Kenneth E. Record

Vancomycin pharmacokinetics in normal and morbidly obese subjects.

In an uncontrolled study, vancomycin pharmacokinetics were determined in four normal (total body weight [TBW], 65.9 to 89.1 kg) and six morbidly obese (TBW, 111.4 to 226.4 kg) subjects. The morbidly obese subjects were investigated 3 to 4 h after gastric bypass surgery. Mean terminal half-lives, volumes of distribution, and total body clearances for the normal controls and the morbidly obese (TBW, 111.4 to 226.4 kg) subjects. The morbidly obese subjects were investigated 3 to 4 h after gastric bypass surgery. Mean terminal half-lives, volumes of distribution, and total body clearances for the normal controls and the morbidly obese subjects were 4.8 h, 0.39 liter/kg, and 1.085 ml/min per kg versus 3.2 h, 0.26 liter/kg TBW, and 1.112 ml/min per kg TBW. The mean terminal half-life and volume of distribution values were significantly different between the two groups. Strong correlations were found between TBW and both volume of distribution (correlation coefficient, 0.943) and total body clearance (correlation coefficient, 0.981). There results implied that TBW should be used to calculate vancomycin doses for morbidly obese patients. This was supported by the finding that there was no significant difference in the daily dose (in milligrams per kilogram per day) required to produce an average steady-state concentration of 15 micrograms/ml in the two groups (23.4 +/- 1.5 mg/kg per day for normal weight subjects and 24.0 +/- 3.4 mg/kg per day TBW for the postsurgery morbidly obese subjects). Therefore, the morbidly obese required higher total doses (in milligrams per day) than did normal weight subjects to achieve the same mean steady-state concentrations. In addition, normal weight and morbidly obese subjects had similar volumes of the central compartment (7.7 and 6.4 liters, respectively). To avoid high transient peak concentrations which would occur when obese patients are given larger total doses (in milligrams per day), maintenance doses may be given at more frequent intervals. The shorter mean terminal half-lives observed in morbidly obese patients allows more frequent dosing without excessive accumulation.

Tobramycin pharmacokinetics in morbidly obese patients

Tobramycin kinetics were examined in 9 morbidly obese women following a single intavenous (120 mg) bolus. After the injection, serum elimination conformed to a 2‐compartment open model with a and β t½s of 0.285 and 2.1 hr. The volume of distribution (Varea) was determined to be 0.44 l/kg ideal body weight (IBW) and 0.20 l/kg total body weight (TBW). To normalize Varea to 0.26 l/kg, 58% of the patients’ adipose weight (TBW — IBW) must also be taken into account.

Impact of antiemetic selection on postoperative nausea and vomiting and patient satisfaction

Study Objective. To determine the impact of antiemetic selection on postoperative nausea and vomiting (PONV) and patient satisfaction after ambulatory surgery.

Comparison of Urinary Urea Nitrogen Excretion and Measured Energy Expenditure in Spinal Cord Injury and Nansteroid-Treated Severe Head Trauma Patients

Severe head trauma patients (HT) exhibit markedly elevated energy expenditure and 24-hr urinary urea nitrogen excretion (UUN) values. The objective of this study was to compare seven spinal cord injured patients (SCI) to seven HT for changes in UUN and measured energy expenditure (MEE) over the first 18 days following injury. Energy expenditure was measured by indirect calorimetry and compared to values predicted by the Harris Benedict Equation (PEE). There were six quadriplegics and one paraplegic in the SCI group. HT patients had peak Glasgow Coma Scale scores of 3 to 10 for the first 24 hr postinjury. Patients were studied prospectively and matched for age, sex, and admitting weight Week 1 following the injury, SCI had mean UUN values of 0.18 +/- 0.04 g/kg/day vs 0.18 +/- 0.01 for HT patients. The mean MEE/PEE ratio was 0.56 for the SCI and 1.4 for HT (p less than 0.01). Over the entire study period the mean UUN value for SCI was 0.23 +/- 0.03 g/kg vs 0.21 +/- 0.01 for HT. The mean MEE/PEE ratio for SCI was 0.94 while HT remained elevated at 1.5 (p less than 0.05). Although the UUN was comparable in SCI vs HT, there was a significant difference in MEE/PEE between the groups. The elevation in UUN observed in SCI is not due to a hypermetabolic state. This suggests that different mechanisms promote the increased nitrogen excretion observed in these two populations.

