Patricia L. Orlando

Evidence for a heritable predisposition to death due to influenza.

Animal model studies and human epidemiological studies have shown that some infectious diseases develop primarily in individuals with an inherited predisposition. A heritable contribution to the development of severe influenza virus infection (i.e., that which results in death) has not previously been hypothesized or tested. Evidence for a heritable contribution to death due to influenza was examined using a resource consisting of a genealogy of the Utah population linked to death certificates in Utah over a period of 100 years. The relative risks of death due to influenza were estimated for the relatives of 4,855 individuals who died of influenza. Both close and distant relatives of individuals who died of influenza were shown to have a significantly increased risk of dying of influenza, consistent with a combination of shared exposure and genetic effects. These data provide strong support for a heritable contribution to predisposition to death due to influenza.

The role of dehydroepiandrosterone in diabetes mellitus

Much has been written in the lay literature regarding potential benefits of dehydroepiandrosterone (DHEA). Although it was removed from the over‐the‐counter market in 1985, the Dietary Supplement Health Education Act of 1994 allowed the drug to be marketed as a food supplement. Because DHEA no longer falls under the scrutiny of the Food and Drug Administration, many unverified claims have been put forth in the press espousing its therapeutic value. This barrage of “infomercials” has left the average American consumer (and health care professional) curious about DHEA and its possible therapeutic utility. One focus of recent research is to define the role of DHEA in diabetes mellitus. Although it has been claimed that decreased levels of endogenous DHEA are associated with diabetes, impaired glucose tolerance, hyperglycemia, and insulin resistance, much of the information is based on cross‐sectional studies. Other claims correlate decreased endogenous DHEA levels with adverse cardiovascular effects. Some information is contradictory and indicates high doses of exogenous DHEA may produce adverse cardiovascular effects, an undesirable outcome in patients with diabetes mellitus. At this time, its administration in patients with diabetes is not warranted. Long‐term trials evaluating the role of exogenous DHEA and its effect on patients with diabetes should be conducted.

Pressure Ulcer Management in the Geriatric Patient

OBJECTIVE: To increase the understanding of pharmacists and other health-system clinicians regarding pharmaceutical applications of pressure ulcer prevention and treatment in geriatric patients. DATA SOURCES: An extensive MEDLINE retrieval was conducted which encompassed the years 1967–1998; the search terms used included pressure sore, pressure ulcer, decubitus ulcer, and geriatrics. DATA SUMMARY: Pressure ulcers affect populations with limited mobility, reduced cognition, and less-independent activities of daily living, such as the elderly. Identification of the high-risk patient is required for successful prevention outcomes. For existing lesions, a variety of treatment modalities exist, not all of which have demonstrated therapeutic benefit. Given these options, clinicians are faced with treatment selection challenges that should be based on the clinical setting, available scientific evidence, and individualized patient care needs. CONCLUSIONS: Prevention of pressure ulcerations is imperative to reduce patient morbidity, mortality, and overall healthcare costs. Given the number of treatment options available, pharmacists can assist in the treatment selection process. Education of the patient and family regarding pressure ulcer prevention and treatment requires early and ongoing involvement by the interdisciplinary team.

Acute Care Clinical Pharmacy Practice: Unit- versus Service-Based Models

This commentary from the 2010 Task Force on Acute Care Practice Model of the American College of Clinical Pharmacy was developed to compare and contrast the “unit‐based” and “service‐based” orientation of the clinical pharmacist within an acute care pharmacy practice model and to offer an informed opinion concerning which should be preferred. The clinical pharmacy practice model must facilitate patient‐centered care and therefore must position the pharmacist to be an active member of the interprofessional team focused on providing high‐quality pharmaceutical care to the patient. Although both models may have advantages and disadvantages, the most important distinction pertains to the patient care role of the clinical pharmacist. The unit‐based pharmacist is often in a position of reacting to an established order or decision and frequently is focused on task‐oriented clinical services. By definition, the service‐based clinical pharmacist functions as a member of the interprofessional team. As a team member, the pharmacist proactively contributes to the decision‐making process and the development of patient‐centered care plans. The service‐based orientation of the pharmacist is consistent with both the practice vision embraced by ACCP and its definition of clinical pharmacy. The task force strongly recommends that institutions pursue a service‐based pharmacy practice model to optimally deploy their clinical pharmacists. Those who elect to adopt this recommendation will face challenges in overcoming several resource, technologic, regulatory, and accreditation barriers. However, such challenges must be confronted if clinical pharmacists are to contribute fully to achieving optimal patient outcomes.

