OBJECTIVE: To examine the effect of medication reconciliation with and without patient counseling among patients at the time of hospital discharge on the number and type of interventions aimed at preventing drug-related problems.

METHODS: A prospective observational study in a general teaching hospital was performed. Patients discharged from the pulmonology department were included. A pharmacy team assessed the interventions with and without patient counseling on discharge medications for each patient.

RESULTS: Two hundred sixty-two patients were included. Medication reconciliation without patient counseling was responsible for at least one intervention in 87% of patients (mean 2.7 interventions/patient). After patient counseling, at least one intervention (mean 5.3 interventions/patient) was performed in 97% of patients. After patient counseling, discharge prescriptions were frequently adjusted due to discrepancies in use or need of drug therapy. Most interventions led to the start of medication due to omission and dose changes due to incorrect dosages being prescribed. Patients also addressed their problems/concerns with use of the drug, which were discussed before discharge.

CONCLUSIONS: Significantly more interventions were identified after patient counseling. Therefore, patient information is essential in medication reconciliation.

OBJECTIVE: To assess older adults' current use of, knowledge of, and preferences for medication management tools and supports.

METHODS: A cross-sectional study was conducted at a continuing care retirement community. All 152 independent-living residents were approached for participation. We developed a 6-page survey to gather information about knowledge of and preferences for medication management tools (eg, medi-sets, bubblepacks) and supports (eg, family, caregivers, regimen simplification). Information on demographic variables, medication management capacity, cognition, self-reported difficulty taking medications, and medication use were collected along with survey answers during an in-home interview. ² and t-tests were used to compare knowledge and preferences by complexity and organizer use.

RESULTS: Our sample consisted of 109 participants ranging in age from 73 to 98 years (average 85.9). Most of the subjects were well educated (average 15.5 y of education), 98% were white, and 80% were female. The majority (82%) were using a medication tool, mainly simple, self-filled medi-sets (62%) and easy-open vials (55%). Knowledge about, use of, and preferences for other devices, including pharmacist-filled tools and programmable devices, were low. Participants who used medication organizers rated self-filled medi-sets higher than did non-users (4.7 vs 1.6; p < 0.01). Only 18% of participants had asked a provider to simplify their medications, while 40% did not realize that they could do so. Of those who did ask a provider, 80% asked a physician.

CONCLUSIONS: Educational strategies are needed to increase awareness of the pharmacist's role in facilitating medication management and the option of simplifying complex regimens. It is within the scope of pharmacy to provide this type of medication education.

OBJECTIVE: To evaluate the pharmacokinetics of MPA and its glucuronide (MPAG) in antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis patients with renal manifestations and to determine the effects of clinical (urinary protein excretion, serum albumin, creatinine clearance) and demographic (age, race, sex) variables on MPA and MPAG pharmacokinetics.

METHODS: Twenty-three patients taking MPA at steady-state were evaluated. Plasma and urine samples were collected over 24 hours. Analyses included noncompartmental pharmacokinetics and statistics including Mann-Whitney U test and univariate/multiple regression.

RESULTS: MPA clearance (Cl/F 288 ± 154 mL/min) was approximately 2-fold higher than previously reported from transplant patients and predicted by weight and race (ranked MPA Cl/F = -11.766 + 0.2035 [wt] + 4.9578 [race]; R² 41.8%; p = 0.005). Creatinine clearance (CrCl) less than 60 mL/min resulted in higher MPA exposure, total area under the curve (AUC)_0-12, and AUC_6-12, as well as unbound AUC_0-12. The metabolic ratio (MPAG_AUC/MPA_AUC) of 8.67 ± 5.57 was lower than that previously reported in renal transplant recipients.

CONCLUSIONS: Diminished kidney function (eg, CrCl <60 mL/min) demonstrated enhanced MPA and MPAG exposure in patients with ANCA vasculitis. However, unlike renal transplant recipients, patients with ANCA vasculitis had enhanced Cl/F and diminished metabolic ratio, suggesting the need to comprehensively evaluate the role of disease-specific factors on MPA pharmacokinetics.

OBJECTIVE: To evaluate the frequency and severity of ADRs likely caused by ARV therapy in pregnant women who are HIV-positive.

METHODS: A retrospective analysis of HIV-infected women who received ARV therapy during pregnancy and delivered between January 1997 and February 2006 was conducted. Incidence of maternal ADRs was determined through evaluation of laboratory findings, documented physical examinations, and patient self-reports. An AIDS Clinical Trials Group severity grading scale was applied to the ADRs. Cause-effect relationship was adjudicated based on the Naranjo probability scale and, if causality was found, that information was included.

