William G. Troutman

Prevention of Kidney Injury Following Rhabdomyolysis: A Systematic Review

OBJECTIVE To conduct a systematic literature review to evaluate evidence-based recommendations for the prevention of rhabdomyolysis-associated acute renal failure (ARF). DATA SOURCES PubMed (1966-December 2012), International Pharmaceutical Abstracts, Science Citation Index, and Cochrane databases (1970-December 2012) were searched. There were no language restrictions. STUDY SELECTION AND DATA EXTRACTION Studies selected dealt with treatment of rhabdomyolysis (crush syndrome) or prevention of ARF in patients with rhabdomyolysis. Articles excluded did not present original data or described only the management of ARF after it developed. Single case reports were excluded. Extracted data included study type; population; definitions of rhabdomyolysis and ARF; fluid, sodium bicarbonate, and mannitol dosages; and study findings. DATA SYNTHESIS Twenty-seven studies met the inclusion criteria. No controlled trials compared intravenous fluid administration plus sodium bicarbonate to fluid administration alone. Three concluded that there was no significant difference in the rates of ARF between patients receiving and those not receiving sodium bicarbonate; however, urine alkalinization was not documented. Eight investigations concluded that delayed fluid administration increased the risk of ARF. No controlled study compared volumes of fluid administered or targeted urine output goals. Fluid type, therapy duration, and monitoring parameters varied widely; 4 used a urine output goal in adults of more than 300 mL/h or 300 mL/h or more. No evidence supported a preferred fluid type or that sodium bicarbonate with or without mannitol was superior to fluid therapy alone. CONCLUSIONS Intravenous fluids should be initiated as soon as possible, preferably within the first 6 hours after muscle injury, at a rate that maintains a urine output in adults of 300 mL/h or more for at least the first 24 hours. Sodium bicarbonate should be administered only if necessary to correct systemic acidosis and mannitol only to maintain urine output of 300 mL/h or more despite adequate fluid administration.

Variability in the assessment of adverse events in a multicenter clinical trial

BACKGROUND Consistent documentation, characterization, and evaluation of adverse events (AEs) are needed during multicenter clinical trials to ensure accuracy of data reported to the US Food and Drug Administration and in the medical literature. OBJECTIVE The purpose of this study was to identify and characterize variations in the assessment of AEs by clinical trial personnel. METHODS During the annual meeting of personnel from a multicenter, controlled clinical trial of an investigational new drug treatment for opioid dependence, an oral presentation of procedures for AE data collection was given to 25 principal investigators and ancillary study personnel who assessed AEs for the study. A post-test using 3 hypothetical AE cases in which AEs were categorized by type of reaction, relatedness to study drug, severity, action taken, and outcome was completed by study participants. Cases and expected responses were reviewed for content and validity by clinical research pharmacists who were not involved with the study. The level of agreement with expected responses was assessed using McNemar symmetry chi-square tests. RESULTS Assessments of type of AE, relatedness to study drug, and severity were less frequently aligned with expected responses than were action taken and outcome (P < 0.013). Less consistency with expected responses was found in I case than in the other 2, suggesting that certain types of AEs may be more difficult to assess. CONCLUSIONS There was considerable variability in categorization of AEs in an exercise following training for AE data collection. Type of report, relatedness, and severity were found to have more variability in reporting than did action taken or outcome. The results suggest that unless data are gathered to verify reliability of reporting, subcategorization of AE data should be undertaken cautiously. Further research is needed regarding methods for improving consistency in reporting of AEs.

Evaluation of Drug Information in an Internet Newsgroup

OBJECTIVE To determine the accuracy and potential harmfulness of the drug information in a newsgroup on the Internet, sci.med.pharmacy. DESIGN In this cross-sectional study, two independent reviewers analyzed the nonsubjective drug information in this newsgroup. Drug information was classified as correct, incorrect or could not verify. Information was determined to have no harm, minor harm, moderate harm, or severe harm. RESULTS About one-half of the drug information was found to be correct in this newsgroup. Although 68% of the drug information was found to result in no harm, 19.4% was classified as harmful. CONCLUSIONS If drug information on the Internet contains inaccuracies, its ready accessibility may pose a public health problem. With the number of Internet users growing, health professionals need to be aware of the potential for dissemination of misinformation, and need to become familiar with the Internet and the various health information resources available to the public.

