Thomas W. Woolley

Clonazepam for Treatment of Sleep Disturbances Associated with Combat-Related Posttraumatic Stress Disorder

BACKGROUND: Clonazepam is widely used for the treatment of posttraumatic stress disorder (PTSD)—related sleep disturbances despite very limited published data supporting its use for this indication. OBJECTIVE: We conducted a pilot-controlled trial to provide more data on this clinical practice and lay the foundation for more definitive studies. METHODS: The study was designed as a randomized, single-blind (ie, patient only), placebo-controlled, crossover clinical trial involving administration of clonazepam 1 mg at bedtime for one week followed by 2 mg at bedtime for one week. The following week served as a washout period before the alternate treatment was begun. Patients completed sleep diaries each morning upon awakening throughout the study. Parameters included quantity of sleep, quality of sleep, frequency and intensity of difficulty falling or staying asleep, and frequency and intensity of recurrent distressing dreams. RESULTS: Six patients with combat-related PTSD participated in the study. There were no statistically significant differences between clonazepam and placebo for any measure, although clonazepam therapy resulted in mild to moderate numeric improvements in difficulty falling or staying asleep. Adverse effects of clonazepam were generally mild and essentially indiscernible from those attributed to placebo. Only one patient elected to receive further treatment with clonazepam at the conclusion of the trial. CONCLUSIONS: Clonazepam therapy was largely ineffective in improving sleep disturbances, particularly nightmares, associated with combat-related PTSD. The small sample size was a significant limitation of this study, but the prospective design and single-blind, placebo-control parameters were strengths. Further studies are needed to further define the role of this widespread clinical practice.

Google Scholar Versus PubMed in Locating Primary Literature to Answer Drug-Related Questions

Background: Google Scholar linked more visitors to biomedical journal Web sites than did PubMed after the databases initial release; however, its usefulness in locating primary literature articles is unknown. Objective: To assess in both databases the availability of primary literature target articles; total number of citations; availability of free, full-text journal articles; and number of primary literature target articles retrieved by year within the first 100 citations of the search results. Methods: Drug information question reviews published in The Annals of Pharmacotherapy Drug Information Rounds column served as targets to determine the retrieval ability of Google Scholar and PubMed searches. Reviews printed in this column from January 2006 to June 2007 were eligible for study inclusion. Articles were chosen if at least 2 key words of the printed article were included in the PubMed Medical Subject Heading (MeSH) database, and these terms were searched in both databases. Results: Twenty-two of 33 (67%) eligible Drug Information Rounds articles met the inclusion criteria. The median number of primary literature articles used in each of these articles was 6.5 (IQR 4.8, 8.3; mean ± SD 8 ± 5.4). No significant differences were found for the mean number of target primary literature articles located within the first 100 citations in Google Scholar and PubMed searches (5.1 ± 3.9 vs 5.3 ± 3.3; p = 0.868). Google Scholar searches located more total results than PubMed (2211.6 ± 3999.5 vs 44.2 ± 47.4; p = 0.019). The availability of free, full-text journal articles per Drug Information Rounds article was similar between the databases (1.8 ± 1.7 vs 2.3 ± 1.7; p = 0.325). More primary literature articles published prior to 2000 were located with Google Scholar searches compared with PubMed (62.8% vs 34.9%; p = 0.017); however, no statistically significant differences between the databases were observed for articles published after 2000 (66.4 vs 77.1; p = 0.074). Conclusions: No significant differences were identified in the number of target primary literature articles located between databases. PubMed searches yielded fewer total citations than Google Scholar results; however, PubMed appears to be more specific than Google Scholar for locating relevant primary literature articles.

