Profile and outcome of patients presenting with agrochemical poisoning to the emergency department.

BACKGROUND: Deliberate self-harm (DSH) is one of the leading causes of mortality and morbidity in India. Agrochemicals are the most commonly used compounds for DSH. The spectrum of Agrochemicals in use varies from region to region and time period with newer compound being regularly introduced into the market. METHODOLOGY: This retrospective cohort study included patients presenting with agrochemical poisoning to the ED during January 2017 to December 2018. Patient data was retrieved form the ED triage registry software and clinical workstation, following which their hospital outcome was determined. RESULTS: During the study period, 1802 patients presented with DSH among which Agrochemical poisoning comprised 33.5% (604/1802). The mean age was 31 years and incidence of agrochemical poisoning was found to be higher in young adults (16-30 years-55.8%). The prevalence was more common in males (62.4%). The common agrochemical compounds consumed were insecticides (91%), herbicides (4.3%), fungicides (1.5%), fertilizer (1.5%), and plant growth regulators (1.5%). Majority (80.96%) of the patients were discharged alive from the hospital, 17% left against medical advice due to bad prognosis and 12 patients (2%) died in the hospital. CONCLUSION: Insecticides (mainly Organophosphates) are the most common agrochemicals used for DSH. Their management is better understood leading to better outcomes compared to other chemicals. The proportion of agrochemical use in DSH has reduced over the last decade. Imidacloprid (Insecticide) and Plant growth regulators are the new compounds for which appropriate management is not yet established and more research is needed.

Verteporfin for age-related macular degeneration.

OBJECTIVE: To review the pharmacology, pharmacokinetics, clinical efficacy, adverse effects, drug-drug interactions, and the therapeutic issues concerning the use of verteporfin in patients with age-related macular degeneration (AMD). DATA SOURCES: Published articles and abstracts in English were identified by MEDLINE (1990-August 2000) searches using the search terms verteporfin, treatment of age-related macular degeneration, and photodynamic therapy (PDT). Additional references were identified from the bibliographies of the retrieved articles. Data were also obtained from approved product labeling. DATA EXTRACTION: The literature was assessed for adequate description of patients, methodology, and outcomes. DATA SYNTHESIS: Verteporfin is a synthetic benzoporphyrin derivative and a cytotoxic photosensitizing agent, which is one component of PDT. PDT involves administration of verteporfin for injection and nonthermal red light at a wavelength of 689 nm. It is metabolized, to a small extent, to its diacid metabolite by liver and plasma esterases. Information concerning drug interactions is limited. In clinical trials, verteporfin was effective in patients with wet AMD as demonstrated in standard visual acuity scores. Adverse events were related to injection site reactions and visual disturbances. CONCLUSIONS: Verteporfin is a welcome alternative to laser photocoagulation, which can result in damage to the retina and lead to visual loss. Although long-term trials have not been performed in humans, results from monkeys indicate possible improvement in vision following PDT with verteporfin.

Effect of gender on the pharmacokinetics of ofloxacin.

STUDY OBJECTIVES: To assess the influence of gender on the pharmacokinetics of ofloxacin. DESIGN: Open-label study. SETTING: Academic medical center. PATIENTS: Five healthy men and seven healthy women volunteers. INTERVENTIONS: Subjects received a single oral dose of ofloxacin 400 mg, and serial blood samples were collected for 24 hours. Plasma concentrations of ofloxacin were determined by high-performance liquid chromatography and pharmacokinetic parameters were determined. Statistical comparisons between genders were made with the Wilcoxon rank sum test. MEASUREMENTS AND MAIN RESULTS: Median volume of distribution at steady state/systemic bioavailability (V(ss)/F) was significantly smaller in women than in men, although when normalized for total body weight there were no differences. Except for terminal elimination half-life, which was 10% shorter in women, no other pharmacokinetic values were significantly different between genders. Median peak concentrations, although not statistically different, were 28% higher in women. CONCLUSION: Ofloxacin V(ss)/F values were smaller in women than in men, explained by gender-related differences in weight.

Decrease in expenditures and selected nosocomial infections following implementation of an antimicrobial-prescribing improvement program.

