Effect of Intravenous Azithromycin on the QT Interval of ICU Patients.

Background: Azithromycin is a commonly prescribed antibiotic included in many first-line regimens for pneumonia. Azithromycin also carries an FDA warning for increased risk for abnormal cardiac electrical activity, including QTc prolongation. Objective: To examine the effect of intravenous azithromycin on the QT interval in a cohort of patients receiving antibiotic therapy for community acquired pneumonia. Methods: A single-center, retrospective chart review of patients admitted to the Intensive Care Unit (ICU). The primary endpoint was change in QTc 48-72 hours after antibiotic initiation. The primary outcome was analyzed using ANOVA matched comparison. Results: Between 6/1/2019 and 3/31/2020, 241 total ICU patients received doses of either antibiotic. After application of exclusion criteria, the total number of patients included in analysis was 93, including 75 azithromycin patient and 18 doxycycline patients. The baseline QTc in the azithromycin group was 449 (95% CI 438-461) and the 72-hour QTc was 442 (95% CI 427-453) with an average change in QTc of -4 ms (P = .14). No statistically significant difference was found in QTc interval change between azithromycin and doxycycline. Conclusion: In this study, azithromycin use was not associated with a statistically significant increase in QTc interval. Based on these results, for the majority of patients receiving azithromycin, QTc prolongation is not likely a major concern. However, caution may still be warranted in patients considered high risk.

Suboptimal Dosing of Benzodiazepines and Levetiracetam in a Cohort of Status Epilepticus Patients and Outcomes Associated with Inadequate Dosing.

Background: Status epilepticus (SE) is a neurologic emergency that can result in serious morbidity and mortality. Recent studies have suggested underdosing of both benzodiazepines (BZDs) and antiseizure medications (ASM) which may result in poorer outcomes. Objectives: This study aims to determine the dose of BZDs and levetiracetam given in our emergency department for episodes of SE and determine the outcomes associated with this dosing. Methods: We conducted a retrospective cohort study of all adult patients with SE admitted to our hospital from 2017 to 2020. We collected demographic data, type of SE, dose of BZD and levetiracetam, and outcomes which included mortality and a calculated Glasgow outcome scale (GOS). We compared outcomes of patients with SE who received adequate dosing (according to practice guidelines) to those who did not. Results: 111 adult patients were included of whom 91% were seen initially in our emergency department. 75% had convulsive SE on presentation. Approximately 55% and 68% of patients did not receive an appropriate dose of BZD or levetiracetam, respectively. Inadequate dosing of BZD was associated with worse clinical outcomes based on GOS (43.6% favorable outcome vs 62.5% with adequate dosing P = .046 (95% CI, 1.01-4.60)) and inadequate dosing of both drugs was also associated with a worse GOS outcome (HR, 2.91 (95% CI, 1.05-9.67, P = .02). No difference was found in length of stay or mortality alone. Conclusion: Our study found inadequate dosing of drugs to treat SE in adults was common in our institution and was associated with worse outcomes.

Unusual presentation of lepidic adenocarcinoma in a healthy female.

BACKGROUND: Lepidic adenocarcinoma represents a histologic pattern of non-small cell lung cancer that characteristically arises in the lung periphery with tracking alongside pre-existing alveolar walls. Noninvasive and invasive variants of lepidic adenocarcinoma are dependent on parenchymal destruction, vascular, or pleural invasion. The lepidic-predominant lung malignancies are collectively recognized as slow growing with rare metastasis and excellent prognosis. The World Health Organization classification of lung malignancies depends on molecular and histopathological findings. CT findings most commonly include ground-glass characteristics, commonly mistaken for inflammatory or infectious etiology. These tumors are generally surgically resectable and associated with better survival given infrequent nodal and extrathoracic involvement. Rarely these tumors present with diffuse pneumonic-type involvement associated with worse outcomes despite lack of nodal and distant metastases. CASE PRESENTATION: A 63-year-old Caucasian athletic immunocompetent female presented with 2 months of progressive shortness of breath, fatigue, loss of appetite and 15 pound weight loss. History was only notable for well controlled essential hypertension and hypothyroidism. Contrast computed tomography angiogram and positron emission tomography revealed diffuse hypermetabolic interstitial and airspace abnormalities of the lungs without lymphadenopathy (or distant involvement) in addition to right hydropneumothorax and left pleural effusion. Baseline laboratory testing was unremarkable, and extensive bacterial and fungal testing returned negative. Bronchoscopy and video-assisted thoracoscopic surgery was subsequently performed with pleural fluid cytology, lung and pleural biopsies returning positive for lepidic adenocarcinoma with 2% programmed death ligand 1 expression and genomic testing positive for PTEN gene deletion. Prior to treatment, the patient perished on day 15 of admission. CONCLUSION: We present a rare case of lepidic predominant adenocarcinoma with extensive bilateral aerogenous spread in the context of no lymphovascular invasion in a healthy, low risk patient. This case presentation may add to the body of knowledge regarding the different behavior patterns of lepidic predominant adenocarcinomas.