Evaluation of Outpatient Parenteral Antimicrobial Therapy at a Veterans Affairs Hospital.

We reviewed outpatient parenteral antimicrobial therapy at a Veterans Affairs Medical Center to identify opportunities for antimicrobial stewardship intervention. A definite or possible modification would have been recommended in 60% of courses. Forty-one percent of outpatient parenteral antimicrobial therapy courses were potentially avoidable, including 22% involving infectious diseases consultation.

Transition Hand-Off from Inpatient to Outpatient Treatment of Acute Pyelonephritis in an Elderly Male

Pyelonephritis is the progression of a urinary tract infection (UTI) to the kidney. In younger patients the infection may not be as severe and may even be treated with oral antibiotics. However, in elderly males pyelonephritis can be more complex and may require hospitalization and treatment with intravenous antibiotics. In the United States UTIs are responsible for frequent visits to emergency departments by elderly individuals. Current literature suggests that pyelonephritis in elderly males is a serious infection that may result in significant morbidity and mortality. Pharmacists are in a unique position to oversee the transition of antibiotic treatment from the inpatient to outpatienT SETTING.

Mohs Micrographic Surgery: Key Pharmacologic Considerations

OBJECTIVE To describe Mohs micrographic surgery and evaluate whether direct oral anticoagulants should be withheld in patients with atrial fibrillation (Afib) prior to the procedure and to consider what type of antibiotic prophylaxis should be used. SETTING A community setting in which an elderly patient is living independently at home. PRACTICE DESCRIPTION Academic-affiliated internal medicine clinic that cares for adult patients of all ages, including elderly patients living independently in their own home. The practice occasionally consults with geriatric specialty pharmacists to obtain drug information regarding drug therapy. PRACTICE INNOVATION Identify and assess literature regarding therapeutic issues regarding patients with Afib, whether direct oral anticoagulants should be withheld prior to dermatologic surgery, and what type of antibiotic prophylaxis should be provided prior to the procedure. MAIN OUTCOME MEASUREMENTS Highlight literature that assesses surgical bleeding risk if direct oral anticoagulants are continued, and alternatively, the risk of a thromboembolic event if discontinued; and address antibiotic prophylaxis prior to Mohs micrographic surgery in a patient with Afib. RESULTS In an elderly patient with Afib, a pharmacist should evaluate bleeding risk if direct oral anticoagulants are continued, risk for stroke if anticoagulants are discontinued, and determine appropriate antibiotic prophylaxis prior to Mohs micrographic surgery. CONCLUSION In patients with Afib treated with direct oral anticoagulants who will have dermatologic surgery, the bleeding risk is usually low, whereas risk of a possible thromboembolic event is high, and antibiotic prophylaxis should be done to prevent infection.

Book Review: Physician's Guide to End-of-Life CarePhysician's Guide to End-of-Life Care Edited by SnyderLois JD and QuillTimothy E MD. Published by The American College of Physicians—American Society of Internal Medicine, Philadelphia, 2001. ISBN 1-930513-28-3. Paperbound, xx + 267 pp. (23 × 15.5 cm),

This easy-to-use, paperbound, 267-page reference was developed by the American College of Physicians–American Society of Internal Medicine End-of-Life Care Consensus Panel and the College’s Ethics and Human Rights Committee to provide a practical approach to teaching palliative care concepts to trainees as well as clinicians who care for seriously ill patients. The book is divided into 3 primary sections with chapter subsets. Section I, Chapter 1 deals with discussing palliative care with patients at various stages of progressive chronic illness. It offers effective interview techniques to the clinician while it also educates on responding appropriately to family needs. Chapter 2 emphasizes the identification of patient goals for the provider who is developing the plan of care. Additional guidelines are provided on how to deal with patients unable to make informed decisions. Chapter 3 explores the appreciation of the healthcare provider for patient cultural differences to enhance communications regarding end-of-life care. The final chapter of Section I discusses the role of the clinician in end-of-life care using a problem-based approach while still appreciating “the art and heart of medicine.” In Section II, Chapter 5 discusses pain management within a multidisciplinary environment, with emphasis on the World Health Organization Analgesic Ladder and the Agency for Health Care Policy and Research guidelines for cancer pain treatment. This chapter explores various options for pharmacologic and nonpharmacologic pain management of a hypothetical patient. Chapter 6 addresses the management of depression in the terminally ill patient, considering advantages and disadvantages of various pharmacologic agents. Again, a case is used in Chapter 7 to demonstrate how delirium is an obstacle to high-quality palliative care and how pharmacologic agents may be used to treat an agitated delirium. Chapter 8 examines the role of the intensive care unit and the process of foregoing life-sustaining treatment to focus on patient and family comfort. Clinical guidelines and practicalities for terminal sedation and voluntarily refusing eating and drinking are presented and integrated into the palliative care model. The final chapter of Section II discusses various forms of grief and its identification in patients. Section III consists of 3 chapters that deal primarily with the financial and legal aspects of end-of-life care. Past and current legal myths are presented regarding, for example, termination of life support, assisted suicide, and living wills. Various avenues are explored regarding how financial arrangements (e.g., private, third party, governmental) could encourage more optimal care. Given that end-of-life care is not a perfect science, methods to reform the process are discussed to optimize highvalue and high-quality care. Overall, this reasonably priced text is a valuable reference for various clinicians working with seriously ill patients and their families. The book provides balance with either a case-based or advantages/disadvantages approach. Although the title states that this book is a “physician’s guide,” the material is extremely useful for any member of the multidisciplinary team.

