Torsades de pointes associated with high dose levomethadyl acetate (ORLAAM).

A patient undergoing management of heroin dependency with high dosages of the long-acting methadone derivative, levomethadyl acetate HCl (LAAM; ORLAAM) developed a prolonged QTc interval and polymorphic QRS complexes on EKG consistent with torsades de pointes (TdP). The patient was taking other drugs known to prolong the QTc interval (fluoxetine and IV cocaine), and those known to antagonize the activity of the P450 enzymes responsible for the metabolism of LAAM and its active metabolite (fluoxetine, cocaine and marijuana). No previous reports have appeared in the literature attributing this adverse event to LAAM therapy; however, five similar cases have been reported to the manufacturer. Animal studies indicate that LAAM and metabolites prolong the action potential duration of myocardial cells. We propose that predisposed patients on high doses of LAAM may be at risk for developing TdP. Patients being treated with LAAM should receive dosages consistent with guidelines and be evaluated for concomitant diseases, interacting drug therapies, and EKG abnormalities.

A diagnostic cluster system for skilled nursing facilities.

BACKGROUND AND OBJECTIVES: Diagnostic cluster systems have been developed to assist in analyzing diagnoses in outpatient and inpatient settings but not in convalescent hospital settings. We developed a diagnostic cluster system for skilled nursing facilities (SNFs) designed to include or capture a greater proportion of such diagnoses than a previously established inpatient diagnostic cluster system. METHODS: We tested the ability of the new SNF diagnostic cluster system to code diagnoses on records from SNFs in different geographic areas. Then we compared the proportion of admitting diagnoses captured by the new SNF diagnostic cluster system and by a previously established inpatient system. RESULTS: The new diagnostic cluster system captured between 92% and 96% of admitting diagnoses at the study SNFs. There was no statistically significant difference among the facilities in the proportion of diagnoses captured by the new system. By comparison, the previously established inpatient system captured only 59%-65% of these admitting diagnoses. The new system captured significantly more diagnoses than the previously established inpatient system. CONCLUSIONS: The new SNF diagnostic cluster system can be used to capture and code diagnostic data from SNFs.

The evolution of aminoglycoside therapy: a single daily dose.

After five decades of clinical use, aminoglycosides continue to be important antibiotics in the management of gram-negative infections. However, antimicrobial therapy with gentamicin, tobramycin, amikacin and netilmicin has been complicated by the risk of nephrotoxicity and ototoxicity. Considerable research has been conducted to determine the optimal aminoglycoside dosing method that will produce maximum efficacy with minimal toxicity. Experimental data and clinical experience suggest that aminoglycoside regimens modified from standard dosing (every eight to 12 hours) to once-daily dosing may provide improved clinical outcomes, with reduced toxicity and cost of therapy. Gentamicin, tobramycin and netilmicin may be administered in single daily dosages ranging from 4 to 7 mg per kg, and amikacin may be given in a dosage of 15 to 20 mg per kg once daily.

Closet hypoglycemia.

An elderly nondiabetic woman was found stuporous and unresponsive at home. In the emergency department, testing revealed that she had a serum glucose of 40 mg/dL (2.2 mmol/L). No underlying metabolic cause could be determined. An inspection of her medications disclosed a professional medication sample bottle labeled as containing a nonsteroidal anti-inflammatory drug (NSAID) that actually contained chlorpropamide tablets. Drugs, notably sulfonylureas, must be considered as a possible cause of unexplained severe hypoglycemia.

Hypersensitivity and anaphylactoid reactions to ciprofloxacin.

OBJECTIVE: To report three cases of life-threatening hypersensitivity reactions to the oral administration of ciprofloxacin. CASE SUMMARY: Life-threatening hypersensitivity reactions to oral ciprofloxacin, characterized by diffuse, erythematous, nonpruritic, blanching rash, with fever and hypotension, occurred in two HIV-infected patients. One of these reactions was considered anaphylactoid. A similar hypersensitivity reaction was documented in a non-HIV-infected patient. DISCUSSION: Premarketing clinical trials described no reports of life-threatening anaphylactoid hypersensitivity reactions to ciprofloxacin. However, postmarketing surveillance studies have documented their occurrence. Seven cases of anaphylactoid reaction to ciprofloxacin have now been documented in HIV-infected patients. CONCLUSIONS: As with trimethoprim/sulfamethoxazole, HIV-infected people treated with ciprofloxacin may be at special risk for hypersensitivity reactions.

The role of medications in geriatric sexual function.

Geriatric patients take proportionately more drugs than do their younger counterparts. This, along with an aging sexual physiology, places them at greater risk for experiencing adverse drug reactions affecting sexual function. The major therapeutic categories implicated in drug-induced geriatric sexual dysfunction are the psychotherapeutic agents, such as the antidepressants and the neuroleptics, and the cardiovascular agents, predominantly the antihypertensives. There are limited drug therapies available for the treatment of sexual dysfunction in the elderly. Therapies associated with some limited clinical success include the use of testosterone and bromocriptine for impotence associated with androgen deficiencies, intracavernosal injection of vasoactive drugs, and yohimbine. Women with inadequate maintenance of vaginal lubrication may benefit from topical lubricants or estrogens and orally or transdermally administered estrogens.

Use of long half-life parenteral cephalosporins in ambulatory practice.

Cefonicid (Monocid) and ceftriaxone (Rocephin) are long half-life cephalosporins that may be used for serious infections in the outpatient setting. They may be used as an extension of initial hospital treatment, or therapy can be initiated and completed in many cases with the patient remaining at home. Sufficient clinical experience exists with both ceftriaxone and cefonicid to recommend these agents for selected patients having pyelonephritis, osteomyelitis, or soft tissue infections. Cefonicid, perhaps in combination with erythromycin, will provide excellent coverage for complicated community-acquired pneumonias. Ceftriaxone is effective as single-dose therapy for even complicated gonococcal infections. The use of long half-life cephalosporins in ambulatory practice may result in substantial cost savings for certain patients.

Improved spectrophotometric determination of glycerol and its comparison with an enzymatic method.

A chemical method for the determination of glycerol was developed and compared to an enzymatic assay for sensitivity and reproducibility. The chemical assay is based on glycerol oxidation to formaldehyde and subsequent reaction with chromotropic acid to yield a colored product. With this method, as little as 5 micrograms of glycerol/ml can be detected. The enzymatic assay is based on enzymatic glycerol phosphorylation followed by glycerol phosphate dehydrogenation by nadide (nicotinamide adenine dinucleotide). The reduced nadide is used to reduce iodonitrotetrazolium violet to its colored formazan product. The enzymatic method can be used to deterine 50 micrograms of glycerol/ml in aqueous samples.