RESULTS: There were 103 women who accounted for 133 pregnancies that resulted in deliveries. Of the 111 pregnancies in which treatment was received, regimens included 26 nucleoside reverse transcriptase inhibitor monotherapy, 40 nonnucleoside reverse transcriptase inhibitor (NNRTI)-based, 44 protease inhibitor (PI)-based, and 1 PI/NNRTI combination therapy. Ninety-eight ADRs were documented in 49 pregnancies. The most common ADRs were gastrointestinal (n = 48), followed by central nervous system symptoms (n = 15), anemia (n = 15), elevated liver/pancreatic enzyme levels (n = 11), and cutaneous reactions (n = 8). Severe ADRs included elevations in liver/pancreatic enzymes (n = 3), nausea and vomiting (n = 3), and anemia (n = 2). Seven women required a change in therapy due to an ADR.

CONCLUSIONS: Approximately 7 ADRs were reported for every 10 pregnancies in this cohort. Most ADRs were mild to moderate. Short exposure times in most women (second and third trimester) may have accounted for the lack of long-term toxicities. Although ADRs did not pose a major barrier to use of ARVs in pregnancy, close monitoring of pregnant women receiving ARV therapy continues to be warranted.

OBJECTIVE: To study clinician perspectives on the importance of different antiretroviral adherence support activities and compare these with clinicians' self-reported actual adherence support practices.

METHODS: From March to August 2005, surveys were mailed to physicians, pharmacists, and nurses who provide care to HIV patients in Ontario, Canada. The 84-item survey asked providers to rate how necessary it was to provide 30 types of adherence support activities and how frequently they actually provided each of the types of adherence support. From this, we assessed healthcare provider perceptions of best or ideal practices in supporting medication adherence and actual or usual care in adherence support provision. We also examined whether an adherence support gap existed between the provision of best practice adherence support and actual adherence support in clinical practice.

RESULTS: One hundred sixty-nine of 300 mailed surveys were returned, for a response rate of 56%. Respondents were highly specialized in HIV care and nearly all practiced in urban settings. Respondents indicated that most of the surveyed adherence support activities should be provided to all patients. However, most clinicians did not actually provide these adherence supports to their patients to the extent that they desired. We calculated an adherence support gap that ranged from 31% to 75% across the different types of adherence support activities.

CONCLUSIONS: We observed important adherence support gaps between ideal best practices in the provision of adherence support and actual provision of adherence support in clinical practice.

OBJECTIVE: To determine whether, when losartan was used in combination with soy extract, a significant pharmacokinetic interaction would be observed in healthy female volunteers.

METHODS: Eighteen healthy Chinese female volunteers were recruited. In an open-label, 2-phase study, losartan 50 mg was given to each subject, with and without soy extract. Plasma concentrations of losartan and E-3174 were determined by liquid chromatography-tandem mass spectrometry for 12 and 24 hours, respectively. On day 8 through day 21 of the study, following a 7-day washout period, each subject consumed two 1000-mg Genistein Soy Complex tablets orally after meals, twice daily, for 14 days. On day 22, all volunteers received losartan 50 mg and blood samples were collected again.

RESULTS: All subjects completed the study, without adverse drug effects. Over the 14-day pretreatment period, soy extract did not significantly influence the pharmacokinetics of losartan or E-3174. The ratio of the area under the curve of the drug and metabolite after losartan administration, with and without soy extract ingestion, was 0.21 ± 0.05 and 0.23 ± 0.05 (mean ± SD), respectively. The difference was not statistically significant (p = 0.22).

CONCLUSIONS: Our data indicate that a significant interaction between soy extract and losartan is unlikely to occur in females.

OBJECTIVE: To compare the actual risk status versus the personal risk perceptions for developing diabetes among pharmacists.

METHODS: Perceived risk was measured in this cross-sectional study with the validated Risk Perception Survey for Developing Diabetes (RPS-DD). The RPS-DD has 4 main subscales aimed at capturing multiple dimensions of perceived risk and is scored on the following scale: 1 (almost no risk), 2 (slight risk), 3 (moderate risk), and 4 (high risk). Actual risk was assigned according to the American Diabetes Association (ADA) Diabetes Risk Test. Differences between higher and lower ADA risk participants were analyzed. Regression analyses were conducted to examine risk factors associated with pharmacists' self-reported perception for developing diabetes.

