Patricia Marshik

Reliability of the Medtrac MDI Chronolog

BACKGROUND The Medtrac MDI Chronolog is an electronic device for monitoring adherence to metered-dose inhalers. It replaces previous models of the Nebulizer Chronolog and uses a different mechanism of recording actuations. OBJECTIVE This study was carried out to determine whether the new model can accurately record and report the date, time, and number of metered-dose inhaler actuations. METHODS Four canisters of beclomethasone (Beclovent) were discharged through four Chronologs with fresh batteries at a rate of 1, 2, 4, or 8 times twice daily for 7 days. Four additional canisters were used as controls and discharged simultaneously through the standard actuator. The weight of all canisters and Chronolog battery voltage were measured before and at the end of the 7-day experiment. The data retrieved from the Chronologs were compared with the information recorded manually during each discharge. RESULTS The loss in canister weight was consistent for the number of puffs discharged from all four Chronolog units and controls. However, the accuracy of the Chronologs in recording the number of actuations varied between 50% and 100%. The largest amount of data loss occurred with the unit used to discharge 8 puffs and was associated with a dead battery at the end of the 7-day trial. For actuations that were retrievable, the Chronologs accurately recorded the date and time. CONCLUSIONS Unexpected battery voltage drain and other mechanical problems that we encountered may cause data loss and the false appearance of missed doses. Thus the units that we tested were not sufficiently reliable to monitor patient adherence.

Response to nonprescription epinephrine inhaler during nocturnal asthma

BACKGROUND Many health care professionals believe that a nonprescription epinephrine metered-dose inhaler is less effective and shorter acting and has more cardiovascular adverse effects than prescription beta2-agonists. OBJECTIVE To determine if increasing the epinephrine dose improves efficacy safely. METHODS Eight patients with nocturnal asthma (age range, 20-46 years) were treated in a randomized, crossover manner on 2 different nights while sleeping in a clinical research center. On awakening from asthma symptoms, 2, 4, and 8 actuations of epinephrine or albuterol were administered at 17-minute intervals (14 cumulative actuations). Forced expiratory volume in 1 second (FEV1), asthma symptoms, and systemic effects were measured before the first dose, during the 9- to 17-minute period after each dose, and 30 minutes after the last dose. RESULTS The mean +/- SD FEV1 at the onset of symptoms was 45% +/- 11% and 44% +/- 12% predicted before epinephrine and albuterol, respectively, and increased to a maximum of 86% +/- 11% and 93% +/- 10%, respectively (P = .04). Symptoms decreased as FEV1 improved and did not return after either treatment; 6 patients were symptom free after 14 cumulative actuations of epinephrine compared with 6 cumulative actuations of albuterol. Heart rate decreased to 71 +/- 10/min after epinephrine but increased to 92 +/- 14/min after albuterol (P = .001). After the last dose, serum potassium concentration was 3.6 +/- 0.3 micromol/L after epinephrine and 3.2 +/- 0.4 micromol/L after albuterol (P = .01). CONCLUSION Epinephrine was nearly as effective as albuterol in terminating an acute episode of airway obstruction but without cardiovascular effects in these otherwise healthy young adults.

Antimicrobial Stewardship Intervention and Feedback to Infectious Disease Specialists: A Case Study in High-Dose Daptomycin

Infectious Diseases specialists have used high-dose daptomycin (≥6 mg/kg/day) in select patients with difficult to treat methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant Enterococcus (VRE) infections to optimize outcomes. Antimicrobial stewardship programs enforce antimicrobial formulary restrictions; however, interventions specifically aimed at Infectious Disease specialists can be particularly challenging. The purpose of this study was to create a high-dose daptomycin algorithm for Infectious Disease specialists that are consistent with best-practices. Daptomycin prescribing habits pre- and post-daptomycin algorithm implementation were evaluated using a quasi-experimental study design. Patients were included if ≥18 years of age and received daptomycin for ≥48 h. Patients were excluded if daptomycin was initiated on an outpatient setting. During the 12-month pre-intervention phase, 112 patients were included, with 73 patients in the 12-month post-intervention phase. A statistically significant decrease in the mean daptomycin dose from 9.01 mg/kg to 7.51 mg/kg (p < 0.005) was observed, resulting in an annual drug cost-savings of over

A novel approach to study the pMDI plume using an infrared camera and to evaluate the aerodynamic properties after varying the time between actuations

75,000 without adversely affecting readmission rates due to infection. Creation of a daptomycin algorithm with consideration of pathogen, disease state, and prior treatment, is an effective means of influencing prescribing habits of Infectious Disease specialists.

Comparison of the Systemic Effects of Fluticasone Propionate and Triamcinolone Acetonide Administered in Equipotent Doses in Children with Asthma

Plume characteristics, such as temperature and velocity, emitted from pMDIs could significantly affect the dose delivered to the lung. Currently, high speed cameras and thermocouples are used separately to evaluate these parameters. We used a low-noise infrared camera to evaluate both the temperature and velocity of the emitted plume from pMDIs. Additionally, we investigated whether the fine particle fraction (FPF) is affected when time between actuations is varied. We tested three different albuterol sulfate pMDIs: ProAir® HFA, Proventil® HFA, and Ventolin® HFA. The plume and aerodynamic characteristics from these pMDIs were evaluated, after varying the time between actuations (15, 30, 60, and 120s), using the infrared camera and a next generation impactor, respectively. The aerodynamic characteristics were evaluated with and without a valved holding chamber (VHC). ProAir HFA had the softest plume followed by Proventil HFA and Ventolin HFA. Further, Ventolin HFA was slightly cooler and had significantly lower FPF than ProAir HFA and Proventil HFA. All inhalers had higher FPF when used with VHC. Further, we observed that the time between actuations affected the FPF across pMDIs. Moreover, generalized guidelines suggesting one-minute interval between actuations for pMDIs should be reconsidered, with and without a VHC.

A comprehensive evaluation of IL4 variants in ethnically diverse populations: association of total serum IgE levels and asthma in white subjects

Equal efficacious doses of the inhaled corticosteroids can result in significant differences in systemic effects due to differences in their pharmacokinetic profile. The purpose of this study was to evaluate a model to compare systemic activity of inhaled corticosteroids given in topically equipotent doses in children. Systemic effects were measured by 24-hour urinary free cortisol (UFC) and a.m. and p.m. serum osteocalcin. Efficacy was monitored by a.m. and p.m. exhaled nitric oxide (eNO) and a.m. peak expiratory flow (PEF). Twenty-one children, 6-16 years old on inhaled corticosteroids at ≥400 μg/day beclomethasone dipropionate (BDP) equivalent were placed on BDP for a 2-week, open-label, run-in, baseline period. Patients were then randomized into a double-blind, double-dummy, crossover trial for two 3-week periods of equipotent doses of fluticasone propionate (FP) or triamcinolone acetonide (TAA) as defined by the NHLBI Expert Panel Report 2. At the end of baseline and each treatment phase patients wer...