Evaluation of Intranasal Corticosteroid Sensory Attributes and Patient Preference for Fluticasone Furoate for the Treatment of Allergic Rhinitis

PURPOSE

Allergic rhinitis (AR) is a highly prevalent disease, affecting the quality of life of millions of Americans. Intranasal corticosteroids (INCs) are widely recommended as first-line therapy for moderate to severe AR. Although these drugs exhibit similar safety and efficacy, a potentially differentiating factor within this class is the varying sensory attributes associated with each INC. The objective of this literature review was to evaluate product characteristics, sensory attributes, and patient preferences of fluticasone furoate intranasal spray (FFNS) compared with other INCs.

METHODS

A narrative literature search for studies evaluating FFNS was performed in MEDLINE and Google Scholar. Key terms included "allergic rhinitis," "anti-allergic agents," "intranasal administration," "fluticasone furoate," and "patient preference." Studies published from 2007 to present were included. Nine trials met the search criteria, each evaluating FFNS versus placebo or other INCs for efficacy, safety, and/or preference, and were included. Approximately 2400 patients with AR were enrolled across varying study protocols.

FINDINGS

In 4 placebo-controlled trials, FFNS showed significant efficacy in relieving symptoms of AR and a tolerable safety profile. Three trials evaluating FFNS and fluticasone propionate nasal spray (FPNS) found that FFNS was significantly preferred over FPNS regarding scent, aftertaste, and leakage down the throat/nose. The results of 2 trials found that FFNS was preferred overall over mometasone furoate nasal spray (MFNS).

IMPLICATIONS

INCs are effective first-line treatments for AR and show significant reduction in nasal and ocular symptoms. Patients preferred the scent, aftertaste, and mist gentleness of FFNS ∼2:1 over the same sensory attributes of FPNS. Patients experienced less negative sensory characteristics with FFNS compared with MFNS, preferring FFNS to MFNS overall. Selecting an INC with favorable attributes in accordance with patient preferences could potentially improve adherence, therapeutic outcomes, and health care costs.

The Influence of pH Control on the Prevention and Management of Gastrointestinal Bleeding

Gastrointestinal bleeding from stress-related mucosal damage (SRMD) is caused by a breakdown in the pro cesses that normally protect the gastric mucosa from the corrosive effects of gastric acid and the proteolytic enzyme pepsin. Prostaglandins stimulate some of these protective factors, which include mucus secretion, bi carbonate secretion, rapid cellular repair and rapid blood flow. Acid and pepsin inhibit blood clotting in the stomach by inhibiting platelet aggregation and the func tion of all of the blood clotting factors. The inhibition of blood clotting in the stomach exacerbates bleeding caused by ulcers in the stomach and duodenum. Hence, treatment that will raise intragastric pH (lower acid con centration) should be effective in preventing gastric bleeding from SRMD. Patients in intensive care units are at high risk of developing upper gastrointestinal bleed ing from SRMD. It is easier to prevent SRMD bleeding than to treat it once it starts. Hence, patients in intensive care units should be treated prophylactically to prevent bleeding. Controlled trials and clinical experience indi cate that both antacids and H2 blockers in doses high enough to raise the intragastric pH above 4 are effective forms of prophylaxis. Intravenously administered H2 blockers are more convenient to administer and have fewer side effects than the large doses of antacid re quired to maintain the intragastric pH above 4.

Falsely incompatible B-cell flow cytometry crossmatch after pronase treatment: a case report

This report presents a falsely incompatible B cell crossmatch by flow cytometry in a lung transplant recipient. The patient was a 35-year-old Caucasian male with end-stage lung disease secondary to cystic fibrosis whose pretransplantation serologic workup did not disclose the presence of anti-HLA class II antibodies by single antigen bead testing. Unexpectedly, crossmatch of recipient sera with pronase-treated donor lymphocytes resulted in antibody binding to B cells only. The positive reactivity was reproducible in pronase-treated autologous B cells. Recipient sera did not react with nontreated donor or autologous lymphocytes. Herein, we describe our approach to this unexpected crossmatch result and consider the implications of false-positive crossmatch results on transplantation.

Residency scramble: program directors' experiences with the Pharmacy Online Residency Centralized Application Service

PURPOSE

Residency program directors' perceptions of the scramble process in 2013 using the Pharmacy Online Residency Centralized Application Service (PhORCAS) were evaluated.

METHODS

After the ASHP Resident Matching Program ("Match") results were released in 2013, programs were asked to not extend offers to applicants until the following Monday, allowing a week for programs and applicants to evaluate their options and make the best decisions. A survey consisting of open-ended and structured response questions was sent electronically to 1905 program directors. Adherence to the recommended one-week moratorium before extending an offer to applicants for unmatched positions was also assessed.

