Tobacco sales in pharmacies: time to quit.

OBJECTIVE: To assess the pharmacy profession's perceptions of tobacco sales in US pharmacies and explore whether a policy prohibiting sales of tobacco in pharmacies would alter adult consumer shopping behaviour. SUBJECTS AND DESIGN: In California, surveys were administered to 1168 licensed pharmacists and 1518 pharmacy students, and telephone interviews were conducted with 988 adult consumers. RESULTS: Most (58.1%) licensed pharmacists were strongly against sales of tobacco in pharmacies, 23.6% were against it, 16.7% were neutral, 1.2% were in favour of it, and 0.4% were strongly in favour of it. Pharmacists who were current tobacco users were more likely to be in favour of tobacco sales in pharmacies than were pharmacists who were current non-users (p < 0.005). Similar statistics were observed for pharmacy students. Most consumers (72.3%) disagreed with the statement, "I am in favour of tobacco products being sold in drugstores"; 82.6% stated that if the drugstore where they most commonly shopped were to stop selling tobacco products, they would shop there just as often, 14.2% would shop there more often, and 3.2% would shop there less often. CONCLUSION: Little professional or public support exists for tobacco sales in pharmacies.

Prevention of adverse events in hospitalized patients using an antimicrobial review program.

OBJECTIVE: To evaluate whether an antimicrobial review system is associated with a reduction in antimicrobial-associated adverse events. DESIGN: All antimicrobial medication orders for patients hospitalized over a two-year period were evaluated. High-level interventions intended to prevent adverse antimicrobial events were collated. Based on literature estimates of adverse antimicrobial events, potential reduction of high-level adverse antimicrobial events was estimated. SETTING: Department of Clinical Pharmacy and Division of Infectious Diseases at a tertiary care teaching hospital. RESULTS: A total of 452 interventions were classified as "high-level." The incidence of preventable adverse antimicrobial events requiring intervention was 16 per 1000 antimicrobial orders. The incidence of high-level errors necessitating intervention was 4.4 per 1000 antimicrobial orders. An estimated 125 to 198 high-level adverse events were avoided. CONCLUSION: An antimicrobial review program has the potential to reduce significant adverse events in hospitalized patients.

Doxepin in the management of pruritus associated with allergic cutaneous reactions.

The primary treatment of urticaria involves identification and discontinuation of the offending agent. Addition of an antihistaminic agent may then be necessary to control pruritus. Because of variable response rates between patients, several alternative agents may need to be tried before the most effective regimen is found. Based on the studies reviewed here, it appears that low-dose doxepin (10 mg po tid) is a potentially effective and well-tolerated alternative in patients who do not respond to conventional antihistamines. This success may be in part due to the more potent H1- and H2-blocking properties associated with doxepin. Data regarding the topical use of doxepin are less convincing; however, the drug appears to have some clinical use for the short-term treatment of pruritus. Doxepin cream does not appear to be as effective as systemic therapy, and adverse effects (including sedation) and drug interactions are still problematic. Topical use may be best suited to conditions involving intact skin that do not require application to large areas of the body, thereby reducing systemic absorption and adverse effects.

Influence of timing of antibiotic administration on tissue concentrations during surgery.

BACKGROUND: Prophylactic antibiotics must be administered so as to achieve adequate tissue levels before the initial surgical incision. We characterized antimicrobial tissue concentrations following intravenous administration at various times prior to surgical incision. PATIENTS AND METHODS: Twelve patients scheduled for elective colorectal surgery were randomized to receive cefmetazole 2 g by intravenous push either immediately prior to incision or 15 to 60 minutes prior. Blood and wound-muscle samples were obtained at predetermined intervals and assayed by high-performance liquid chromatography. RESULTS: Tissue distribution of the study drug was extremely rapid. All patients had theoretically adequate tissue levels at the time of incision. Levels above MIC90 of the common pathogens were sustained throughout the surgical procedure regardless of the timing of administration. CONCLUSIONS: Administration of cefmetazole immediately prior to surgical incision should be effective prophylaxis for surgical wound infections.

Renal insufficiency associated with intramuscular administration of ketorolac tromethamine.

OBJECTIVE: To evaluate reports of renal toxicity associated with intramuscular ketorolac tromethamine. Medical charts were reviewed for all cases of renal toxicity associated with ketorolac therapy. METHODS: Patients with possible ketorolac-associated nephrotoxicity were identified through our institution's adverse drug reaction reporting program. Patients were included in this report if: (1) renal insufficiency was temporally related to ketorolac administration; (2) resolution of renal insufficiency occurred after discontinuation of ketorolac; and (3) no other causes of renal insufficiency, including other medications, could be identified. RESULTS: Six patients had renal insufficiency secondary to ketorolac administration. The mean age of the patients was 58 years and cardiovascular disease was present in five. Serum creatinine values increased from a mean of 106 +/- 26 mumol/L (1.2 +/- 0.3 mg/dL) to a mean peak value of 256 +/- 195 mumol/L (2.9 +/- 2.2 mg/dL). Recovery of renal function was observed after a mean of 2.3 +/- 0.5 days. CONCLUSIONS: Short-term administration of ketorolac can be associated with reversible oliguric renal insufficiency. Indiscriminate use of ketorolac for pain management in place of narcotic analgesics should be avoided, especially in patients at high risk for toxicity induced by nonsteroidal antiinflammatory drugs.

Medication usage patterns in patients with human immunodeficiency virus infection: a comparison of patient-reported medication usage with medical chart review.

Patients infected with the human immunodeficiency virus (HIV) receive numerous medications from multiple providers. As a result, it is important that medication usage is properly documented in each patient's medical record. Lack of adequate documentation may confound a provider's assessment of drug efficacy, potentially leading to an increased incidence of drug interactions and adverse effects. The objective of this study was to determine if discrepancies exist between patient-reported medication usage and that documented in the medical record by healthcare providers. Data were obtained using structured telephone surveys and medical chart review. Study participants were recruited from the University of California, San Francisco Medical Center AIDS Clinic. Results obtained for 41 patients demonstrated discrepancies between patient-reported medication usage and that documented in the medical record ranging from 9 to 92 percent, depending on the class of drug. The largest differences were observed with the "as-needed" class of drugs: benzodiazepines (92 percent), morphine (60 percent), and codeine (56 percent). Differences were also noted for scheduled medications: ketoconazole (54 percent), clotrimazole (45 percent), acyclovir (38 percent), zidovudine (15 percent), and pentamidine (9 percent). These observed discrepancies reaffirm the need for accurate exchange of information between provider and patient to promote the most effective, rational, and safe drug therapy. Careful reviews of medication usage at each visit and use of pharmacy-based medication profiles are potential mechanisms to improve documentation of medication usage in HIV-infected patients.