Cytomegalovirus Colitis After 5‐Fluorouracil and Interferon‐α Therapy

Cytomegalovirus (CMV) infection is an opportunistic viral infection primarily affecting immunocompromised patients. Patients with inflammatory bowel disease have an increased risk for developing CMV infections of the gastrointestinal tract. While receiving continuous infusion of 5‐fluorouracil and interferon‐α, a 72‐year‐old woman with stage IV pancreatic carcinoma developed severe colitis with diarrhea that was refractory to conventional antidiarrheals. A biopsy specimen from the colon revealed CMV inclusions, which were confirmed by immunofluorescence. The patient was given ganciclovir 210 mg (5 mg/kg) every 12 hours for 14 days, and the diarrhea resolved after approximately 8 days of therapy. This is the first reported case of CMV colitis associated with combination 5‐fluorouracil and interferon‐α therapy.

Lactose: the hidden culprit in medication intolerance?

Although reports are rare, lactose-containing medications may cause patient discomfort and subsequently affect medication adherence.

Drug delivery for intractable cancer pain. Use of a new disposable parenteral infusion device for continuous outpatient epidural narcotic infusion.

Administration of narcotic analgesics through the epidural route has proven useful for treating pain of acute and chronic nature. This route of narcotic administration is frequently chosen for cancer patients with intractable pain that may be refractory to treatment by conventional oral or parenteral therapy. Implantable constant infusion devices have been commonly described as an alternative drug delivery system for this type of patient. This case report describes the use of the Travenol Infusor (Travenol Laboratories Inc., Deerfield, Illinois) an external, lightweight, disposable, drug delivery device for delivering continuous epidural morphine infusion to a patient with severe cancer pain. The patient has achieved stable pain relief for greater than 8 months without hospital admission for pain control, or management of complications due to the drug delivery system. The Travenol Infusor may prove to be an alternative drug delivery system for patients requiring continuous epidural narcotic infusion.

Antimicrobial Options in the Treatment of Adult Staphylococcal Bone and Joint Infections in an Era of Drug Shortages

Staphylococcus aureus is the most pathogenic bacterium and the most common cause of osteomyelitis, affecting 50% to 70% of cases. Many antistaphylococcal agents with varying activity against methicillin-susceptible S aureus and methicillin-resistant S aureus are available in the US market. This article reviews the most common antistaphylococcal agents used in the treatment of bone and joint infections in adult patients and focuses on the antimicrobial agents mechanism of action, US Food and Drug Administration-approved indications, place in therapy, monitoring parameters, and common side effects.

National survey of pharmacy services in free medical clinics

OBJECTIVES To characterize the current model of pharmacy services in free clinics, identify the extent to which free clinics serve as training sites for student pharmacists and residents, elucidate pharmacy service gaps in free clinics, and compare results to a 2001 survey. DESIGN Descriptive, non-experimental, cross-sectional study. SETTING Free medical clinics in the United States in early 2008. PARTICIPANTS Clinics registered at www.freeclinicfoundation.org. INTERVENTION A 26-point questionnaire addressed clinic and pharmacy demographics, pharmacy services, medication storage and distribution processes, and systems management. Survey invitations were sent via postal mail, with responses submitted via hardcopy or online (Survey Monkey). Nonresponders received a second mailing 4 weeks later. MAIN OUTCOME MEASURES Characteristics determined by survey responses. RESULTS 42% of clinics responded (216 of 518). The median annual clinic budget was

Hemodialysis clearance of pentobarbital during continuous infusion

145,000, with 1% to 20% spent on medications. Of responding clinics, 30% had a licensed pharmacy that was staffed on average by 3.4 pharmacist volunteers and 0.1 pharmacist employees. Of the 83.5% (177 of 212) that dispensed drugs, clinics filled 67 prescriptions per day with cardiovascular, gastrointestinal, and anti-infective agents as top classes. Pharmacy personnel provided mainly traditional (e.g., distributive) services (61.1%), and 19.3% of clinics trained student pharmacists. Since 2001, the number of clinics (355 vs. 518) and prescriptions dispensed (29 vs. 67 per day) increased but the percentage with a licensed pharmacy (33% vs. 30%) and mean number of pharmacist volunteers/employees (3.8/0.1 vs. 3.4/0.1) remained constant. CONCLUSION The model of free clinic pharmacy services is a modified community practice. Pharmacy personnel have the opportunity to expand their role and pharmacy practice in free clinics.