RESULTS

A total of 531 completed surveys were returned (28.2% response rate). Programs with 119 of the 133 unmatched postgraduate year 1 positions were represented in the results. The ma jority of directors were satisfied with the use of PhORCAS overall, rating it easier (60.3%) or at least the same (24.8%) as processes used in the past. Programs with unmatched positions thought using PhORCAS made it easier to fill positions (64.5%). Sixty percent of program directors contacted applicants the week after the Match. Most directors (79%) followed the recommendation of waiting until April 1 or later to make offers; however, 49% thought others did not follow the guidelines. Program directors offered many concerns about the stressful nature of the scramble process and offered several recommendations for improvement.

CONCLUSION

Residency program directors found that the use of PhORCAS and guidelines from the ASHP Commission on Credentialing improved the scramble process and facilitated the filling of unmatched residency positions.

Examination of the Relationship Between Antimicrobials and Thrombocytosis

Objective:

To evaluate whether there is a relationship between antimicrobial therapy and the development of thrombocytosis.

Data Sources:

Literature was accessed through EMBASE (1977-June 2012) and MEDLINE (1977-June 2012) using the terms thrombocytosis and antimicrobial. In addition, reference citations from publications identified were reviewed.

Study Selection and Data Extraction:

All English-language publications identified were evaluated. For case reports, the Naranjo probability scale was used to calculate the likelihood of the drug causing the reaction.

Data Synthesis:

Thrombocytosis occurring during antimicrobial therapy is well documented, with several case reports and clinical trial observations. However, a direct causal relationship is not yet supported by the available literature. Platelets are welt known to be an acute phase reactant, with an elevated count occurring after acute conditions such as blood loss, inflammation, or infection. Thrombocytosis during antimicrobial therapy may be the result of an infectious process and not an adverse drug event.

Conclusions:

Based on the current available literature, a definitive link cannot be established between antimicrobial therapy and occurrence of thrombocytosis.

Relationships between colleges of pharmacy and academic medical centers

PURPOSE

The nature of the relationships between academic medical centers and colleges of pharmacy, particularly in respect to experiential education, was studied.

METHODS

A 22-item questionnaire was developed to assess the extent and type of student experiences academic medical centers offered, the presence of a contractual agreement, satisfaction level, role of pharmacy staff and residents, and perceived value of the relationship. The questionnaire was distributed electronically to pharmacy directors at 90 University HealthSystem Consortium (UHC) academic medical centers, with subsequent responses analyzed with descriptive statistics.

RESULTS

The response rate was 52% (n = 47), representing a broad geographic distribution of UHC members. All academic medical centers reported having a relationship with at least one college of pharmacy. The mean number of academic affiliations for each respondent was 2.4. The majority of medical centers were satisfied with these relationships. All academic medical centers provided fourth-year pharmacy student clerkship training, with 20% and 27% offering experiential activities for second- and third-year students, respectively. Compensation from colleges of pharmacy for practice-based education was typically directed to the pharmacy department, with a mean of $500 per rotation. The majority of medical centers also trained pharmacy residents, with 62% of these engaging the residents in student experiential education. The most common motivations for offering student experiential education were fulfilling professional responsibility, developing future employees, and financial compensation.

CONCLUSION

While relationships between academic medical centers and colleges of pharmacy were generally positive, the growing need for early experiential education sites, increased class sizes, and shortage of qualified preceptors necessitate a reexamination of the relationships to ensure that they continue to benefit both parties.

Defending against violence in hospitals

The authors examine the rise of violence in the healthcare setting and present some practical methods for identifying high-risk individuals and reducing the incidence of violence. Some commonsense strategies are presented to help healthcare security professionals combat workplace violence.

The future of medication information practice: a consensus

OBJECTIVE

To analyze the current practice of drug information and develop a strategic plan for a "valued" specialty of medication information practice.

DATA SOURCES

The Consortium for the Advancement of Medication Information, Policy, and Research (CAMIPR) met in June 1994 to initiate a strategic plan for a future of medication information practice. A multidimensional situation analysis and strategic planning process was conducted and the results are discussed.

RECOMMENDATIONS

Trends in health care (e.g., healthcare reform, managed care) will impact the future of medication information practice, and the medication information specialist must evolve with society's values. Medication information practice must transform and attention will likely focus on medication policy research/ development and information systems. However, new skills, resources, and relationships must be developed to facilitate this evolution. In addition, interest in the practice of drug information has declined. Strategies are presented to enhance the "value" and "image" of future medication information practice.