Topical ophthalmic exposure to rattlesnake venom

An 18-year-old woman was struck in the eye from a distance of about 1 m by a stream of venom projected by a western diamond-back rattlesnake. She experienced an immediate burning sensation in the eye. The eye was irrigated first with tap water and later with a commercial eye wash solution. The patients symptoms abated and no further eye injury was noted. Topical ophthalmic exposures to North American snake venom usually produce only transient symptoms, but the venom from tropical snakes has produced significant eye injury.

Tobramycin-induced hypersensitivity reaction.

Objective: To report a case of a hypersensitivity reaction associated with the use of intravenous tobramycin in a patient with cystic fibrosis. Case Summary: An 18-year-old man was hospitalized for exacerbation of his cystic fibrosis. Tobramycin 125 mg iv q6h and ceftazidime 2 g iv q8h were administered through the patients implantable access system in the left chest. Within seconds of receiving the third dose of tobramycin, the patient experienced shaking, his left arm turned white, and urticaria and pruritus were noted on the left side of the patients chest. The patient had experienced a similar incident, accompanied by breathing difficulty, with intravenous tobramycin 4 years príor to this incident. The patient had been skin-tested for tobramycin allergy and had been desensitized and was receiving tobramycin since that time without incident. The patients desensitization was maintained with tobramycin 160 mg/d hs by nebulization, but the drug had been discontinued by the patient 6 months prior to the latest event. Discussion: Hypersensitivity reactions to aminoglycosides are unusual. Hypersensitivity to 1 aminoglycoside antibiotic frequently is associated with hypersensitivity to at least 1 other aminoglycoside. In patients who develop hypersensitivity to an aminoglycoside antibiotic, desensitization may be an effective alternative to changing therapy. Conclusions: Tobramycin is very important in the drug regimen for Pseudomonas aeruginosa infections in patients with cystic fibrosis. Effective desensitization can be maintained by daily administration of nebulized tobramycin.

Consensus-Derived Objectives for Drug Information Education

Drug information education is an expectation of all pharmacy curricula. The inconsistencies in current drug information instruction stimulated the creation of an invitational conference with the purpose of defining a set of objectives for didactic and experiential drug information instruction for the year 2000. Twenty-three drug information educators and practitioners participated in the conference. After the adoption of a set of assumptions and through the development of consensus, the conference participants created a goal, general educational objectives, and broad didactic and experiential course outlines. The work of the conference can be used in the development of new courses or the refinement of existing drug information courses in colleges of pharmacy.

Emergency Induction of Emesis Using Liquid Detergent Products: A Report of 15 Cases

Solutions of liquid detergent products were used to induce emesis in 15 patients who could not or would not obtain syrup of ipecac. Four patients refused to drink any of the solution and two others refused part, one of whom vomited. In the patients who drank all or part of the solution, 91% (10/11) vomited with a mean time to the onset of emesis of 6.5 min. None of these patients developed symptoms attributable to the ingested poison or the detergent solution. Liquid detergent solutions may be a useful alternative emetic for the poison center when a patient cannot be given syrup of ipecac.

An estimation of the annual incidence of poisoning using automated telephone polling

An automated telephone poll was conducted in Bernalillo County NM during February, 1988. The equipment made 33,458 telephone calls and 2,703 households responded to the eight items included in the poll. The results included a minimum of 810 poisoning incidents in these households in the previous year, giving an annual incidence of poisoning in this population of 108 per 1,000. This rate is considerably higher than previous estimates. Other results included a trend toward delaying poisoning therapy until symptoms developed or taking the poisoned patient directly to an emergency department. If these results are confirmed by conventional polling, poisoning is a major public health problem. Furthermore, confirmation would establish automated telephone polling as a valuable tool for rapidly and inexpensively surveying large populations.