RESULTS: Pharmacists (N = 218, 46.2 ± 12.2 years [mean ± SD], 47.7% male, 85.9% white) completed the survey. The Comparative Disease and Environmental Risk mean subscale scores were 1.98 ± 0.43 and 1.86 ± 0.41, indicating slight risk perceptions for the subscales, respectively. The single-item self-reported perceived risk for developing diabetes was 2.25 ± 0.90, indicating a slight to moderate perceived risk for this disease. The Optimistic Bias score was 2.60 ± 0.64, suggesting a trend toward more optimistic bias and a lower perceived risk for the development of diabetes. The Personal Control score was 3.38 ± 0.47, illustrating that pharmacists endorsed personal control over the development of diabetes. Higher ADA risk participants reported less optimistic bias compared with lower risk respondents (p = 0.005). Comparative disease risk perception (correlation [r] = 0.38; p < 0.0001) and degree of optimistic bias (r = -0.49; p < 0.0001) emerged as the only predictors for diabetes related risk perception

CONCLUSIONS: Pharmacists exhibited a slight to moderate risk perception for developing diabetes, reported a trend toward more optimistic bias, and demonstrated personal control over developing diabetes. Significant comparisons between higher and lower risk respondents were observed only with the optimistic bias subscale.

OBJECTIVE: To assess nurses' beliefs and reported practices concerning pharmaceutical marketing and sponsorship strategies.

METHODS: We conducted parallel Web- and paper-based surveys of a sample of senior registered nurses employed by government-funded health boards in 2 regions of New Zealand to explore their contact with the pharmaceutical industry as well as their beliefs and practices regarding information, gifts, and sponsorship provided by pharmaceutical companies. Returns were tested using Fisher's exact test to determine consistency in response between regions. Results for key outcome variables, including attitude toward the value of industry-derived information, were analyzed by region and in aggregate.

RESULTS: Most nurses had contact with pharmaceutical sales representatives (69/106), accepted gifts from representatives (79/105), and believed information from the pharmaceutical industry probably improved their practice (71/106). Half believed that they would be able to detect misleading information if it were present, and 35% believed that accepting gifts and sponsorship was ethically acceptable. We found positive associations between the belief that information from the industry improved practice and reported acceptance of conference funding (OR 3.63; 95% CI 1.41 to 11.55), free food (OR 3.24; 95% CI 2.03 to 7.55), or gifts (OR 3.52; 95% CI 1.38 to 8.95). Nurses generally acknowledge the presence of pharmaceutical marketing in the hospital and the ethical challenges it presents; nonetheless, they also generally accept marketing gifts and may underestimate both the ethical challenges and their own susceptibility to persuasion.

CONCLUSIONS: Given the increasing role that nurses may play in pharmaceutical marketing strategy, the profession should consider its position vis-à-vis the industry.

DATA SOURCES: Multiple MEDLINE searches were performed (November 2008) to identify studies for inclusion, using a comprehensive list of search terms including, but not limited to, LMWH, enoxaparin, dalteparin, tinzaparin, obesity, weight, renal, kidney, elderly, monitoring, and anti-Xa.

STUDY SELECTION AND DATA EXTRACTION: Only articles published in English that were relevant for this review were included.

DATA SYNTHESIS: In the majority of patients, standardized prophylaxis or treatment doses of LMWHs can be used without the need for monitoring and adjusting regimens. For patients with severe renal impairment (estimated creatinine clearance [CrCl] <30 mL/min), doses of some LMWHs should be adjusted or unfractionated heparin should be used instead. CrCl should be estimated using the Cockcroft-Gault method. Differences are noted in the degree of accumulation of various LMWHs in patients with moderate-to-severe renal impairment, and thus, the degree of dose adjustment may differ among the various LMWHs. Increasing the prophylactic doses of LMWH may be appropriate in morbidly obese patients (body mass index ≥40 kg/m²). The use of total body weight is appropriate for therapeutic doses of LMWH in obese patients. Laboratory monitoring of the anticoagulation effect of LMWHs is generally not necessary, but should be considered in patients with morbid obesity (weight >190 kg), those with severe renal impairment, and those with moderate renal impairment with prolonged (>10 days) LMWH use. When anti-Xa activity is monitored, it should be determined using a chromogenic method and a calibration curve based on the LMWH used.

CONCLUSIONS: Additional data are needed for specific dose guiding in obese and renally impaired patients, who are often excluded from larger clinical trials. Practice recommendations are made based on available evidence and authors' clinical opinions.

