Improved health-related quality of life with SSRIs and other antidepressants.

STUDY OBJECTIVE: To document the health-related quality of life (HRQOL) of depressed patients receiving antidepressant drugs. DESIGN: Cross-sectional study. SETTING: Community pharmacy-based setting. PATIENTS: Fifty-seven depressed patients. INTERVENTION: Independent pharmacist members of the Community Pharmacists Research Network in Georgia administered the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) to subjects. MEASUREMENTS AND MAIN RESULTS: Sixty-one percent of patients were treated with a selective serotonin reuptake inhibitor (SSRI) and 38.6% were treated with a non-SSRI. Those receiving SSRIs scored higher on the mean physical (PCS) and mental (MCS) health summary scores of the SF-36 than those not receiving the drugs. No significant differences were seen in PCS or MCS scores of men and women. CONCLUSION: Community pharmacists documented better HRQOL in patients receiving SSRIs than in those given other antidepressants.

The expanding role of pharmacy and therapeutics committees. The 1990s and beyond.

Traditionally, pharmacy and therapeutics (P&T) committees have been responsible for overseeing the drug use process, using formulary systems to control drug costs. Primarily, these committees act in an advisory capacity as policy-recommending bodies within healthcare systems, for the specific purpose of promoting rational drug therapy. Methodologies utilised by these committees include drug use evaluation, medical staff education, continuous quality improvement, formulary restriction and therapeutic interchange. Future roles of P&T committees will include the evaluation of clinical outcomes information, including quality-of-life issues, to establish policies governing the use of drugs at all levels and in all types of healthcare.

Laboratory tests recommended by pharmacists in a skilled-nursing facility.

The types of laboratory tests recommended by pharmacists in a 185-bed skilled-nursing facility, the rate of physician acceptance of the recommendations, the reasons for and costs of the tests, and the outcomes of the tests were determined. Patients for whom laboratory tests had been recommended by a pharmacist from 1982 to 1987 were identified; this information had been taken from patients' charts during routine review by a pharmacist and entered into a computer database. The following information was recorded: type of laboratory test recommended, physician response to the recommendation, cost of the test, and outcome of the test. The investigator determined reasons for the recommendations by using the Department of Health and Human Services list of apparent irregularities that, if present, could indicate problems with drug therapy. During the study period, pharmacists requested 99 tests for 63 patients; physicians ordered 87 (87.9%) of those tests. Tests done most frequently were the SMA-6 (serum concentrations of sodium, potassium, chloride, glucose, blood urea nitrogen, and carbon dioxide), serum concentrations of various drugs, and anticoagulation studies. The reasons given most frequently for requesting the tests were routine monitoring, the most recent results being more than six months old, suspected drug toxicity or drug-drug interactions, and the need for information to determine whether drug therapy should continue. Results of 36 of the tests prompted a change in drug therapy, whereas 56 tests indicated that the current therapy was appropriate and safe.(ABSTRACT TRUNCATED AT 250 WORDS)

Recovery of phenytoin from solutions of caseinate salts and calcium chloride.

The recovery of phenytoin from solutions of intact protein components of enteral nutrition products was studied. Diluted phenytoin oral suspension was added to 10 1-mL samples of solutions of sodium caseinate, calcium caseinate, a mixture of sodium and calcium caseinates, and calcium chloride as well as to 10 1-mL samples of a distilled water control to produce theoretical concentrations of 10 micrograms/mL. The samples were filtered using an ultrafiltration technique and assayed for phenytoin concentration by high-performance liquid chromatography. The mean concentration of phenytoin in the filtrates of the test samples was significantly lower than the mean concentration in the control samples. The recovery of phenytoin from sodium caseinate solutions was significantly lower than that from solutions of calcium caseinate or calcium chloride. There was no significant difference between recovery of phenytoin from sodium caseinate solutions and that from solutions of sodium and calcium caseinates. Decreased phenytoin absorption from enteral nutrient solutions in vitro may be associated with the presence of caseinate salts and calcium chloride. However, this relationship cannot be extrapolated to in vivo absorption.

