ABSTRACT
Introduction: Digital artery aneurysms are a rare event but cases have been reported in the literature. The hemostasis disorders make these aneurysms particularly dangerous with potentially irreversible hand complications: Compression of adjacent vascular and nervous structures, embolization of associated thrombi, finger ischemia, and necrosis. Case Report: We reported a case of digital ischemia due to a ruptured aneurysm of a digital collateral artery, leading to the diagnosis of congenital hemophilia A. Hematoma evacuation allowed finger revascularization. Complete symptom resolution required ligature excision associated with Factor VIII supplementation. Conclusion: Aneurysms of the digital collateral arteries are a rare event. In the case of a hemophilic patient, surgical management is necessary, and medical treatment alone is not sufficient. The consequences of a ruptured aneurysm in this type of patient can be serious. A close monitoring is required to ensure the absence of early recurrence.
ABSTRACT
BACKGROUND: Appropriate training for community pharmacists may improve the quality of medication use. Few studies have reported the impact of such programs on medication management for patients with chronic kidney disease (CKD). STUDY DESIGN: Multicenter, cluster-randomized, controlled trial. SETTING & PARTICIPANTS: Patients with CKD stage 3a, 3b, or 4 from 6 CKD clinics (Quebec, Canada) and their community pharmacies. INTERVENTION: Each cluster (a pharmacy and its patients) was randomly assigned to either ProFiL, a training-and-communication network program, or the control group. ProFiL pharmacists completed a 90-minute interactive web-based training program on use of medications in CKD and received a clinical guide, patients' clinical summaries, and facilitated access to the CKD clinic. OUTCOMES: Drug-related problems (primary outcome), pharmacists' knowledge and clinical skills, and patients' clinical attributes (eg, blood pressure and glycated hemoglobin concentration). MEASUREMENTS: Drug-related problems were evaluated the year before and after the recruitment of patients using a validated set of significant drug-related problems, the Pharmacotherapy Assessment in Chronic Renal Disease (PAIR) criteria. Pharmacists' questionnaires were completed at baseline and after 1 year. Clinical attributes were documented at baseline and after 1 year using available information in medical charts. RESULTS: 207 community pharmacies, 494 pharmacists, and 442 patients with CKD participated. After 1 year, the mean number of drug-related problems per patient decreased from 2.16 to 1.60 and from 1.70 to 1.62 in the ProFiL and control groups, respectively. The difference in reduction of drug-related problems per patient between the ProFiL and control groups was -0.32 (95% CI, -0.63 to -0.01). Improvements in knowledge (difference, 4.5%; 95% CI, 1.6%-7.4%) and clinical competencies (difference, 7.4%; 95% CI, 3.5%-11.3%) were observed among ProFiL pharmacists. No significant differences in clinical attributes were observed across the groups. LIMITATIONS: High proportion of missing data on knowledge and clinical skills questionnaire (34.6%) and clinical attributes (11.1%). CONCLUSIONS: Providing community pharmacists with essential clinical data, appropriate training, and support from hospital pharmacists with expertise in nephrology increases pharmacists' knowledge and reduces drug-related problems in patients with CKD who are followed up in clinics incorporating a multidisciplinary health care team.