35. www.acponline.org

The ManualofClinicalMicrobiology, now in its sixthedition,continues its recordas beingthe benchmark reference for diagnostic microbiology. This book, intended for microbiologists, pathologists, infectious diseasepractitioners, medicaltechnologists, infection controlspecialists, and clinicalpharmacists specialized in infectious diseasepharmacotherapy, representsa compendium for the selection,performance, and interpretation of laboratory-based methodsimportantfor diagnostic and therapeuticinterventions in the clinicalsetting. This edition is newly formatted, retainingseveralfeaturesof the successful fifth edition. The table of contents is easier to use with features that are more easily scannable and efficient than the previous edition. The book is divided into 10 sections and consists of 123chapters.Section I deals with general issues in clinical microbiology, including a globalassessment of the typesof microbiologic organisms(both indigenous and pathogenic) found in various body systems (e.g., respiratory tract, genitourinary tract) as well as those organisms associated with wounds and bums; bacteriology and mycology specimen collection guidelinesoutlined in a JO-page table; and backgroundinformationregarding clinical microscopy and detailed staining methods with color plates.Section II deals with managementand regulatory issues for efficient laboratory services.SectionIII providesa comprehensive description of fundamental principlesand functionalapplicationssurrounding five new diagnostic technologies: biochemical identification systemsfor bacteriaand fungi; immunoassays incorporating microbialantigensand microbial-antigen-specificantibodies; gas-liquid and HPLC methods used in microorganism identification; moleculardiagnostic tests (DNA probesand nucleicacidamplification) for organismcharacterization; and cell culturetechniques. SectionIV incorporates fivechaptersdealingwith the role of the laboratory in infection control and prevention. Chapter 15,whichis especially informative, describesthe impactof nosocomial infectionsin the acutecare hospitalsetting. Patientfactors, mortality rates,and other microbiologic characteristicsare detailed for primary nosocomial infectionsites (i.e., urinaryand respiratory tracts, bloodstream, and surgicalsite infections). Thissection describes the roleof infection control epidemiology and methods,including the necessary steps for an appropriate epidemiologic evaluation. Laboratory procedures that epidemiologically analyzemultiple isolatesto determinethe presenceof one or severalmicrobial strains is the focusof Chapter 17,whichoutlinespros andcons of the phenotypic and genotypictyping systems.Pathogensassociatedwith food-borne diseasealso are discussed with methods for practical sample collection and preservation. Tablesoutliningcategories of food-borne diseasewith respectiveincubationperiodsare providedalong with an extensivelisting of foods and likelypathogenscommonlyimplicatedin these illnesses. The use of antisepsis, disinfection, and sterilization is discussed as an essential componentof an effective infection controlprogram. SectionsV-IX encompassmore than 1000pagesand 89 chaptersdevotedto bacteria, chlamydiae, rickettsiae, fungi,and virusesand parasites. These sectionsnote recentphylogenetic and nomenclatural changesand includemany new tables, providevarioushelpful identification characteristics in easy-to-understandcharts and tables, discuss antimicrobial susceptibilities and serologic tests, outline complete morphologic and metabolicqualitiesof the major fungi with expandedchapters,and present an expanded discussion regardingantiinfectiveresistancewith respectto the majorgroupsof pathogens. The 10thand final section, AntimicrobialAgents and Susceptibility Testing, provides briefmonographic summaries of the various antimicrobialclasses. A tablelistsall available antimicrobial agentswithassociated half-lives and averageserumpeakconcentrations. Extensive information regarding the biochemical mechanisms of resistance with genetic support of resistanceis presentedfor the clinicallyrelevantantibiotic families.This sectionalso has beenexpandedto includea description of tests used to detect high-level aminoglycoside resistance in enterococci, vancomycinresistancein enterococci, oxacillinresistance in staphylococci, and tests that determine the presence of beta-Iactamaseor bactericidal activity. Newchaptersdetailinggeneticmethods for detecting antimicrobial resistance and testingfor parasitic drug resistance alsoare included. Overall, the sixtheditionof the ManualofClinicalMicrobiology provides an increasedemphasison infectioncontrol, new emergingpathogens, and associated resistance patterns. This text represents the gold standardof excellence for any clinician or laboratorian workingin an infectious disease arena. For the pharmacist trained in infectiousdisease pharmacotherapy, this manualshouldbe included in the libraryas a reliable,consistent, and extremely thorough reference.