DATA SOURCES: Literature retrieval was performed through PubMed/MEDLINE (2005-December 2008) using the terms methylphenidate, amphetamines, central nervous system stimulants, and attention-deficit/hyperactivity disorder. In addition, reference citations from publications identified were reviewed and drug manufacturers were contacted for any possible additional references.

STUDY SELECTION AND DATA EXTRACTION: Double-blind clinical trials found using the search criteria listed above were included for review. Open-label studies and studies prior to 2005 were included if no double-blind trials were published for that formulation within the time period reviewed.

DATA SYNTHESIS: The literature reviewed here demonstrates the efficacy and safety of stimulant medications in children and adolescents with ADHD. However, there are 19 different formulations of stimulants, leading to confusion and errors in prescribing and dispensing of these drugs. Knowing and understanding the advantages and disadvantages of the different formulations can lead to individualized treatment. Formulations like Concerta, Focalin-XR, Adderall-XR, and Vyvanse provide the convenience of once-daily dosing. Each of these provides varying amount of stimulants at different times of the day. Vyvanse has a unique delivery system that may lower the risk of patients abusing their medication. Daytrana gives patients more control over their dosing by being able to choose when the patch is removed; it is also a feasible alternative for children who cannot swallow pills. For patients who cannot swallow tablets or capsules, the capsules of Focalin-XR, Adderall-XR, Metadate-CD, and Ritalin-LA can be opened and sprinkled on applesauce.

CONCLUSIONS: Stimulants are effective medications to treat the symptoms of ADHD. The multiple available dosage forms allow for individualization of treatment.

DATA SOURCES: MEDLINE, EMBASE, and International Pharmaceutical Abstracts databases were searched for studies published between January 1992 and December 2008. Key words included medication review, drug regimen review, pharmaceutical services, pharmaceutical care, pharmacists, medications, appropriateness, suboptimal, underuse, aged, elderly, randomized controlled trial, inappropriate, prescribing, and intervention.

STUDY SELECTION AND DATA EXTRACTION: To be included in the review, studies must have been conducted in patients 65 years or older, published in English, randomized and controlled, and must have included an intervention delivered by a pharmacist or had a pharmacist as a member of the intervention team. From each relevant study, the following data were extracted: study duration, country, number of patients, year of publication, objective, type and impact of the intervention, method used to assess suboptimal prescribing, and data concerning the quality of the study.

DATA SYNTHESIS: A total of 38 articles were identified, of which 12 matched our inclusion criteria. Seven articles included interventions initiated by pharmacists, and the remaining 5 described interventions in which the pharmacist was a part of the multidisciplinary team. A broad range of tools was used to measure prescribing appropriateness; we found that a consensus on the best approach has not been reached. Most of the studies involving pharmacists showed significant improvement in suboptimal prescribing at one or more time points. However, most of these interventions were directed toward reducing the overuse or misuse of medications.

CONCLUSIONS: Pharmacy services to reduce suboptimal prescribing have shown promising and noteworthy improvements. More research is needed to address the underutilization of medications in the elderly and healthcare impact of reducing suboptimal prescribing.

DATA SOURCES: A MEDLINE search was conducted from 1966 through December 2008. Additional sources included abstracts from meetings of the Interscience Conference on Antimicrobial Agents and Chemotherapy and the Infectious Diseases Society of America from 2001 to 2008 and information available from the manufacturer's Web site.

STUDY SELECTION AND DATA EXTRACTION: In vitro and clinical studies, in addition to Phase 1, 2, and 3 clinical trials, were included.

DATA SYNTHESIS: Iclaprim, a novel diaminopyrimidine and DHFR antagonist, has a mechanism of action similar to that of trimethoprim. It has in vitro activity mainly against gram-positive organisms, including resistant Staphylococcus aureus. In Phase 2 and 3 clinical trials, oral and intravenous administration of iclaprim was effective and well tolerated for the treatment of complicated skin and skin structure infections (cSSSI). Trials are currently ongoing for the treatment of ventilator-associated and healthcare-associated pneumonia.

CONCLUSIONS: Iclaprim is a promising antimicrobial agent for the treatment of gram-positive organisms, including resistant S. aureus and trimethoprim-, macrolide-, fluoroquinolone-, and glycopeptide-resistant strains. Additionally, in vitro activity similar to that of trimethoprim has been observed against gram-negative and atypical organisms.