Subject(s)
Community Pharmacy Services , Medication Therapy Management , Nephrology/education , Pharmacists/standards , Renal Insufficiency, Chronic/drug therapy , Blood Pressure/drug effects , Clinical Competence/standards , Community Pharmacy Services/organization & administration , Community Pharmacy Services/standards , Drug-Related Side Effects and Adverse Reactions/prevention & control , Education/methods , Female , Glycated Hemoglobin/analysis , Health Services Accessibility/standards , Humans , Male , Medication Therapy Management/education , Medication Therapy Management/standards , Middle Aged , Patient Acuity , Quality Improvement , Staff Development/methods , Surveys and QuestionnairesABSTRACT
BACKGROUND: Cisplatin-induced nephrotoxicity occurs in about one-third of patients who receive this chemotherapy drug. In late 2012, the study institution began measuring serum creatinine on day 7 after administration of cisplatin to identify patients with acute renal failure. OBJECTIVE: To evaluate the extent of nephrotoxicity associated with cisplatin and the influence of risk factors for nephrotoxicity. METHODS: This retrospective study involved patients who received a first cycle of cisplatin-based chemotherapy between November 1, 2012, and November 1, 2013. Patients' medical records were reviewed to determine the increase in creatinine level (graded according to the National Cancer Institute Common Terminology Criteria for Adverse Events) and the influence of certain prespecified risk factors, such as age, concomitant medications, initial dose of cisplatin, and related medical conditions. RESULTS: Among the 80 patients evaluated, 14 (17%) experienced no increase in the level of serum creatinine (grade 0), 44 (55%) experienced a grade 1 increase, 19 (24%) a grade 2 increase, and 3 (4%) a grade 3 increase; no patients experienced a grade 4 increase. Patients with the greatest risk of a grade 2 or 3 increase were those treated with hydrochlorothiazide (odds ratio [OR] 9.35, 95% confidence interval [CI] 2.49 to 35.14) or an angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker (OR 5.02, 95% CI 1.76 to 14.32). After adjustment, only hydrochlorothiazide was associated with an increased risk of nephrotoxicity (OR 5.39, 95% CI 1.04 to 28.07). Among patients taking hydrochlorothiazide, the average incremental increase in serum creatinine was 59.9 µmol/L (95% CI 34.3 to 85.4 µmol/L). CONCLUSIONS: Taking hydrochlorothiazide was associated with a significant increase in serum creatinine following cisplatin therapy. On the basis of these results, patients should stop taking hydrochlorothiazide before undergoing cisplatin-based chemotherapy.
CONTEXTE: La néphrotoxicité associée au cisplatine se produit chez environ le tiers des patients qui reçoivent ce médicament de chimiothérapie. À la fin de 2012, l'établissement de santé des auteurs a commencé à mesurer la créatinine sérique au jour 7 après l'administration de cisplatine afin de repérer les patients atteints d'insuffisance rénale aiguë. OBJECTIF: Évaluer le degré de la néphrotoxicité associée au cisplatine et déterminer si des facteurs de risque favorisent cette néphrotoxicité. MÉTHODES: Cette étude rétrospective a été menée auprès de patients ayant subi un premier cycle de chimiothérapie à base de cisplatine entre le premier novembre 2012 et le premier novembre 2013. Les dossiers médicaux des patients ont été examinés afin de détecter les cas d'augmentation de créatinine sérique (qui ont été classés selon les critères pour une terminologie commune des événements indésirables du National Cancer Institute) et l'influence de facteurs de risque préétablis (âge, médicaments concomitants, dose initiale de cisplatine et pathologies associées). RÉSULTATS: Parmi les 80 patients analysés, 14 (17 %) n'affichaient aucune augmentation du taux de créatinine sérique (degré 0), 44 (55 %) présentaient une augmentation de degré 1, 19 (24 %) affichaient une augmentation de degré 2 et 3 (4 %) présentaient une augmentation de degré 3; aucun ne présentait une augmentation de degré 4. Les patients qui couraient le plus grand risque de connaître une augmentation de degré 2 ou 3 étaient ceux traités avec l'hydrochlorothiazide (risque relatif approché [RRA] de 9,35, intervalle de confiance [IC] à 95 % de 2,49 à 35,14) ou d'un inhibiteur de l'enzyme de conversion de l'angiotensine ou d'un bloqueur des récepteurs de l'angiotensine II (RRA de 5,02, IC à 95 % de 1,76 à 14,32). Après ajustement, seul l'hydrochlorothiazide était associé à une augmentation du risque de néphrotoxicité (RRA de 5,39, IC à 95 % de 1,04 à 28,07). Parmi les patients qui prenaient de l'hydrochlorothiazide, l'augmentation différentielle moyenne de créatinine sérique était de 59,9 µmol/L (IC à 95 % de 34,3 à 85,4 µmol/L). CONCLUSIONS: La prise concomitante d'hydrochlorothiazide a été associée à une augmentation significative de la créatinine sérique après un traitement de cisplatine. Considérant ces résultats, les patients devraient cesser de prendre de l'hydrochlorothiazide avant de recevoir une chimiothérapie à base de cisplatine.