Blood Pressure Monitoring with Home Monitors versus Mercury Sphygmomanometer

OBJECTIVE: To determine the accuracy of three automatic monitors (arm, wrist, finger) for blood pressure measurement manufactured by Omron compared with a standard mercury sphygmomanometer. PRIMARY END POINT: Difference in the mean blood pressure readings from each monitor; the secondary end point was difference in pulse readings. DESIGN: A single-visit, crossover trial tested each device twice on the left arm of each participant; the average of the two readings was recorded. The pulse readings from each monitor were also recorded. ANOVA was used to compare mean blood pressure readings and pulse readings from each device. RESULTS: A total of 55 persons (mean age 53 y; 36 women) met inclusion criteria and completed the study. The mean systolic and diastolic readings obtained from the electronic arm unit were comparable to the mercury readings (124.4/78.02 vs. 129.45/77.87 mm Hg, respectively; p > 0.05 for both readings). The mean results obtained from the wrist and finger monitors differed significantly from those of the mercury readings (145.44/89.58 and 113.94/69.07 mm Hg, respectively; p < 0.05 for both monitors compared with control). No difference was measured in the mean pulse readings between the comparisons (p = 0.72). The absolute difference in systolic and diastolic blood pressure readings from control varied the least with the arm monitor. CONCLUSIONS: Compared with the mercury sphygmomanometer, the arm monitor was the most accurate in measuring blood pressure. The wrist and finger monitors resulted in statistically significant mean systolic and diastolic differences compared with the mercury sphygmomanometer.

Efficacy of Add-On Topiramate Therapy in Psychiatric Patients with Weight Gain

BACKGROUND: Weight gain is a common adverse effect of many psychotropic medications including antipsychotics, antidepressants, and mood stabilizers. There is a growing body of evidence that topiramate may be useful as an add-on therapy to induce weight loss in patients who have experienced psychotropic-induced weight gain. OBJECTIVE: To determine the efficacy and tolerability of topiramate for treatment of weight gain in a naturalistic mental health clinic setting. METHODS: A retrospective chart review was conducted at a community mental health clinic. Subjects were non-elderly adults who received topiramate therapy beginning in 2002–2005 for documented weight gain during treatment with psychotropic drugs. Primary outcome measures included response rate (based on weight loss of any magnitude) and mean changes in weight and body mass index (BMI). RESULTS: Forty-one patients were included in the study. There was a 58.5% (n = 24) response rate. Mean reductions in weight and BMI were approximately 2.2 kg and 0.5 points, respectively. Responders lost an average of 7.2 kg, whereas nonresponders gained an average of 5.0 kg. Patients with a baseline weight of at least 91 kg and those receiving a greater number of psychotropic medications were more likely to experience success with topiramate therapy. Of the 24 patients who responded to therapy, 22 experienced onset of weight reduction by the next clinic visit (1–4 mo) following either initiation of therapy or titration to the eventual therapeutic dose, and the usual rate of weight loss was 0.45–1.4 kg per month. Therapy was typically initiated at 50 mg/day. The mean maximum dose was 93.9 mg/day and the median maximum dose was 100 mg/day. Seven (17.1%) patients had documented adverse effects to topiramate therapy. CONCLUSIONS: Topiramate therapy resulted in overall modest (ie, <2%) decreases in weight and BMI, but many patients experienced more impressive weight loss. Therapy was generally well tolerated.

Sleep Quality Among Pharmacy Students

Objective. To determine the quality of sleep among pharmacy students in the didactic portion of the curriculum at one school of pharmacy. Methods. The study consisted of an anonymous, voluntary survey that included the Pittsburgh Sleep Quality Index (PSQI), a self-rated instrument that measures sleep habits for a month. Results. The survey was completed by 253 students. Students in the lower grade point average (GPA) category had higher scores on 2 of 7 components of the PSQI and on the global score. Poor sleep quality, indicated by a global PSQI score of greater than 5, was reported by 140 students. The rate of poor sleeping was higher among students in the lower GPA category. Conclusion. Poor sleep quality was pervasive among surveyed pharmacy students in the didactic portion of the pharmacy school curriculum, especially among those with lower GPAs.

Pharmacist-Developed Sedation Protocol and Impact on Ventilator Days

Background: Up to one-third of intensive care unit (ICU) patients require mechanical ventilation. Mechanical ventilation is associated with numerous complications including ventilator-induced lung injury and gastrointestinal bleeding due to ulcerations.1 Sedation protocols are used in order to optimize treatment and decrease days spent on mechanical ventilation. Objective: The purpose of this trial is to evaluate the effectiveness of an ICU sedation protocol. The primary end point was days on mechanical ventilation. Design: A retrospective chart review was performed. The medical records of 21 patients treated prior to the protocol and 21 patients treated after protocol implementation were reviewed. Results: The duration of mechanical ventilation was decreased in the postprotocol patients compared to the preprotocol patients. The mean duration of mechanical ventilation in the preprotocol group was 6.39 ± 5.24 versus the postprotocol group which was 3.78 ± 3.21 days. After implementing the sedation protocol, the number of days to extubation was decreased by 2.61 days. Conclusion: The use of sedation protocols can decrease the days spent on mechanical ventilation. The results also illustrate the enormous impact pharmacists have on policy and protocol development.