Hospital violence

The author discusses the problem of healthcare violence, including factors that contribute to it, how to identify high-risk individuals, the socioeconomic impact of assault injuries, violence associated with prisoners as patients, and psychiatric ward violence. He also provides an outline of emergency department security survey procedures, as well as guidelines for improving hospital security.

Using pharmacist clinical intervention data for quality improvement of medication use and physician assessment

BACKGROUND

Patient-specific intervention data are often used for drug usage evaluation (DUE), but their use in physician assessment is less often discussed. In response to the quality assurance department's request, the pharmacy department at the Medical College of Georgia (Augusta) developed a database and a reporting system that supports quality assessment of the medical staff, identifies housestaff education needs, and directs efforts for improvement in medication use. THE REPORTING SYSTEM: In 1991 the comprehensive, concurrent screening of drug therapy by pharmacists formed the foundation of the hospital's DUE program. Each month information from the pharmacy database is sorted with use of a spreadsheet software program to generate medical department-level reports and for use in physician reappointment. Identified performance deficiencies can be used to educate individual prescribers and to develop educational programs for the department or specialty areas. Feedback from the medical staff assessment is useful for pharmacist education, such as identifying newly reported indications and dosage regimens.

RESULTS

During the first six months after all pharmacists began participating in the reporting program, a mean of 224 interventions were recorded monthly. For the period January through June 1994, 400-550 interventions were recorded monthly. System improvements in medication during the first year of implementation included hospitalwide guidelines for parenteral potassium and phosphate dosing and administration and a renewed focus on patient allergies.

CONCLUSION

Emphasis for use of intervention data has shifted from identifying "problem" persons to improving performance by identifying topics for corrective education and redesigning systems to promote positive patient outcomes.

The role of nondepolarizing neuromuscular blocking agents in mechanically ventilated patients

Prolonged use of the nondepolarizing neuromuscular blocking agents in the critical care setting has greatly increased in the recent past. Accompanying the increased use of these agents are numerous accounts of long-lasting adverse outcomes such as muscular atrophy and neuropathy that can be attributed to pharmacologic paralysis. There has been a financial impact on hospitals as well. Responding to these facts, the medical staff at the Medical College of Georgia Hospital and Clinics recently approved guidelines for the use of nondepolarizing neuromuscular blocking agents in the intensive care setting. These guidelines recommend clinical indications for these agents and dosing ranges reflecting current medical opinion.

A prospective study of patient-controlled analgesia. Impact on overall hospital course

Previous studies have shown that patient-controlled analgesia (PCA) provides effective pain control in the postoperative patient. To determine the impact of PCA technology on the overall hospital course, we designed a randomized controlled study comparing patients receiving analgesia using PCA infusion (Abbott Lifecare, Abbott Laboratories; Chicago, IL) with patients receiving analgesia by traditional intramuscular or intravenous methods. All patients had undergone elective cholecystectomy. Sixty-nine patients completed the study, 35 received traditional postoperative analgesia, and 34 received analgesia using the PCA infuser. Comparison of both groups demonstrated no significant difference in postoperative bowel activity with both groups receiving liquids on the first postoperative day. There was no significant difference between the two groups with respect to postoperative length of stay (3.4 days for PCA vs 3.6 days for traditional). Patients demonstrated a wide range of analgesic requirement in the first 24 hours but the average of the total analgesic required was higher in the PCA group (average, 29.5 mg) than the traditional group (22.8 mg). Urinary complications occurred more commonly in the group of patients receiving traditional analgesia than in the group of patients receiving analgesia with the PCA device. When compared with patients receiving analgesia by traditional methods, patients receiving the PCA infusion required more analgesia with fewer urinary complications and similar postoperative length of stay.

The influence of fibronectin administration on the incidence of sepsis and septic mortality in severely injured patients. The Medical College of Georgia Fibronectin Research Group