Pressure sores in the elderly. A systematic approach to management.

Pressure sores are a serious but often avoidable problem. The best management plan focuses on early identification of high-risk patients, appropriate allocation of resources, and adequate techniques of pressure relief. A standardized treatment plan that is familiar to care givers should be followed. The clinician must correct all conditions that retard the healing process, including nutritional deficits and underlying medical problems. Multiple-drug therapy must be eliminated, and only established skin care protocols should be followed. Use of systemic antibiotics is reserved for complications, such as osteomyelitis, cellulitis, and sepsis.

The abdomen.

This article describes the normal anatomy and physiology of the abdomen. Physical examination techniques illustrate the evaluation of the abdominal structures. The text describes physical presentation of selected diseases and discusses their pathophysiology. The text material is applied through a case study.

Current concepts in clinical therapeutics: pressure sores.

The etiology, pathophysiology, clinical presentation, prevention, management, and complications of pressure sores are reviewed. Three specific patient populations are at high risk of developing pressure sores: spinal-cord-injury, geriatric long-term-care, and orthopedic patients. Pressure sores usually develop at bony prominences on the body as a result of four etiologic elements: pressure, shearing forces, friction, and moisture. Excessive pressure causes poor tissue perfusion, which is normally compensated for by shifts in body position. However, in these patient populations, various abnormalities prevent patients from recognizing or compensating for this pressure. Once a lesion forms, it may progress through four stages marked by worsening necrosis, infection, and tissue loss. The best treatment of pressure sores is prevention. Various mechanical devices may assist the patient in decreasing or distributing pressure, but quality nursing care is essential for debilitated or disabled patients. If a pressure sore develops, treatment should focus on (1) eliminating local pressure, (2) cleaning and removing necrotic tissue, (3) creating a tissue-growth environment, and (4) treating factors that retard wound healing. Drug therapy includes agents for chemical cleansing and debridement of pressure sores and systemic antibiotics for complications such as septicemia or osteomyelitis. Despite efforts to improve treatment of pressure sores, prevention remains the best treatment.

Recovery of phenytoin from an enteral nutrient formula.

The recovery of phenytoin from phenytoin oral suspension dispersed in an enteral nutrient formula was determined. The study was conducted in two phases. In phase 1, diluted phenytoin oral suspension was added to 10 1-mL samples of full-strength Osmolite and 10 1-mL samples of a distilled water control solution to produce a theoretical concentration of 10 micrograms/mL. The samples were filtered through an ultrafiltration membrane and assayed for phenytoin concentration by a homogeneous enzyme-multiplied immunoassay technique. In phase 2, varying amounts of diluted phenytoin oral suspension were added to 30-mL quantities of half-strength Osmolite or control solution to determine the effect of phenytoin concentration on recovery of phenytoin; also, a constant amount of diluted phenytoin oral suspension was added to 30-, 60-, and 90-mL quantities of half-strength Osmolite or control solution to determine the effect of solvent volume on recovery of phenytoin. Duplicate samples of each phase 2 mixture were filtered and assayed in the same manner as phase 1 samples. The mean concentration of phenytoin in phase 1 samples was 3.70 +/- 0.28 microgram/mL for Osmolite and 9.87 +/- 0.27 microgram/mL for control solution; this difference was significant. The percentage of phenytoin recovered from phase 2 samples of Osmolite increased with increasing phenytoin concentration and decreased with increasing volumes of Osmolite. The decreased recovery of phenytoin from the enteral nutrient formula used in this study has potential clinical importance, but further research in humans is needed to substantiate these in vitro observations.

Drug therapy communications to family physicians in a nursing home.

The investigation described in this paper evaluated the effectiveness of written drug-therapy communications to family physicians working in a nursing home. Data analysis tracked the nature of the recommendation, as well as physician acceptance/rejection. The most frequent recommendations involved drug-level determinations, drug withdrawal and dosage modifications. The acceptance rate implied that clinically appropriate suggestions were made by the pharmacists. Communications between pharmacist and physician influenced clinical decisions. The study concluded that written recommendations of a pharmacist are an effective method of physician communication in a nursing home.