Near-Miss Transcription Errors: A Comparison of Reporting Rates Between a Novel Error-Reporting Mechanism and a Current Formal Reporting System

Purpose The medication use process comprises several steps. In institutions without full implementation of computerized prescriber order entry (CPOE), transcription is a critical step in this process. As focus is increasingly placed on identifying near-miss errors, this study aimed to compare near-miss transcription error (NMTE) reporting rates between an institutions formal reporting system and an NMTE reporting mechanism. Methods Two NMTE reporting mechanisms were assessed for 3 months. These mechanisms included the institutions formal error-reporting system and a specific transcription error queue within the institutions order imaging software. Date, patient-care unit, and type of transcription error were recorded for each order image in the transcription error queue and for each transcription error reported formally. Following data collection, reporting rates for both systems were compared. Results Data collection spanned 92 days and an estimated 460,000 medication orders. In total, 1,563 NMTEs were reported using the transcription error queue and 12 errors were reported via the formal reporting mechanism. Of the 1,563 errors identified via the transcription error queue, 325 (20.79%) were of an unknown type. Reporting rates (with unknown errors removed) were 0.27% and 0.0026% for the novel system and formal reporting system, respectively (P < .001). Conclusion Significantly more NMTEs were reported utilizing the novel system compared with the formal reporting system.

School Funding Issues: State Legislators and School Superintendents—Adversaries or Allies?

This study was undertaken to examine the differences in school funding perceptions between Alabama school superintendents and legislators. The overarching purpose was to determine areas of agreement and disagreement so that intermediaries working with both of these groups can help public policy makers make the best education funding decisions through the legislative process.

Attitudes of Matriculating First-Year Pharmacy Students Toward a Mandatory, Random Drug-Screening Program

Objective. To determine the attitudes of incoming pharmacy students toward a mandatory, random urine drug-screening program. Methods. This was an anonymous, voluntary survey of students at the McWhorter School of Pharmacy (MSOP) using an instrument composed of 40 items. The instrument was administered during orientation week prior to the session during which the policies and procedures of MSOPs drug-screening program were to be discussed. Results. The survey instrument was completed by all 129 (100%) students in the class. Two-thirds of the students were aware of MSOPs drug-screening program prior to applying, but only a few felt uneasy about applying to the school because of the program. The greatest concerns expressed by the students included what would happen if a student unintentionally missed a drug screen or was busy with other matters when called for screening, how much time a drug-screening would take, and the possibility of false-positive drug screen results. The vast majority of students agreed with statements regarding the potential benefits of drug testing. Students who consumed alcohol in a typical week and those with current or past use of an illegal substance held less favorable attitudes toward MSOP’s mandatory drug-screening program compared with students who did not share those characteristics. Conclusion. Although there were definite concerns expressed regarding pragmatic issues surrounding drug screening, the first-year pharmacy students held generally favorable opinions about the schools mandatory drug-screening program.

Impact of the Family and Medical Leave Act on hospital pharmacy practice management

The implementation of the Family and Medical Leave Act of 1993 (FMLA), how employees use such leave, and its effect on pharmacy service provision were examined in a national survey of 494 hospital pharmacy directors (16.2% useable response rate). Although there is some discrepancy regarding how to calculate the 12 weeks of leave time, at least 18.7% of respondents were found to allow less time than allowed by law. In general, respondents indicated that men used FMLA benefits only about 20% less than women. About 20% of respondents indicated that they were unable to expand departmental services with current staffing levels due to the impact of the FMLA and another 50% reported that they were only able to continue usual pharmacy services by hiring additional staff or requesting that employees work overtime. Strategies that respondents used to deal with perceived problems caused by staff usage of FMLA benefits are presented. Employers appear to interpret and enforce the FMLA inconsistently. Pharmacists and pharmacy managers need to obtain a better understanding of their rights and responsibilities under this Act.