Eighty-five trauma patients between the ages of 18 and 55, with American College of Surgeon's (ACOS) trauma scores greater than or equal to 7 were entered into a double-blind, randomized, placebo-controlled study to assess the efficacy of prophylactic fibronectin (Fn) administration on clinical course, sepsis development, and septic mortality. Patients were randomized on admission to receive purified human virus-inactivated Fn or placebo control (human serum albumin, HSA). Fn or HSA was administered on a daily basis if and when the patient was Fn deficient (less than 75% normal). When a Fn deficiency was not evident, the patient received saline. Seventy one patients developed Fn deficiencies during their initial clinical course: 36 received Fn, 35 received HSA. Fourteen patients did not develop a Fn deficiency after trauma and thus received only saline. Analysis of admission data demonstrated no significant differences between the three groups with respect to extent of injury (injury severity score, ACOS trauma score) or physiologic assessments of organ function (serum creatinine, bilirubin, lactic acid). On day 1 after trauma, Fn levels were shown to correlate with other plasma proteins and cellular components (range of r values, 0.24 to 0.75; all p less than 0.05), but not with organ function parameters. Eighteen of 85 patients became septic as judged by clinical criteria. Ten of these patients had received Fn (10 of 36), five had received HSA (5 of 35), and three had received only saline (3 of 14) before the development of sepsis (differences not significant). When septic, nine of 17 patients developed Fn deficiencies. Six patients received Fn while septic, three received albumin, and eight received saline. Seven patients died: 5 of 6 Fn patients, 1 saline, and 1 HSA recipient. Our data suggest that exogenous Fn repletion in states of deficiency does not alter clinical course, the development of sepsis, or septic mortality.

Two critical psychological components of ski racing: fun and feelings

The concepts of having fun and being aware of feeling states are presented as two critical factors in ski racing. First, the positive motivational characteristics of 'fun' are outlined. It is suggested that fun is not only a concept for young athletes but elite ones as well. Preliminary data based on a questionnaire, completed by the United States Alpine Ski Team and approximately 150 ski coaches, are represented. Second, the discussion on feelings refers to the mental programming of tactile sensations and determining one's emotional arousal (feeling state) prior to, and during, competition. Practical suggestions are made with regard to the psychological states and their effects on ski racing.

Drug interactions in surgical patients

Drug interactions, defined as when the administration of a single substance (drug, nutrient, or tobacco) modifies the response to a drug, occur relatively frequently in surgical patients and may result in increased morbidity and lengthened hospital stay. Drug interactions also account for some instances of drug ineffectiveness or exaggerated pharmacologic response. There are many types of drug interactions. However, most of them are related to altered drug pharmacokinetic properties, where there are alterations in drug absorption, distribution, metabolism, or elimination; or altered drug pharmacodynamic actions, where two agents may have synergistic, additive, or antagonistic pharmacologic effects. The term, drug interaction, usually refers to pairs of drug substances administered concurrently, but more than two agents may be involved. When patients are taking a large number of different medications, there may be multiple drug interactions with additive or antagonistic effects, the overall effects of which are difficult to predict. There are hundreds of reported drug interactions, and some may be of important clinical consequence. In surgical patients, the majority of drug interactions involve histamine-2 blockers (particularly cimetidine), digoxin, warfarin, or a variety of agents that may be administered during anesthesia. Recognition of the potential for adverse drug interactions is of primary importance in minimizing their effects. Usually, potentially interacting drugs may be administered concurrently as long as appropriate patient or laboratory assessments are performed. For some agents, such as digoxin or theophylline, serum drug concentrations may aid in the avoidance of adverse drug interactions.

A Psychological Study of Health, Injury, and Performance in Athletes on the US Alpine Ski Team

In brief: We assessed life events, depression, and general well-being (health concerns, energy, life satisfaction, cheerfulness, tension, and emotional control) in 73 members of the US Alpine Ski Team. We compared these psychological factors with subsequent surveys of general health, illness, and athletic performance and found that psychological status (especially general well-being) was associated with subsequent health problems, injuries, and performance levels. These findings indicate that coaches and sports medicine specialists must be sensitive to psychological disorders in elite athletes and provide appropriate clinical assessment and treatment.

Potential drug interactions in surgical patients

The incidence and frequency of potentially serious drug interactions were evaluated in hospitalized surgical patients. Drug profiles of patients on the general surgical service of a tertiary-care teaching hospital were retrospectively reviewed for two six-month periods to determine how often drugs that are known for major interactions were prescribed concurrently. Interactions were studied that were relatively well documented and potentially harmful to the patients. A total of 1825 patient profiles were reviewed (21,888 patient days). At least one potential drug interaction was found in 17% of the patients. Interactions were found to occur at the rate of 1 for every 59 patient days. Digoxin and cimetidine were the potential interacting drugs in almost 90% of the cases. Hospitalized surgical patients require close monitoring because they frequently receive potentially interacting drugs.