Incidence of a negative hidden curriculum, cynicism, and burnout within pharmacy resident education: A nationwide survey.

INTRODUCTION: The term "hidden curriculum" (HC) is a set of ethical, moral, and value-based teachings communicated in a non-explicit manner. Recent literature has described increasing awareness of the prevalence of the HC and potential negative impact on medical learners; however, this information is lacking in pharmacy resident education. Consequently, we conducted a survey study of United States pharmacy residents to learn their perceptions concerning the HC in pharmacy residency training. METHODS: A nationwide survey of pharmacy residents was conducted in June 2019. The survey assessed the following: presence of negative HC (score 0 to 80), cynicism (score 0 to 25), burnout via Maslach Burnout Inventory depersonalization (MBI-D) (range 0 to 30), and emotional exhaustion via Maslach Burnout Inventory emotional exhaustion (MBI-EE) (range 0 to 54). Higher scores represent increased occurrences of each domain. RESULTS: The mean HC score was 20 (SD 14.7), mean cynicism score was 9 (SD 5.5), MBI-D was 5.5 (SD 4.5), and MBI-EE was 24.2 (SD 12.4). Of those completing an MBI score, 40.4% (82/203) reported burnout in one area, while 15.8% (32/203) reported burnout in both areas. Residents reporting burnout had higher mean HC and cynicism scores. CONCLUSIONS: Awareness to develop and grow cultures that minimize the presence of a negative HC is essential to improve postgraduate pharmacy training.

Cutaneous mucormycosis in a chronic lymphocytic leukemia patient on ibrutinib.

BACKGROUND: Mucorales is a zygomycete fungi known to cause opportunistic infections in immunosuppressed hosts. Spores may be inhaled, causing rhinocerebral or pulmonary infections, or gastrointestinal infections if swallowed. Less often, cutaneous mucormycosis develops after inoculation via broken skin. PRESENTATION: A 72-year old male on ibrutinib and prednisone for chronic lymphocytic leukemia (CLL) presented with localized, right forearm cutaneous mucormycosis at the site of a dog-scratch sustained three weeks prior. The patient failed to respond to cephalexin as an outpatient, prompting biopsy showing ribbon-like pseudo septate hyphae and possible vascular invasion suggestive of Mucorales. Treatment course included liposomal amphotericin B 5 mg/kg IV every 24 h for ten days followed by a 90-day course of posaconazole 300 mg daily after general surgery consultation was sought. CONCLUSION: We outline the second reported case of localized cutaneous mucormycosis arising in the setting of ibrutinib use. Because the combination of immunosuppressed states, ibrutinib and skin trauma may serve as a nidus for mucormycosis, practitioners should be vigilant of thorough skin evaluations in these patients and appropriate anti-fungal treatment. Although amphotericin B has been well studied as first line therapy, oral posaconazole has been shown as an efficacious second-line treatment.

Pentoxifylline or theophylline use in hospitalized COVID-19 patients requiring oxygen support.