OBJECTIVE: To evaluate changes in antimicrobial use and expenditures and the rates of selected nosocomial infections due to resistant organisms associated with implementation of an antimicrobial-prescribing improvement program. DESIGN: Before-after trial comparing 1992 (pre-program), 1993 (a transition year), and 1994 (after full implementation of the program). SETTING AND PARTICIPANTS: Academic medical center, all patients and physicians. INTERVENTION: An antimicrobial-prescribing improvement program with prior approval requirement for use of restricted agents. MAIN OUTCOME MEASURES: Antimicrobial use and expenditures, rates of selected nosocomial infection marker events. RESULTS: Between 1992 and 1994, there were substantial decreases in antimicrobial use, from 158,107 to 137,364 defined daily doses, and in expenditures from $2,486,902 ($24.01 per patient day) to $1,701,522 ($18.49 per patient day). After adjusting for changes in purchase prices and census days, we estimated savings attributable to the program of $279,573 in 1993 and $389,814 in 1994. In addition, we found significant decreases between 1992 and 1994 in the rates of enterococcal bacteremia (.34 vs .16 events per 1,000 patient days; P = .016), selected gram-negative bacteremia (.26 vs .11; P = .015), methicillin-resistant Staphylococcus aureus colonization or infection (.66 vs .20; P < .0001), and Stenotrophomonas colonization or infection (.35 vs .17; P = .019). No significant change occurred in rates of nosocomial candidemia or Clostridium difficile toxin-positive diarrhea. Values for 1993 were intermediate between those of 1992 and 1994. CONCLUSION: Implementation of an antimicrobial-prescribing improvement program was associated with substantial savings in antimicrobial use and expenditures and significant decreases in rates of selected nosocomial infections due to resistant organisms.

Comparison of the ocular beta-blockers.

OBJECTIVE: To compare the similarities and differences among the ocular beta-blockers. Important considerations when comparing these agents are the differences in systemic adverse effects, local tolerability, and cost. DATA SOURCE: Information was retrieved from a MEDLINE search of the English-language literature and bibliographic reviews of review articles. Index terms included beta-blockers, glaucoma, timolol, levobunolol, betaxolol, metipranolol, and carteolol. STUDY SELECTION: Emphasis was placed on eyedrop studies, as well as properly designed and executed clinical trials that assessed dosage, dosing interval, therapeutic response, adverse effects, and cost. DATA EXTRACTION: Data from several studies were evaluated according to the study design, therapeutic response, and adverse effects. DATA SYNTHESIS: Timolol maleate, levobunolol, metipranolol, and carteolol have similar effectiveness in lowering intraocular pressure; however, levobunolol and timolol gel forming solution may have an advantage of once-daily dosing. Studies have not been published comparing the clinical efficacy of timolol hemihydrate with that of other ocular beta-blockers. Metipranolol is cost effective in treating primary open-angle glaucoma; however, it has been associated with more ocular burning, stinging, and granulomatous anterior uveitis than other agents. The intrinsic sympathomimetic activity of carteolol has not yet displayed a definite advantage over the other agents in terms of optic disk perfusion and systemic adverse effects. The control of intraocular pressure with betaxolol has not always been as good as with timolol; however, betaxolol has some advantages over timolol and the other topical beta-blockers in terms of systemic adverse effects. CONCLUSIONS: Considering cost, efficacy, and safety, timolol maleate is the recommended formulary agent because the other agents cannot consistently show an outstanding advantage.

Terfenadine pharmacokinetics in breast milk in lactating women.

The excretion of terfenadine into breast milk has not been reported previously. Disposition of terfenadine was prospectively studied in four healthy lactating mothers (age, 33 +/- 4 years). Subjects received 60 mg terfenadine every 12 hours over a period of 48 hours to achieve steady-state milk and plasma concentrations. Milk and plasma samples were collected at 1/2, 1, 1 1/2, 2, 3, 4, 6, 8, 12, 24, and 30 hours after the last dose. Terfenadine and its active metabolite milk and plasma concentrations were quantitated by HPLC. Terfenadine was not detected in milk or plasma. Mean +/- SD active metabolite data for milk and plasma are as follows: Cmax (ng/ml), 41.0 +/- 16.4 for milk, 309.0 +/- 120.5 for plasma; tmax (hours), 4.3 +/- 2.4 for milk, 3.9 +/- 3.0 for plasma; t1/2 beta (hours), 14.2 +/- 5.4 for milk, 11.7 +/- 6.4 for plasma; AUC(0-12) (ng.hr/ml) 320.4 +/- 99.8 for milk, 1590.0 +/- 300.4 for plasma. Metabolite milk/plasmaAUC(0-12) ratios ranged from 0.12 to 0.28 (mean, 0.21 +/- 0.07). Newborn dosage estimates based on the highest measured concentration of terfenadine metabolite in milk suggests the maximum level of newborn exposure would not exceed 0.45% of the recommended maternal weight-corrected dose. Estimated amounts consumed by the neonate after the mother is given the recommended dose of the drug are not likely to result in plasma levels producing untoward effects.

