Barry J. Gales

Nutritional Support Teams: A Review of Comparative Trials

OBJECTIVE: To evaluate the literature describing the influence of nutritional support teams (NSTs) on the provision of nutritional therapy. DATA SOURCES: A MEDLINE and International Pharmaceutical Abstracts search (key terms: nutritional support, nutritional support service/team, hyperalimentation service/team, metabolic support service/team, service/team) covering 1970–1993 were used to identify pertinent literature. STUDY SELECTION: The results of comparative trials involving NSTs are presented. DATA EXTRACTION: Data from comparative trials examining the influence of NSTs on the provision of enteral nutrition (EN) and total parenteral nutrition are discussed. DATA SYNTHESIS: NSTs dramatically reduced the incidence of catheter-related complications, especially sepsis, by developing central venous catheter insertion and care guidelines. Early studies found that NSTs reduced the incidence of electrolyte and metabolic abnormalities by more stringent laboratory and clinical monitoring, but this was not found consistently in later studies. The ability of consultative NSTs to reduce the incidence of metabolic and electrolyte abnormalities is less clear. NSTs also were more likely to evaluate, document, and subsequently meet a patients nutritional requirements. Studies examining the financial impact of NSTs frequently reported cost savings, but often failed to include personnel costs in their analysis. The provision of EN by an NST reduced the frequency of complications and increased the adequacy of nutritional supplementation. CONCLUSIONS: Early nutritional support teams produced significant benefits largely through the development of protocols and standardization. Current NSTs should increase the dissemination of information supporting their continued benefits. To remain viable, NSTs need to expand their roles, document improved patient outcomes, and show cost-effectiveness.

Adverse Reactions to Human Serum Albumin

OBJECTIVE: To describe the adverse effects associated with human serum albumin (HSA) administration. DATA SOURCES: A MEDLINE search and bibliography scanning were used to identify pertinent review articles, clinical studies, and case reports. STUDY SELECTION: Emphasis was placed on reporting the results of human studies with the primary objective of investigating adverse effects attributable to HSA administration. Clinical trials that reported the occurrence of adverse effects possibly associated with HSA were also reviewed. Animal data were included where pertinent. DATA EXTRACTION: Although isolated case reports were reviewed, data were primarily extracted from human studies involving large series of patients or studies that were randomized and prospective in nature. DATA SYNTHESIS: Alterations in coagulation, renal, cardiovascular, and pulmonary functions were identified as potential adverse effects following the administration of HSA. Occurrences of hypersensitivity reactions, trace metal loading, and serum amino acid alterations associated with these infusions were also noted and are described here. Pulmonary and cardiovascular systems appear to be particularly prone to complications from excessive HSA administration. Adverse effects such as HSA-induced hypersensitivity reactions may be severe, but occur infrequently. CONCLUSIONS: Controlled studies involving large numbers of patients are not currently available for an accurate assessment of the incidence of adverse effects attributable to HSA administration. Many of the reported reactions appear to be extensions of albumins pharmacologic activities and would be expected to worsen following large doses of HSA.

Albumin Audit Results and Guidelines for Use

Objective: To identify patients receiving albumin, develop guidelines for albumin use, and examine distribution and billing procedures. Design: Case series. Setting: Tertiary care center. Patients: All patients received albumin in a four-week period. Patients were identified concurrently using intensive care unit surveys and the pharmacy computer system, and retrospectively using billing statements. Data were analyzed from 73 of 79 patients (92.4 percent); 6 (7.6 percent) had no record of albumin being ordered or administered. Pediatric patient data were used only in the financial calculations. Data Collection: Demographics and albumin dosages were recorded for all patients. Prescribing service and indications for use were recorded in adults. Albumin administered was compared with the amount billed to each patient. Main Results: Sixty adult patients aged 14–91 y (median 62) received 1–69 units (median 4 units [1 unit=12.5 g albumin]) and 470 total units. Surgical services prescribed albumin in 73 percent and medical services in 27 percent of the patients. Common indications for albumin included volume expansion (65 percent), as intraoperative fluid (13 percent), and to increase urine output (10 percent). The pharmacy computer system identified 63 percent of the patients. Of these, 13 percent were not billed for albumin they received. Examinations of patient billing statements found that up to

Granulocyte-Colony Stimulating Factor for Sulfasalazine-Induced Agranulocytosis

17,740 a year (15 percent) of albumin administered is not billed. The floor-stock distribution system used in the intensive care units contributed to most errors. Conclusions: Recommendations addressing the problems identified in this audit were made to the pharmacy, medical, nursing, and billing departments. Guidelines for albumin use were formulated and approved by the hospitals pharmacy and therapeutics committee.

Book Review: Exercise-Induced Asthma: Pathophysiology and Treatment:

OBJECTIVE: To report a case of sulfasalazine-induced agranulocytosis that was successfully treated with granulocyte-colony stimulating factor (G-CSF). CASE SUMMARY: An 82-year-old woman developed agranulocytosis within two months of initiating sulfasalazine therapy. She was hospitalized, empiric antibiotics and antifungal agents were prescribed, and sulfasalazine therapy was stopped. The patient received G-CSF 600 μg/d subcutaneously for six consecutive days, starting on hospital day 5. Agranulocytosis resolved on day 5 and leukopenia on day 6 of G-CSF therapy. No adverse reactions were attributed to administration of this agent and the patient was discharged on hospital day 13. DISCUSSION: Numerous agents, including sulfasalazine, have been associated with agranulocytosis. Agranulocytic patients frequently experience life-threatening bacterial and fungal infections. Administration of colony stimulating factors may reduce the duration of agranulocytosis and incidence of life-threatening infections. CONCLUSIONS: G-CSF administration appears to have decreased the duration of this elderly patients agranulocytosis and hospitalization.

Exercise-Induced Asthma: Pathophysiology and Treatment

first edition, and no previous book contains this information. This book is an important companion to Health Behavior and Health Education: Theory, Research and Practice.1 The latter book provides an overview of more traditional theoretical approaches used in public health and health promotion. The authors and editors of Emerging Theories are highly qualified and have used the theories or models. The editors have organized the book in a straightforward manner, and the writing style is clear and focused. There is little, if any, jargon. The information presented in each chapter provides an overview of the theories or models. One chapter cannot present an in-depth examination of a theory or model. Thus, the exact purpose of the book as outlined by the editors is not met. The book is highly successful, however, in introducing researchers, practitioners, and students to new ways of thinking about health promotion. It provides a first step in learning new information, but readers will require significantly more study to actually apply the models and understand the contexts within which they have been successful. This book should be purchased by researchers and practitioners interested in leading and/or participating in community-wide approaches to improving health. Graduate students in pharmacy administration programs may benefit from the knowledge gained, but it is unlikely that they will use many of the theories or models. Research in pharmacy administration tends to focus on individual rather than community approaches to behavior change. Pharmacy administration researchers interested in collaborative community-wide projects with public health researchers, where pharmacists or medication use is 1 component of a public health initiative, would most certainly benefit from this book. Public health and health promotion agencies, researchers, practitioners, and students are most likely to benefit from this text. The information is well worth the

The Use of Albumin in Clinical Practice

60 investment for the individuals outlined above as well as for health sciences libraries.

Rapid Infusion of Amphotericin B in Dextrose

No wonder you activities are, reading will be always needed. It is not only to fulfil the duties that you need to finish in deadline time. Reading will encourage your mind and thoughts. Of course, reading will greatly develop your experiences about everything. Reading exercise induced asthma pathophysiology and treatment is also a way as one of the collective books that gives many advantages. The advantages are not only for you, but for the other peoples with those meaningful benefits.