INTRODUCTION: The phosphodiesterase inhibitors theophylline and pentoxifylline have anti-inflammatory properties that may make them useful in COVID-19 pneumonia. We conducted a retrospective review of hospitalized COVID-19 patients requiring oxygen who received these drugs. OBJECTIVES: To examine the potential efficacy and safety of theophylline and pentoxifylline in COVID-19 pneumonia patients. METHODS: Adults with a positive test for SARS-COV2 and were hospitalized due to pneumonia requiring either high flow nasal cannula or mechanical ventilation were included. Patients with a history of asthma or chronic obstructive pulmonary disease were preferentially given theophylline. All other patients received pentoxifylline 400 mg orally TID. A group of hospitalized COVID-19 patients receiving standard of care acted as a comparison group. The coprimary outcomes were a change in C-reactive protein (CRP) and ROX score between groups from day 1 to day 4 of therapy. RESULTS: Two hundred and nine inpatients were reviewed. Fifty-eight patients received pentoxifylline/theophylline, with 151 patients serving as the comparison group. Active therapy was associated with an increase in the ROX score (mean: 2.9 (95% CI: 0.6, 5.1)) and decrease in CRP (mean: -0.7 (95% CI: -4.7, 3.2). Mortality rates were theophylline/pentoxifylline 24% and comparison group had a 26%, respectively. CONCLUSION: In this retrospective study, theophylline and pentoxifylline were associated with an increase in ROX score and nominal decreases in CRP and mortality. Treatment was safe with few adverse reactions documented. We believe that this study could the basis for randomized-controlled trials to further explore these drugs' role in COVID-19.

Retrospective Safety Evaluation of a Pharmacist-Assisted Total Dose Iron Sucrose Protocol in Hospital Inpatients With Iron Deficiency Anemia.

BACKGROUND: Intravenous (IV) iron sucrose can be used for iron deficiency anemia (IDA), but little information exists on total dose infusion (TDI) of this drug. At a tertiary hospital, an iron sucrose TDI protocol was implemented with staff pharmacists aiding physicians in appropriate dosing. OBJECTIVES: We sought to define the safety and efficacy of this protocol in adults ≥18 years old with IDA. METHODS: We conducted a retrospective chart review of patients who received iron sucrose TDI. Inclusion criteria included patients ≥18 years old who were hospitalized and received iron sucrose in doses ≥300 mg. We reviewed the medical record for adverse reactions to any TDI of iron sucrose as well as pre-TDI and post-TDI hemoglobin (Hgb) levels to assess efficacy. RESULTS: A total of 238 patients received iron sucrose TDI for IDA during the study period. One hundred ninety-three (81%) patients were female, and the mean age in our cohort was 60.6 years. Mean pre-TDI Hgb was 8.76 g/dL. The mean total dose of iron sucrose in the total cohort was 680 mg (range: 300-2500 mg). Adverse effects attributable to iron sucrose were reported in 15 patients, with nausea being the most common effect (7/238, 2.9%). When matching patients' preadmission and postadmission records, a Hgb increase of 2.1 g/L was found (P < .001). No increase in liver function tests was found in any patient. CONCLUSIONS: A pharmacist-assisted iron sucrose TDI protocol for patients with IDA successfully increased serum Hgb and was well tolerated. Anaphylaxis was not reported.

Sensitivity and Specificity of prior Methicillin-Resistant Staphylococcus aureus Nasal Swab Results for Predicting Methicillin-Resistant Staphylococcus aureus Infections in Intensive Care Unit Admissions Over a 1-Year Period: A Pilot Study.