OBJECTIVE: To determine the awareness of, views on, and attitudes of members of the Scottish general public toward nonmedical prescribing, with an emphasis on pharmacist prescribing.

METHODS: A questionnaire was mailed in November 2006 to a random sample of 5000 members of the general public in Scotland aged 18 and over, obtained from the UK electoral roll. The questionnaire contained items on awareness of nonmedical prescribing, levels of comfort with specific health professionals, and attitudes toward pharmacist prescribing.

RESULTS: Response rate was 37.1%. More than half of the individuals who responded were taking prescribed drugs. Nine hundred and seventy-eight (56.6%) were aware that trained health professionals could write prescriptions for medicines previously only prescribed by physicians. Awareness was associated with: increasing age (p < 0.001), having a health professional in their immediate family (p < 0.001), self-rated general health (p < 0.005), and a higher education level (p < 0.01). In logistic regression, all factors were retained as independent predictors of awareness (p < 0.001). Comfort levels for nonmedical prescribing were highest for pharmacists (median 4, IQR 3-5 [1 = low, 5 = high]), closely followed by nurses, and lowest for radiographers (median 2, IQR 1-4) (p < 0.001). While more than half of the respondents supported pharmacists having a prescribing role, fewer felt that pharmacists should prescribe the same range of drugs as physicians. There were concerns about lack of privacy in a pharmacy, despite acknowledging its enhanced convenience.

CONCLUSIONS: Our results indicate that more than half of the respondents were aware of nonmedical prescribing. A higher proportion was more comfortable with prescribing by pharmacists and nurses than with other healthcare professionals. Several issues relating to aspects of clinical governance were highlighted, specifically education and data handling.

OBJECTIVE: To examine the health beliefs of pharmacy customers in Germany, the impact of those beliefs on over-the-counter (OTC) medication use, and associations with sociodemographic variables.

METHODS: By means of literature review and methodical surveys, a standardized questionnaire was designed that contained 68 items concerning health beliefs, habits of OTC product use, decision criteria that customers used when purchasing drugs, and information about the sociodemographic background of the participants. Main outcome measures were reliability (Cronbach's ) and correlations. A random sample of 58 pharmacies in Saxony, Germany (10 questionnaires per pharmacy), invited their customers to take part in our study.

RESULTS: One hundred twenty-three questionnaires (response rate 53.48%) were completed and returned to us. The outcome suggests that there is a strong association between health beliefs and frequency of use or the type of OTC drug (eg, illness attributions: p < 0.05; preventive lifestyle: p < 0.05). There were no significant associations between sociodemographic variables and chosen drugs.

CONCLUSIONS: Health beliefs, in terms of the general attitude toward health and illness, illness attribution, prevention, and the attitude toward treatment strategies, influence the kind of remedy (conventional vs complementary medication) that consumers seek. These results may have implications for consultations in pharmacies or for product marketing.

CASE SUMMARY: A 54-year-old previously well woman presented to the emergency department with a painful, injected right eye. There was no history of trauma or use of contact lenses. On examination, the right eye was estimated to have visual acuity of hand movement. Slit lamp examination detected a 2.5 x 3.5 mm dense, central corneal infiltrate with overlying epithelial defect. The eye had mild corneal edema with anterior chamber inflammation. Microbiology testing revealed S. apiospermum as the primary pathogen. Hourly administration of topical natamycin 5% resulted in initial improvement in visual acuity to 20/50, with reduction in the size of the central infiltrate. However, 1 month later, the eye infection relapsed, with recurrence of epithelial defect (3.1 x 3.1 mm) and decline in visual acuity to 20/100. Antifungal therapy was switched to topical voriconazole 1%, administered every 2 hours. Vision improved to 20/30 within 5 days, and the central defect had completely re-epithelialized within 1 week.

DISCUSSION: Treatment of S. apiospermum keratitis remains inadequate. A high natamycin minimum inhibitory concentration is necessary to treat S. apiospermum infection, which may explain the persistence of central infiltration despite ongoing therapy. The combined use of topical and oral voriconazole for the treatment of S. apiospermum keratitis has been reported. However, this is the first report of a successful clinical experience using topical voriconazole without oral therapy to manage S. apiospermum keratitis. This eliminates some disadvantages associated with oral voriconazole such as high cost, potential significant toxicity, and drug interactions.

CONCLUSIONS: The voriconazole 1% eye drop used alone is a promising, cost-effective, safe option for managing fungal keratitis, even that caused by S. apiospermum. It may have a larger role to play than simply that of adjunctive therapy.