Book Review: Manual of Clinical Microbiology. 6th EditionManual of Clinical Microbiology. 6th Edition Edited by MurrayPatrick R, BaronEllen Jo, PfallerMichael A, TenoverFred C, and YolkenRobert H Published by the American Society for Microbiology, Washington, DC, 1995. ISBN 1-55581-086-1. Hardbound, xxiii + 1482 pp. (28.5 × 21.5 cm),

Cases in MedicalMicrobiology and InfectiousDiseases represents a case-based learning approach to problem identification and problem solving within the infectiousdisease arena. The book is designed to supplement any good microbiology text or infectious disease experiential rotation. Pharmacistsspecializing in antiinfectivepharmacotherapy, who either teach pharmacy studentsor are involvedwith a pharmacy staff development series, may find this text worthwhile in emphasizing important clinical points involving the infected patient. Infectious-disease pharmacy preceptorscould use the text with residents and fellows to facilitate discussionon infectiousdisease recognitionand management issues. The primary goal of this text is to allow the studentor clinician to develop a working knowledge that supplements the information learned about bacteriology, mycology, parasitology, and virology. The secondary goals for the reader include the development of a differential diagnosis and the expansion of a medical terminology base while maintaining a positive learningexperience. The case formats include two different infection presentations: (I) those typical infections that emerge caused by more frequently encountered pathogens, and (2) more severe, life-threatening infections attributable to less common organisms. The cases include: (I) clinical characteristics (similar to a history of present illness);(2) pathogencharacteristicsand a potential laboratorydiagnosis;(3) epidemiologicfactors important to the diagnosis; and (4) an emphasis on prevention with a lesseremphasison treatment. The book comprises 66 cases and is divided into four primary sections: Medically Important Bacteria (cases 1-34); Fungi (cases 35--43); Parasites(cases44-50); and Viruses(cases 51--66). The initialcase studies stressbasic principlesof bacterialinfections;the authors then proceed to more difficultcases. The format includesa brief patient case followed by four to six questions. The questions direct the reader through a logical, step-by-step process to develop a differentialdiagnosis and management plan. Each case is then followed by a discussion section that provides detailed answers to these questions, along with a reference list for additional reading. Although the reader may easily refer to this answer section, more benefit is gained from working through the case format to test and supplementones knowledgebase and skills in problem identification and solution. Summary tablesof the medically importantpathogens are providedat the conclusionof each section.These tablesmay be consultedduring the problem-solving exercisesand help the reader to characterizequalitiesof the pathogen versus the given infectionpresentation.The table of medically important bacteria is especially helpful, because it categorizes the bacteria as being gram-positive or -negative, aerobic or anaerobic, and by fermentation and oxidation characteristics. A glossary of more than 200 medical terms is located in the back of the text, as is a sectionof normal laboratoryvalues. Sixteen high-resolutioncolor figures of bacterial, parasitic, and fungal cultures or stains emphasize special microbiologic morphologiesand descriptions. Although this book does not place a heavy emphasis on pharmacotherapy issues of infectious disease management, it represents an excellent text for group discussion and teaching sessions. The problembased format of each case allows the pharmacist to use respectivecases as springboards for discussions on pharmacotherapy issues. The problem-based learning process can then be applied to discussions surrounding these pharmacyissues. This text is an excellent supplementary resource for any pharmacist, residency or fellowship preceptor, academician, or clinical coordinator who specializes in antiinfectivepharmacotherapyand who incorporates problem-basedlearning when teachingantiinfectivemanagement to students and staff.