OBJECTIVE: Methicillin-resistant Staphylococcus aureus (MRSA) continues to be a pathogen worldwide. Empiric anti-MRSA therapy is often prescribed in hospital inpatients with potential infection. Recent studies have suggested, particularly for respiratory infections, that MRSA colonization as determined by nasal swab has a high negative predictive value (NPV) for MRSA infections during the index hospitalization. We examined the predictive value of a prior intensive care unit (ICU) MRSA nasal swab on the results from a subsequent ICU admission in the same patient and the results of the latter admission MRSA nasal swab. METHODS: A retrospective chart review of patients 18 years or older admitted to a large tertiary care hospital in the Midwest of the United States in 2016 who had a MRSA nasal swab performed and had an ICU admission stay of over 24 h was conducted. This group of patients was matched to a patient list of subjects who were admitted as an inpatient to the same ICU at least once during the following year. Data were collected on demographic and clinical information, as well as the results of MRSA swabs and the presence of a MRSA infection during both hospitalizations. Predictive values were calculated using 2 × 2 tables including sensitivity and specificity of a first MRSA swab result with a MRSA infection during the subsequent ICU stay. FINDINGS: Seventy-seven patients were matched who had MRSA swabs performed on two separate ICU admissions. The negative predictive value of the first MRSA swab result on a MRSA infection during the second ICU stay was 96%. CONCLUSION: In this pilot study, a previous negative MRSA nasal swab may predict a lack of a MRSA infection in a subsequent infection during a 1-year period.

Apparent interference with extracorporeal membrane oxygenation by liposomal amphotericin B in a patient with disseminated blastomycosis receiving continuous renal replacement therapy.

PURPOSE: We describe the use of liposomal amphotericin B and amphotericin B deoxycholate in a critically ill patient with pulmonary blastomycosis receiving both venovenous extracorporeal membrane oxygenation (ECMO) and continuous renal replacement therapy (CRRT). SUMMARY: A 50-year-old African American man presented for dyspnea and cough and was noted to have blastomycosis on bronchoscopy. He developed respiratory failure and acute kidney injury, requiring mechanical ventilation, ECMO, and CRRT. After 4 days of liposomal amphotericin, the transmembrane pressure gradient on the membrane oxygenator increased dramatically without visualization of a clot, requiring a circuit exchange. A trough amphotericin B level taken the day before the exchange was undetectable for amphotericin B. After the circuit exchange, the patient was switched to amphotericin B deoxycholate. A subsequent trough level was 3.8 µg/mL. The patient improved and was able to be decannulated. However, he did require tracheostomy and long-term hemodialysis. CONCLUSION: In our case we believe that liposomal amphotericin B was significantly removed by ECMO and was responsible for the failure of the ECMO circuit. We would suggest amphotericin B deoxycholate be used in such patients preferentially and that serum levels of the drug be assessed when possible.

A practical guide for pharmacists to successfully implement penicillin allergy skin testing.

PURPOSE: The purpose of this article is to offer practical guidance for pharmacists to successfully implement penicillin allergy skin testing (PAST). SUMMARY: Less than 10% of patients labeled as having a penicillin allergy are confirmed as present upon skin testing. This labeling results in use of alternative antibiotics and thus unwanted adverse consequences including potentiated antimicrobial resistance, increased costs, and worse clinical outcomes. Stewardship guidelines recommend PAST to enhance use of first-line agents; however, this was a weak recommendation with low-quality evidence. Recent efforts and subsequent research since publication of guidelines have demonstrated beneficial effects from increasing use of PAST among stewardship programs to improve outcomes. A number of different models exist demonstrating successful implementation of PAST at various healthcare facilities. There are important logistical factors to consider during implementation of PAST such as target population, optimal preparation, leadership structure, resource availability, and state regulations. Pharmacists as leaders of antimicrobial stewardship teams and experts in drug allergies are a natural fit to help implement PAST in healthcare settings to improve overall outcomes. This article offers guidance to institutions considering implementation of PAST. CONCLUSION: PAST is rapidly becoming an effective, long-term antimicrobial stewardship tool to optimize antimicrobial prescribing in both the inpatient and outpatient settings. Pharmacists have demonstrated significant benefit as providers of PAST services in a variety of healthcare settings with a number of different healthcare professionals.

A collaborative program to increase adult pneumococcal vaccination rates among a high-risk patient population receiving care at urgent care clinics.

