Edna Patatanian

Retinoic acid syndrome: a review

The retinoic acid syndrome (RAS) is an unpredictable but frequent complication which may develop after administration of all‐trans retinoic acid (ATRA) most commonly in patients with acute promyelocytic leukaemia (APL). In this review, we describe the incidence, predictive factors, clinical course, outcome and treatment of RAS in patients with APL treated with ATRA. The incidence of RAS in patients receiving ATRA is about 14–16%, with an associated mortality of about 2%. Initial high white blood cell (WBC) count, rapidly increasing WBC count and/or the presence of the CD 13 expression on leukaemic cells may help in identifying patients likely to develop RAS. Concurrent chemotherapy will probably decrease the risk of developing RAS but often exacerbates bleeding, leading to leucocytosis, thrombocytopenia, disseminated intravascular coagulation and fibrinolysis. Prophylactic steroids are not recommended but prompt administration of steroids at the first sign of unexplained dyspnea, fever, weight gain or pulmonary infiltrate, is critical. Liposomal ATRA is being investigated to induce haematological cure in APL without chemotherapy and to reduce the incidence of RAS but further validation of its usefulness is necessary.

A review of methotrexate-induced accelerated nodulosis.

Objective. To review the English‐language literature on methotrexate‐induced accelerated nodulosis, compile case reports of its occurrences, and make recommendations on the clinical management of patients.

Hemostatic Mouthwashes in Anticoagulated Patients Undergoing Dental Extraction

Objective: To evaluate the efficacy and safety of local acting hemostatic agents in patients who are undergoing dental extraction(s) and are taking oral anticoagulants. Data Sources: A search of MEDLINE (1966–July 2006), International Pharmaceutical Abstracts (1970–July 2006), and EMBASE (1966–July 2006) was conducted using the key terms anticoagulation, warfarin, hemostatic mouthwashes, epsilon aminocaproic acid, tranexamic acid, dental extraction, and oral surgery. Bibliographies of relevant papers were reviewed for additional references. Study Selection and Data Extraction: English-language literature, including abstracts, clinical trials, and review articles, were reviewed. Clinical trials were included if they evaluated hemostatic mouthwashes in patients receiving continued anticoagulation and undergoing dental extractions or various oral surgeries including dental extraction. Eight clinical trials met study selection criteria for evaluation of hemostatic mouthwashes in anticoagulated patients undergoing dental extraction. Eight studies evaluated tranexamic acid; one assessed epsilon aminocaproic acid. All studies were reviewed for efficacy and safety of hemostatic mouthwashes and intensity of continued anticoagulation therapy. Data Synthesis: Eight small studies enrolled populations that varied in the indications for oral anticoagulation (OA), target INR ranges, and oral surgeries performed. Patients receiving uninterrupted OA and using hemostatic mouthwashes had no greater and, in some cases, lesser bleeding incidence compared with various other treatment groups (including interrupted OA, uninterrupted OA, autologous fibrin glue with uninterrupted OA, and reduced OA with heparin bridge). No severe adverse effects were reported. No studies assessed the risk of thromboembolism between the different treatment strategies. Conclusions: Findings in recent studies indicate that dental extractions in anticoagulated patients can be performed without temporary discontinuation of oral anticoagulant therapy with the use of hemostatic mouthwashes to control localized bleeding. This practice should be more widely adopted due to minimized bleeding and thromboembolic risks.

Drug-Induced Yawning—A Review

Objective: To review the current literature on drug-induced yawning. Data Sources: Literature was accessed through MEDLINE/PubMed (1996-July 2011), International Pharmaceutical Abstracts (1997-July 2011), and EMBASE, using the search terms yawning, drug-induced yawning, and adverse drug reactions. Study Selection and Data Extraction: Relevant clinical trials and case reports were selected and included to present background information. Bibliographies of all relevant articles were reviewed for additional citations. Data Synthesis: Yawning is a common stereotype behavior with unknown physiologic function that occurs in most vertebrates and humans as early as 15 weeks of intrauterine life. Yawning Is under the control of several neurotransmitters and neuropeptides, Including dopamine, serotonin, oxytocin, and acetylcholine. Among drugs, antidepressants, opioids, dopaminergic agents, benzodiazepines, and induction agents are the main pharmacologic classes associated with yawning. Conclusions: Yawning is rarely a serious adverse reaction and is not frequently listed in the drug summary. Most available data are based on case reports, small studies, and older literature. Clinicians should be aware of the agents commonly triggering this behavior.

Dextromethorphan/quinidine for the treatment of pseudobulbar affect.

