John Noviasky

Smallpox: Clinical Features, Prevention, and Management

OBJECTIVE To describe a general overview of smallpox, clinical presentation, diagnosis, adverse events, and management of both pre- and postexposure vaccination. DATA SOURCES Literature was identified by search of MEDLINE (1966–June 2003) and International Pharmaceutical Abstracts (1966–May 2003) databases using the key terms smallpox, bioterrorism, biological warfare, and smallpox vaccine. STUDY SELECTION AND DATA EXTRACTION Articles identified from data sources were evaluated, and relevant information was included in this review. DATA SYNTHESIS Smallpox is spread by human-to-human contact with an infected host and therefore can be contagious. The mortality rate for smallpox is approximately 30%. While the disease was completely eradicated by 1980 with successful use of smallpox vaccine, concern has been raised that smallpox may emerge as a tool of bioterrorism. This concern, combined with the reality of current smallpox vaccination programs in the military and selected civilian populations, mandates a clear understanding of vaccination-related adverse events and contraindications by all healthcare professionals. The vaccine may cause moderate to severe adverse events such as eczema vaccinatum, progressive vaccinia, and generalized vaccinia. CONCLUSION The balance between the risks and benefits of mass vaccination in prevention of an epidemic is not clear. The Centers for Disease Control and Prevention has established a guideline for appropriate use of smallpox vaccine in the civilian population.

Mixing and compatibility guide for commonly used aerosolized medications.

PURPOSE A mixing and compatibility guide for commonly used aerosolized medications was developed. SUMMARY Compatibility guides for injectable drugs are available as a reference for pharmacists, nurses, and medical personnel. These charts are commonly used in hospitals and other health care institutions and provide a quick, easy reference for compatibility of frequently used intravenous medications. Respiratory therapists are frequently directed to administer various aerosolized medications and are often faced with the challenge of uncertain compatibility of these drugs when mixed together. However, there appear to be limited data regarding the compatibility of these aerosolized admixtures. After a careful review of the literature, a compatibility chart was developed that should provide significant value to pharmacists, nurses, and respiratory therapists who administer aerosolized medications. The authors of a recently published evaluation of the compatibility of common inhalation solutions summarized their findings in a concise table. This table served as a template to develop a more comprehensive mixing and compatibility guide in the form of an easy-to-use reference chart, which includes additional agents, compatibility references on the chart, and compatibility information for pharmacists, nurses, physicians, and respiratory therapists. CONCLUSION A compatibility guide for aerosolized medications was developed for use by staff who administer these agents.

Rhabdomyolysis associated with phentermine

PURPOSE A case of rhabdomyolysis associated with the use of phentermine is reported. SUMMARY A 32-year-old Caucasian man with a recent history of strenuous exercise sought treatment for significant back, shoulder, and radiating inguinal pain. The patients home medications included the following, administered orally: esomeprazole, levothyroxine, irbesartan- hydrochlorothiazide, metoprolol succinate, metoclopramide, dicyclomine, oxycodone-acetaminophen, and oxycodone extended-release. He also used testosterone topical gel. During the hospital stay, it was discovered that the patient had been taking phentermine hydrochloride 37.5 mg twice daily, double the recommended dosage, for approximately one week before and on the day his symptoms started. His initial laboratory test values were as follows: troponin I, 17.46 ng/mL; creatine kinase (CK), 114,383 units/L; CK-MB, 745.5 ng/mL; and serum creatinine (SCr), 2.8 mg/dL. The patient was diagnosed with rhabdomyolysis of the left deltoid muscle, shoulder, posterior scapula, and upper thorax and with secondary acute renal failure. The patients urine output was initially poor and rapidly declined to anuria on day 2 of admission. He received i.v. hydration with 0.45% sodium chloride at an initial rate of 200 mL/hr with 75 meq/L of sodium bicarbonate for urinary alkalinization. He did not require renal replacement therapy, and his urine output began to improve to 0.5 mL/kg/hr on hospital day 5 and was 1.42 mL/kg/hr before discharge. Use of the Naranjo et al. adverse-event probability scale revealed that phentermine was the probable cause of the patients rhabdomyolysis. CONCLUSION A 32-year-old man developed rhabdomyolysis after ingesting double the recommended dosage of phentermine for a week in addition to engaging in strenuous activity.

Controversy and conflict in the treatment of acute decompensated heart failure : Limited role for nesiritide

The use of nesiritide for acute decompensated heart failure (ADHF) has been clouded with controversy since its approval in 2001. Extensive marketing and many review articles have established this drug as a safe and superior product to current standards. However, its safety has been called into question by the results of a meta‐analysis, and its superiority of important outcomes (length of stay, mortality, decreased readmission rate) has never been proved by a randomized trial against agents with similar vasodilator properties (e.g., nitroglycerin). A review of the available literature on nesiritide in the areas of mortality, renal effects, retrospective studies, use in off‐label indications, length of stay, and mortality is presented and illustrates why its use should be limited or even eliminated. After review of this article, the reader should be able to answer the question—if nesiritide had never been approved for use in patients with ADHF, would we have missed it?—with a negative reply.