OBJECTIVE: We report a project that utilized pharmacy students to increase pneumococcal vaccination rates in patients aged 19-64 years with high-risk medical conditions within urgent care clinics. The study also sought to better identify the number of patients previously vaccinated for pneumococcal disease. A total of 1,178 patients were considered eligible for pneumococcal vaccination during the study period, 287 (24.4%) of whom were determined to be previously vaccinated through chart assessment or patient interview. Of the remaining 891 patients, chart documentation of pneumococcal vaccination administered at the time of the urgent care visit was present for 96 patients (10.7%) in the intervention clinics compared with 6 patients in 2 control clinics who received the usual standard of care (P < .0001).

Overdoses and Substance Toxicity in Patients Admitted to Intensive Care Units in a Midwestern U.S. City.

Toxic exposures with serious outcomes have increased over the last decade. Limited data exists on the pattern and outcomes of overdose-exposure patients requiring intensive care unit (ICU) admission. The primary objective of this study was to characterize the causes, treatments, and outcomes of toxic exposures in a mid-sized Midwestern health system. The secondary objective was to report cumulative economic costs associated with these patients. Data were obtained from medical records of patients 18 years or older with a diagnosis code of overdose admitted to the ICU at 2 teaching hospitals between August 1, 2012, and July 31, 2014. There were 470 (10%) of the 4,495 total ICU admissions that met inclusion criteria during the study period. Average patient age was 39 (SD = 14.2) years, with 64% females. Intentional overdose exposure was the cause of 87% of admissions. The majority (70%) of exposures involved multiple pharmacological agents, including ethanol. Most patients did not require therapeutic maneuvers, nor used decontamination methods. Primary substance classes included analgesics, benzodiazepines, ethanol, selective serotonin reuptake inhibitor antidepressants, and methamphetamine. Two hundred sixty-five (56%) patients were ICU to direct home discharges, whereas 198 (42%) were transferred to a lower level of care. The mortality rate in the sample was 1%. Average hospital charges per admission were $20,375 and average ICU charges were $5,284, which summed to more than $2 million in total charges. Causes, treatments, and outcomes of toxic exposures admitted to the ICU in a mid-sized Midwestern city reveal a potential ICU burden. Financial health care costs associated with these toxic exposures were substantial. Greater public health efforts are needed to attempt to minimize preventable admissions and better understand antecedents.

Prevalence and characteristics of hospital inpatients with reported fluoroquinolone allergy.

Background Fluoroquinolone (quinolones) antibiotics are commonly prescribed worldwide. Hypersensitivity reactions to these agents have been reported, but little systematic data exists concerning prevalence, types of reactions, or associated factors. Objective To identify the prevalence of patients reporting an allergy to quinolones, types of reactions claimed, and patient information associated with allergy. Setting A tertiary 370 bed level 1 trauma center, located in a Midwestern City in the United States. Method A retrospective cohort study was conducted. Included in the study were all unique patients 18 years or older admitted to our hospital in 2016 with a length of stay ≥ 24 h. Collected data elements included types of reaction, other drug allergies claimed, and patient characteristics. As a comparator group, an equal sized random sample of patients admitted during the same period reporting penicillin allergy was identified. Main Outcome Measure prevalence and descriptors of quinolone allergy. Results There were 327 patients with a quinolone allergy and 317 patients with a penicillin allergy used as the study sample. Hospital prevalence rate for quinolone allergy was 2%. Hives, rash, and nausea/vomiting were the most common reported reactions. These patients tended to be older than penicillin allergy patients and had an association with concomitant intravenous contrast allergy. Tendonitis or tendon rupture was reported in quinolone patients. Conclusion The prevalence of patients claiming a quinolone allergy in the study hospital was 2%. Common hypersensitivity reactions were reported. Data tended to support a possible association between intravenous contrast allergy and quinolone allergy.

Addition of Allopurinol for Altering Thiopurine Metabolism to Optimize Therapy in Patients with Inflammatory Bowel Disease.

