Possible acute thrombocytopenia post esomeprazole and hydantoin coadministration.

Thrombocytopenia, defined as a platelet count less than 150 000/µL, occurs as a result of decreased production, sequestration, or peripheral destruction. Drug-induced thrombocytopenia is a clinically important adverse drug event involving many drugs including hydantoins. This report details an acute reaction of thrombocytopenia in a 55-year-old, critically ill, African American male patient after receiving a loading dose of fosphenytoin and a subsequent dose of IV phenytoin. The patient presented with an intracranial hemorrhage with hematoma and a blood pressure of 204/143 mm Hg. A fosphenytoin load infused for seizure prophylaxis and the first dose of a phenytoin maintenance regimen were followed by episodes of hypotension. In response to the hypotension, phenytoin was discontinued. On hospital day 2, the patient's platelet count had dropped dramatically from the morning before, 150 000 to 28 000/µL. The platelet count subsequently returned to baseline within 7 days of phenytoin discontinuation. The proposed cause of phenytoin-induced blood dyscrasias is direct or hapten-mediated toxicity by an arene oxide intermediate metabolite. Most documented cases of thrombocytopenia occur after a week or longer of phenytoin administration with the coadministration of glucocorticoids and cimetidine or proton pump inhibitors. An immediate decrease in platelets as seen in this case has not been previously described in the literature. Such a rapid induction of thrombocytopenia from phenytoin is suggestive of a direct cytotoxic effect on circulating platelets.

Effect of a seminar on pharmacy student attitudes toward residency training.

PURPOSE: Students at a college of pharmacy were surveyed before and after a one-hour seminar on residency training to determine whether the information changed their opinions of pursuing a residency and identify predisposing factors and barriers to pursuit of a residency. METHODS: Attendance at the seminar was mandatory for students in professional years 1 through 3 (P1-P3). Before the seminar, students provided information on demographics, grade point average (GPA), involvement in organizations, and previous pharmacy experience, degrees, and careers. They were asked to choose from a list of reasons they were or were not considering residency training and to answer yes or no questions about the residency application process. Students numbered their preseminar form for matching with their postseminar form. RESULTS: Before and after surveys were obtained for 221 students. Thirty-nine percent of the students before the seminar and 40% afterward were considering residency training, not a significant difference. Students with a GPA greater than 3.5, those in the P1 class, those with a previous career, and those involved in multiple organizations or holding office in an organization were more likely to consider a residency. Students' knowledge about the residency application process was significantly greater after the seminar. The most commonly cited barriers to residency were availability of pharmacy jobs without a residency, "burnout with school," lack of interest, and financial and family obligations. CONCLUSION: A mandatory one-hour seminar on residencies did not influence pharmacy students' opinions of and plans for residency training, but it did identify factors affecting their decisions.

Clopidogrel-induced thrombotic thrombocytopenic purpura-hemolytic uremic syndrome after coronary artery stenting.

The antiplatelet drug clopidogrel has largely replaced ticlopidine, due to an association between ticlopidine and thrombotic thrombocytopenic purpura-hemolytic uremic syndrome (TTP-HUS). Clopidogrel at first was thought to be void of this potentially fatal adverse effect, but recent case reports have called that assumption into question. Even with proper treatment (plasma exchange), TTP-HUS can persist for weeks. Clinicians should be aware of this possible adverse effect because prompt therapy is imperative for patients' survival. Earlier reports of clopidogrel-related TTP-HUS have involved patients who had received at least 72 hours of therapy. We describe a case of TTP-HUS in a patient who had received only a 300-mg loading dose of clopidogrel.