OBJECTIVE To evaluate the role of dextromethorphan/quinidine (DM/Q; Nuedexta™) in the treatment of pseudobulbar affect (PBA). DATA SOURCES A literature search of MEDLINE/PubMed (January 1966-June 2013) was conducted using search terms pseudobulbar affect, pathological laughing and/or crying, emotional lability, dextromethorphan, and quinidine. STUDY SELECTION AND DATA EXTRACTION English language clinical trials and case reports evaluating the safety and efficacy of DM/Q in PBA were included for review. Bibliographies of all relevant articles were reviewed for additional citations. DATA SYNTHESIS PBA, a poorly understood disorder, is characterized by involuntary crying and/or laughing. In the past, antidepressants and antiepileptics have been used off-label with mixed results. Four clinical trials have evaluated the use of DM/Q for the treatment of PBA. Although the therapeutic outcomes with DM/Q have been positive, interpretation of the published evidence is limited by small sample size and short treatment duration. CONCLUSIONS Based on the data available, DM/Q may be a viable, short-term treatment alternative for PBA. Long-term safety and efficacy data are lacking.

Development and Implementation of a Pharmacy Fall Prevention Program

Purpose Describe the development, implementation, and outcomes of a pharmacy fall prevention program (PFPP) that incorporates medication profile review and a medication fall risk score to identify high-risk patients. Summary Falls are a common cause of morbidity and mortality among elderly patients in the United States. Injury-related falls may contribute to frequent visits to emergency departments (EDs) and hospitals, as well as functional and emotional decline. Falls account for more than 10% of ED visits and more than 5% of hospital visits. Numerous reports describe common risk factors associated with falls of hospitalized patients and which safety measures should be taken to prevent or eliminate falls. The fall prevention program has a positive financial impact by reducing injury falls in hospitalized patients. During the first 2 years of implementation, the injury fall rate decreased from 2.06 to 1.07 per 1,000 patient-days (48%). The total falls rate decreased from 5.13 to 3.59 per 1,000 patient-days (30%). This program showed a savings of

Drug-Induced Restless Legs Syndrome:

217,000 per year in prevented falls. Conclusion Incorporating medications and their related adverse effects into a fall prevention program is an integral part of a multidisciplinary approach to reduce total falls and related injuries. The decrease in falls has improved patient safety and quality of care.

Extended duration vancomycin in recurrent Clostridium difficile infection: a systematic review

Objective: To review the literature on drug-induced restless legs syndrome (DI-RLS). Data Sources: The review included a search for English-language literature from 1966 to December 2017 in the MEDLINE, PubMed, and Ovid databases using the following search terms: restless legs syndrome (RLS), periodic limb movement, adverse effects, and drug-induced. In addition, background articles on the pathophysiology, etiology, and epidemiology of RLS were retrieved. Bibliographies of relevant articles were reviewed for additional citations. Study Selection and Data Extraction: All case reports, case series, and review articles of DI-RLS were identified and analyzed. There were only a small number of controlled clinical trials, and most data were from case reports and case series. Results: Several drugs and drug classes have been implicated in DI-RLS, with antidepressants, antipsychotics, and antiepileptics having the most evidence. In addition, RLS may be linked with a number of disorders or underlying predisposing factors as well. Conclusions: The prevalence of RLS is variable and ranges from 3% to 19% in the general population. There are many predisposing factors to RLS, but an emerging body of evidence suggests that there is an association between numerous drugs and RLS.

The future of statins: Alzheimer's disease?

Clostridium difficile infections have a high recurrence rate following acute treatment. Extended duration vancomycin (EDV) is a mainstay for the treatment of recurrent Clostridium difficile infections (rCDI). Clinical disease guidelines recommend a variety of different vancomycin treatment regimens though based on weak, low-quality evidence. Patients typically receive an initial vancomycin treatment course of 7–14 days for the acute infection, followed by an extended duration vancomycin course. Multiple publications on the utility of EDV regimens have been published but few include reported effectiveness outcomes associated with a prescribed treatment regimen. The purpose of this review is to evaluate the safety and efficacy data on extended duration vancomycin regimens used in recurrent clostridium treatment. Five articles, three case series and two randomized open-label clinical trials, were identified which included both elements. Outcomes were evaluable in 174 patients, 31 from randomized trials, with prior average recurrent episodes ranging from 3 to 4. Vancomycin dose ranged from 3500 to >6800 mg with therapy durations extending from 21 days to over 60 days. Follow-up duration ranged from 10 weeks to 12 months. Case series reported success rates for EDV in rCDI from 61% to 100%, while randomized trials found lower success rates from 26% to 58%. Taper and pulse regimens reported superior outcomes compared to pulse-only regimens, 58–100% versus 26–81%, respectively. Comparative EDV data is limited. Current available data supports an EDV regimen which includes both a daily dosing taper followed by an every 48 or 72 h pulse.