Thiopurine drugs, including azathioprine and 6-mercaptopurine, are used commonly in patients with inflammatory bowel disease for maintenance of remission. Although generally well tolerated, adverse effects lead to discontinuation in a significant minority of patients. Pharmacogenomic studies have suggested that metabolic breakdown of azathioprine in an individual is genetically determined. Coupled with the fact that certain thiopurine metabolites, notably 6-thioguanine nucleotide and 6-methylmercaptopurine, are associated with antiinflammatory effects and adverse effects, respectively, some investigators have examined intentionally shunting the metabolism of azathioprine toward increasing 6-thioguanine nucleotide levels by using low doses of the xanthine oxidoreductase inhibitor allopurinol to improve efficacy and decrease toxicity of azathioprine in patients with inflammatory bowel disease. We performed a search of the MEDLINE and Embase databases for basic and clinical research reports of this modality. Pertinent articles were retrieved, reviewed, and assessed by the authors. Case series, cohort studies, and one randomized trial have investigated adding allopurinol to azathioprine therapy in patients with inflammatory bowel disease. Most reports primarily examined metabolite levels in these patients. In general, the literature suggests that this modality was successful at significantly increasing 6-thioguanine nucleotide levels while decreasing 6-methylmercaptopurine levels. Several small reports have suggested that patients with increased 6-thioguanine nucleotide levels had improved symptoms or symptom remission. Adverse effects and discontinuation rates remained similar or were improved in patients who were taking a thiopurine and started allopurinol. In conclusion, the addition of allopurinol may be an option for optimizing thiopurine metabolite production in select patients with low 6-thioguanine nucleotide levels. Appropriate care and monitoring of these patients are mandatory to prevent neutropenia or other adverse effects.

Atrio-Esophageal Fistula: A Case Series and Literature Review.

BACKGROUND Percutaneous catheter radiofrequency ablation (RFA) and cryoablation of the left atrium and pulmonary vein ostia have become successful therapeutic modalities in the management of atrial fibrillation. Atrio-esophageal fistula is a rare complication. Awareness of complication risk is imperative because without prompt diagnosis and urgent surgical intervention, the outcome is often fatal. We present 3 cases of atrio-esophageal fistula following percutaneous catheter radiofrequency ablation (RFA). CASE REPORT Case 1: A 72-year old white male presented 27 days after percutaneous RFA for atrial fibrillation with fever, altered mental status, and melena. Esophagogastroduodenoscopy (EGD) revealed a 1-cm defect in the mid-esophagus. Upon thoracotomy, severe hemorrhage ensued from a concomitant injury to the left atrium. Multiple attempts to repair the left atrial perforation were unsuccessful and the patient died. Case 2: A 71-year old white male presented 29 days after percutaneous RFA for atrial fibrillation with fever and tonic-clonic seizure. Recognition of possible atrio-esophageal fistula was considered and confirmed on thoracotomy. Surgical fixation of the left atria and esophagus were performed. The patient survived and was discharged to a skilled care facility. Case 3: A 75-year old white male presented 24 days after percutaneous RFA for atrial fibrillation with chest pain. An echocardiogram revealed a large pericardial effusion and pericardiocentesis was performed. Despite aggressive measures, the patient died. The autopsy demonstrated a communicating esophageal fistula with the right pulmonary vein. CONCLUSIONS Clinicians tending to patients who have recently undergone atrial ablation need to be aware of atrio-esophageal fistula as a rare but highly fatal complication.

Tourism-Induced Livelihood Changes at Mount Sanqingshan World Heritage Site, China.

Although tourism has the potential to improve the wellbeing of residents, it may also disrupt livelihood systems, social processes, and cultural traditions. The livelihood changes at three rural villages at Mount Sanqingshan World Heritage Site, China, are assessed to determine the extent to which tourism strategies are contributing to local livelihoods. A sustainable livelihood framework is adopted to guide the analysis. The three villages exhibit different development patterns due to institutional, organizational, and location factors. New strategies involving tourism were constructed and incorporated into the traditional livelihood systems and they resulted in different outcomes for residents of different villages. Village location, including the relationship to the site tourism plan, affected the implications for rural livelihoods. High dependence on tourism as the single livelihood option can reduce sustainability. Practical implications are suggested to enhance livelihood sustainability at such rural heritage tourism sites.

Sodium polystyrene sulfonate for the treatment of acute hyperkalemia: a retrospective study.