Effect of enteral feeding with ensure on oral bioavailabilities of ofloxacin and ciprofloxacin.

The relative oral bioavailabilities of ciprofloxacin and ofloxacin when they were coadministered with water or an enteral feeding product (Ensure) were assessed in 13 healthy volunteers. The area under the concentration time curve from time zero to infinity and the maximum concentration of drug in serum for both drugs were reduced by Ensure in comparison with those by water (P < 0.01). However, Ensure reduced the percent relative bioavailability of ciprofloxacin (72% +/- 14%; range, 52 to 96%) significantly more than ofloxacin (90% +/- 8.3%; range, 74 to 105%) (P < 0.005). Coadministration of Ensure significantly diminished ciprofloxacin and ofloxacin absorption, but ciprofloxacin absorption was reduced significantly more than ofloxacin absorption.

Evaluation of an imipenem/cilastatin target drug program.

This article describes an imipenem/cilastatin (I/C) target drug program. The program, developed following completion of a drug usage evaluation study, was designed to improve I/C dosing, reduce central nervous system (CNS) adverse effects, and reduce antibiotic costs. Following completion of an inservice education program for the medical and pharmacy professional staffs, ongoing monitoring of I/C usage was accomplished through the pharmacy-based drug-dosing service. Pharmacists evaluated I/C dosage based upon culture/sensitivity results and indicators of renal function. If deemed inappropriate, the pharmacist contacted the prescribing physician with a dosage recommendation. Two hundred ten courses of I/C therapy were prescribed in the nine-month period following implementation of the target drug program; 26 cases (12 percent) required dosage adjustment. The incidence of CNS adverse effects including seizures decreased from 15 to 1 percent (p = 0.0015). A $6033 drug cost avoidance also resulted from pharmacist intervention.

Impact of college of pharmacy-based educational services within the hospital.

Using a pharmacy intervention form, we measured the influence that university-based pharmacy educational personnel had on the pharmacy department's drug costs and on patient charges over a three-month period. A total of 278 interventions were made; 88.8 percent were implemented. Implemented interventions decreased drug costs by $1661.99 and decreased patient charges by $5938.37. The average implemented intervention decreased drug cost by $6.73 and patient cost by $24.04. Regardless of economic benefits, 218 of the 247 implemented interventions were considered to have positive clinical effects on patient care. Educational personnel were responsible for generating $6028.27 of fee revenues to the pharmacy department through generation of pharmacokinetic drug dosing consults. We conclude that the educational programs provided by the pharmacy department through affiliation with a college of pharmacy directly contributed $7690.26 to the pharmacy department in the form of cost-avoided dollars and revenue generation over a three-month period. The provision of educational services by a hospital pharmacy department results in financial rewards as well as other benefits that have been previously described.

Cost analysis of mixing clindamycin and aminoglycosides.

Data were collected to determine if cost savings could be achieved by mixing clindamycin and aminoglycosides (gentamicin or tobramycin) in the same minibag for intravenous administration. The following issues were investigated: drug and supply costs associated with combination admixtures, pharmacy labor costs, and waste. Over a 17-month period, 1961 combination admixtures were prepared; 62 of these doses were wasted. Drug cost savings of $128.15, supply cost savings of [4719.48, and labor cost savings of [1878.40 were achieved, with an overall cost savings (minus waste) of $5658.01. Overall waste was similar with the combined admixture service and the preparation of separate doses, and the aminoglycoside pharmacokinetic dosing service did not substantially affect use of the combination admixtures. The clindamycin and aminoglycoside admixture system was effective in reducing supply and labor costs.