveness of SDD.

To present a case of possible metoclopramide-induced tardive dyskinesia and document the frequent use of metoclopramide for inappropriate lengths of treatment in elderly, ambulatory subjects.

Descriptive study that identified long-term users of metoclopramide among a population of 4515 elderly subjects.

Participants in an ambulatory health-screening program in Florida (Florida Geriatric Research Program).

Individuals (2898 women and 1617 men) over the age of 65 years who volunteered for annual health screening.

All medication histories for participants were reviewed to identify subjects who reported metoclopramide use on at least one visit to the program.

Thirty-four participants (0.75 percent) reported the use of metoclopramide during at least one visit. Eleven subjects (32.4 percent) reported that they had used this drug for longer than one year. Nine of the 34 subjects (26.5 percent) also reported the use of metoclopramide at their next annual visit.

Results from this study suggest that metoclopramide is frequently prescribed inappropriately to treat gastrointestinal disorders. Long-term use of this drug exposes patients to an unnecessary risk of adverse drug reactions.

To evaluate an education program on metered-dose inhaler (MDI) technique designed for nurses and trained medication aides (TMAs).

The education program included a handout, a lecture incorporating a videotape on correct inhaler and device technique, and hands-on experience with placebo inhalers. The participants' ability to verbalize and demonstrate correct MDI technique was assessed by the same two-person teams before, immediately after, and two months after the program.

Five nursing homes.

Fifty-six nurses and TMAs practicing in nursing homes.

Learning and retention.

The participants' mean (±SD) verbal and demonstration scores increased immediately after the program by 68 ± 18 points for verbalization and 47 ± 16 points for demonstration. The participants were always better at demonstrating than verbalizing MDI technique. The participants' baseline verbal and demonstration scores correlated with the amount learned. Learning was influenced by the individual nursing home (verbal and demonstration) and personal use (demonstration only), but not by academic degree, previous training, past instruction of a patient, or current care of a patient who was receiving inhaler therapy. After two months, the scores were lower than immediately after the program test by 0–92 points for verbalization and 10–80 points for demonstration; however, the mean scores were still significantly greater (p<0.05) than the baseline scores. Retention of knowledge on the correct technique was greater for the demonstration component. Retention was influenced only by the nursing home in which the participant worked, and not any of the other variables.

Our structured education program significantly improved inhaler technique; however, to maintain retention of the material, the program should be frequently repeated.

To review four cases of combined hepatic and renal toxicity that may be associated with the administration of nafcillin in adults. This type of adverse event with the use of nafcillin has not been previously documented in the literature.

References from pertinent articles are identified throughout the text.

Nafcillin is a widely used penicillinase-resistant penicillin. In four patients receiving nafcillin doses greater than 9 g/24 hours, changes in renal and hepatic function markers were noted within 72 hours of the initiation of nafcillin therapy. Laboratory values returned toward baseline when nafcillin therapy was discontinued. Elevations in blood urea nitrogen, creatinine, total bilirubin, and lactate dehydrogenase have been previously described in the literature for penicillin-like agents other than nafcillin. The exact mechanism for such toxicities as well as patient risk factors have not been clearly established.

Caution should be taken when initiating nafcillin therapy. Evaluation of renal and liver function tests prior to initiating nafcillin therapy and within the first 72 hours appears warranted. If hepatic and/or renal toxicity is observed, discontinuation of nafcillin should be considered.

To describe the methods by which a family medicine residency program implements a pharmacotherapy curriculum. The goal of the curriculum is to teach family medicine residents the principles of rational drug therapy.

A university-based family medicine residency program.

Specific learning objectives are discussed and the following teaching strategies are expanded upon: (1) monthly noon conferences; (2) a printed formulary and pharmacotherapy handbook; (3) a pharmacy and therapeutics committee; (4) policy statements for drug representatives and use of samples; (5) an on-site pharmacy; (6) quarterly newsletter, and (7) inpatient consultation coverage.

The role and responsibilities of the pharmacy faculty and pharmacist(s) who implement this curriculum and the methods used to evaluate its effectiveness are also described. The availability and funding of the pharmacy faculty member can sometimes be arranged with local schools of pharmacy seeking clerkship sites. Interaction with pharmacy students also serves to enhance the educational experience of the family medicine residents.

The family medicine program implements a comprehensive curriculum designed to teach family medicine residents the principles of rational drug therapy. The curriculum may be expanded upon as necessary, or, if the entire program is not feasible, certain elements may be extracted and applied in other institutions.

To describe the development of drug surveillance and drug information in The Netherlands.

Historically, the professions of medicine and pharmacy have existed separately with little contact between them. Since the 1960s, this situation has changed in The Netherlands. Both professions are cooperating to an ever-increasing degree, primarily in the areas of computerized drug surveillance and individualized patient drug information, resulting in greater patient benefit.

Exchange of knowledge between physicians and pharmacists, greater cooperation among professionals, use of computerized patient medical records, and involvement of the patient in his own healthcare will have a positive influence on the development of drug assistance in the future.

To determine the ratio represented by essential drugs (EDs) in the total consumption of drugs in Czechoslovakia in 1989.

Retrospective analysis of the assortment and consumption of EDs in 1989.

Department of the Organization and Management of Pharmacy, Faculty of Pharmacy, Bratislava.

Consumption of drugs and/or pharmacotherapeutic groups, expressed by the number of formulations, number of units, and in financial terms.

EDs constitute approximately one-third of the total consumption of drugs in Czechoslovakia (both in terms of volume and finances); almost 60 percent of EDs have dosage forms and concentrations identical to those shown in the World Health Organization Model List of Essential Drugs (Sixth List).

The results obtained indicate that there is need for a regular updating of the drug policy within the public health branch of the government to more effectively regulate the production and import of drugs.