BACKGROUND: Hyperkalemia is a common problem in hospitalized patients, especially those with underlying chronic kidney disease, but evidence-based guidelines for its treatment are lacking. Sodium polystyrene sulfonate (SPS), a cation exchange resin first approved by the FDA for the treatment of hyperkalemia in 1958, is frequently used alone or in conjunction with other medical therapies to lower serum potassium. Recently, the safety and efficacy of SPS have come into question based on multiple reported cases of bowel necrosis associated with SPS administration. OBJECTIVE: The primary objective of this study was to evaluate the use of SPS for the treatment of hyperkalemia, at a large tertiary community teaching hospital, to determine its effectiveness and the incidence of related adverse side effects. METHODS: A retrospective chart review was performed on all adult inpatients receiving single-dose SPS at a 466-bed tertiary community teaching hospital over a 3-year period. RESULTS: 501 patients received SPS for the treatment of hyperkalemia during their index hospital stay. Serum potassium levels decreased by 0.93 mEq/L on average at first recheck after SPS administration, with or without additional medical treatments. Our study identified 10 cases of hypernatremia (greater than 145 mEq/L), 31 cases of hypokalemia (less than 3.5 mEq/L), and 2 cases of bowel necrosis related to the administration of SPS. CONCLUSION: Our results suggest a serum potassium reduction of less than 1 mEq/L after administration of SPS for the treatment of acute hyperkalemia. Additionally, this study offers some evidence that the use of SPS may be associated with harm. We further note the need for standardized guidelines for the treatment of hyperkalemia at our institution.

Topical nitroglycerin ointment for treatment of acute hypertension in hospitalized inpatients.

BACKGROUND: Hypertension in the hospital setting is common; however, guidelines provide limited guidance specific to the inpatient setting. Acute antihypertensive treatment options can be limited in this setting by monitoring requirements of intravenous medications and patients' inability to take oral medications. A possible treatment choice used to treat acute hypertension is nitroglycerin ointment. Nitroglycerin is not approved by the Food and Drug Administration for this condition, and limited evidence exists to support this indication. OBJECTIVE: To evaluate the statistical and clinical effectiveness of nitroglycerin ointment as a treatment option for acute hypertension based on a 20 mm Hg or greater reduction in systolic blood pressure. METHODS: A retrospective chart review at a large tertiary community teaching hospital was performed on all adult noncardiac inpatients with an episode of acute hypertension that resulted in the administration of nitroglycerin ointment. RESULTS: Seventy-two patients met inclusion criteria with a total of 112 applications of nitroglycerin ointment. Of the 112 applications, systolic blood pressure decreased 20 mm Hg or more in 42% of occurrences with a median decrease of 16 mm Hg. CONCLUSION: Study results suggest possible efficacy of nitroglycerin ointment for the treatment of acute hypertension in noncardiac hospitalized patients.

Assessing ecotourism from a multi-stakeholder perspective: Xingkai Lake National Nature Reserve, China.

Ecotourism development is closely associated with the sustainability of protected natural areas. When facilitated by appropriate management, ecotourism can contribute to conservation and development, as well as the well-being of local communities. As such, ecotourism has been proposed and practiced in different forms in many places, including China. This study assesses ecotourism development at Xingkai Lake National Nature Reserve in Heilongjiang Province, China. Key informant interviews were conducted with representatives from the provincial Forestry Department, the Nature Reserve, and the local community. Observation was undertaken on three site visits and secondary data were collected. The potential for providing quality natural experiences is high and tourism development is occurring rapidly. However, current relationships between people, resources, and tourism have yet to provide mutual benefits necessary for successful ecotourism. The multi-stakeholder management style and the ambiguity of landownership within the nature reserve constitute structural difficulties for ecotourism management and operation. Although participation in ecotourism could provide a livelihood opportunity and interests in involvement in tourism have been identified among the local fishing community, current involvement is limited mainly due to the lack of mechanisms for participation. Therefore, it is recommended that management programs and government policies should be established to provide a platform for community participation in ecotourism. Then, a positive synergistic relationship between tourism, environment, and community could be developed. Planning and policy requirements are discussed for ecotourism development in protected areas in China.