Evaluation of pharmacy and therapeutics committee drug evaluation reports.

Pharmacy and therapeutics (P & T) committee drug evaluation reports prepared by pharmacies and drug information centers (DICs) and product package inserts were compared with standard guidelines to evaluate their quality. Letters were sent to 143 hospital pharmacies asking them to submit a previously prepared drug evaluation report on temazepam, moxalactam disodium, or atenolol. The reports and package inserts for these three drugs were evaluated by the presence of 40 elements derived from the published ASHP guidelines for drug evaluation report preparation. Responses were obtained from 124 (87%) pharmacies; however, only 80 reports (60 DIC-prepared and 20 pharmacy-prepared) were received. The reports contained a mean of 28 of the 40 (70%) possible elements. The most frequently omitted elements were AHFS number, potential unlabeled uses, drug-drug interactions, drug-disease-laboratory test interactions, risk and benefit data, prevention and treatment of side effects, comparisons with established treatment, and disadvantages of the drug under consideration. Although the reports prepared by the DICs and pharmacies contained the same amount of information, the DIC-prepared reports included data more frequently on supply sources, therapeutic indications, approved labeling, comparison with established treatment, bioavailability and pharmacokinetics, and recommendations. Most of the reports contained more elements than the corresponding package inserts. The product package inserts did not contain the comparative elements required for P & T committee decisions. Both the pharmacy- and DIC-prepared reports failed to contain all 40 elements recommended in the standard guidelines, suggesting the need for more thorough reports.

Peripheral vascular and lymphatic systems.

This article discusses normal anatomy and physiology of the peripheral vascular and lymphatic systems. Physical examination techniques are described and monitoring principles are illustrated by a case study.

Physical assessment. The heart.

This article discusses normal and abnormal anatomy and physiology of the heart and the techniques used in physical assessment. Specific adverse drug effects are discussed and a case study is provided to illustrate key concepts.

An evaluation of a medication history method.

The purpose of this study was to evaluate a drug history method. The method consisted of a review of systems (ROS) history format, which utilized common symptoms/diseases per organ system matched with corresponding drug treatments. Findings of this method were compared with drug histories documented in the medical record. The study was conducted over an eight-week period on general medicine inpatients and ICU patients. All data retrieved were categorized into total number of drugs found and then analyzed as to legend, nonlegend, and unidentifiable content. Findings were statistically analyzed using chi-square. During the study, 207 patients were admitted. Of these patients, 186 drug histories were obtained; 21 patients could not be interviewed. The ROS method documented 406 drugs as compared with 60 drugs by the medical record (p less than 0.001). Performance time was comparable to similar studies (14 +/- 5.85 min). Using a concise, logically organized technique, more drugs were identified than reported by the medical record. We conclude that the experimental method is a productive method for obtaining a drug history.

Physical assessment series: the thorax and the lungs.

The anatomy of the thorax and lungs and the physiology or respiration are complex. The physical assessment techniques which, on the surface, appear relatively easy to master, require hours of practice of observation, palpation, percussion, and auscultation before the examiner becomes familiar with the more subtle changes of disease process and the wide variations of normal that may be confused with illness. These are skills that may be quickly lost if not regularly applied. But perhaps with the use of such techniques, the pharmacist can play an even greater role in the monitoring of drug therapy.

Particulate contamination in selected parenteral drugs.

The particulate contamination of five frequently prescribed drugs was studied. Samples were obtained in a laminar flow workbench according to millipore technique. The dry sample filters were examined with a binocular microscope at 50x and 100x. Particles were sized as to fibers, greater than 100 microns, 51 to 100 microns, 25 to 50 microns, and 10 to 24 microns. The results show the variability of contamination. Particulate counts appear to correlate with the manufacturing process. Bulk powders are highly contaminated, followed by lyophilize powders, then stable solutions. Until the clinical importance is resolved and manufacturing processes improved, in-line filters may be of value in selected patients.