Evaluation of pharmacy and therapeutics committee drug evaluation reports

Pharmacy and therapeutics (P & T) committee drug evaluation reports prepared by pharmacies and drug information centers (DICs) and product package inserts were compared with standard guidelines to evaluate their quality. Letters were sent to 143 hospital pharmacies asking them to submit a previously prepared drug evaluation report on temazepam, moxalactam disodium, or atenolol. The reports and package inserts for these three drugs were evaluated by the presence of 40 elements derived from the published ASHP guidelines for drug evaluation report preparation. Responses were obtained from 124 (87%) pharmacies; however, only 80 reports (60 DIC-prepared and 20 pharmacy-prepared) were received. The reports contained a mean of 28 of the 40 (70%) possible elements. The most frequently omitted elements were AHFS number, potential unlabeled uses, drug-drug interactions, drug-disease-laboratory test interactions, risk and benefit data, prevention and treatment of side effects, comparisons with established treatment, and disadvantages of the drug under consideration. Although the reports prepared by the DICs and pharmacies contained the same amount of information, the DIC-prepared reports included data more frequently on supply sources, therapeutic indications, approved labeling, comparison with established treatment, bioavailability and pharmacokinetics, and recommendations. Most of the reports contained more elements than the corresponding package inserts. The product package inserts did not contain the comparative elements required for P & T committee decisions. Both the pharmacy- and DIC-prepared reports failed to contain all 40 elements recommended in the standard guidelines, suggesting the need for more thorough reports.

Metabisulfite sensitivity: case report and literature review

Sulfiting agents have recently been identified as food and drug additives responsible for adverse reactions. These reactions are not rare and may result in life-threatening asthma and anaphylaxis. We report a 34-year-old female with intractable asthma and urticaria. Sensitivity to sulfites was suspected based on exacerbation after restaurant meals and metaproterenol 5% inhalant solution. Bronchial provocation challenge resulted in a 28% decrease in FEV1 and a 34% decrease in FEF25-75 at the 0.01 mg/ml dose. Thirty-two cases of sulfite sensitivity reported in the literature are reviewed. Foods and drugs containing sulfites are listed. The pathogenic mechanism is unknown. The FDA allows the addition of sulfites to foods and drugs without disclosure. Only recently has this potential hazard been recognized. The FDA is considering a labeling requirement on drugs that do contain sulfites.

Drug interactions: theory versus practice

Cimetidine inhibition of P-450 oxidative metabolism results in interactions with many drugs, leading to clinically significant drug toxicity. A one-year survey of inpatient prescribing practices revealed a 32.6 percent incidence of concomitant cimetidine and interacting drug use. Retrospective chart review showed statistically significant increased toxic drug plasma levels in patients receiving theophylline and cimetidine, and a strong trend to increased rates of drug toxicity in phenytoin-cimetidine treated patients. Ranitidine appears to be a superior choice in patients receiving drugs metabolized by P-450 oxidation. When cimetidine and known interacting drugs are prescribed together, more frequent assessment of blood levels of the affected drug will be required, increasing substantially the cost to patients. Drug interactions of clinical significance occurring due to altered absorption because of effects of H2-receptor antagonists on gastric secretion are reviewed.

Psychological and physiological effects of relaxation and nitrous oxide training

Training in progressive muscle relaxation can improve psychophysiological response to stress but is often time-consuming and may prove ineffective for some individuals. Nitrous Oxide (N2O)may offer an effective adjunct or alternative to training. This study evaluated the relative efficacy of these procedures. Subjects were randomly assigned to one of four treatment conditions: relaxation-only, N2O only, relaxation with N2O, and room air-control. The relaxation procedure was modeled on color videotape. Nitrous oxide was administered from a balloon. In addition to various psychological measures, treatment effects were measured for skin temperature, heart rate, systolic blood pressure, and two measures of diastolic blood pressure. Subjective reports of tension were also recorded. There was a significant multivariate difference between treatment groups. The relaxation-only procedure was generally superior to the others on most dependent measures. Subjects receiving N2O appear to have experienced an improvement in mood. Paradoxically, the initially more relaxed subjects seemed to derive the greater benefit from the inhalation of N2O. The use of videotape-modeled relaxation procedures is discussed.

A collaborative effort to study methods of teaching physical examination skills

A collaborative study was conducted between two medical schools to evaluate critically the teaching of physical examination skills to first-year medical students, assess the effect of different instructional methods on student performance, and improve teaching programs at both schools. Students at the two schools were videotaped performing a physical examination on a paid model at the completion of their physical diagnosis courses. The videotapes were sent to a third school for independent evaluation based on criteria agreed upon by all three schools. Students participating in a highly structured course and utilizing a very specific behavioral checklist as both a teaching and evaluating instrument tended to perform more complete physical examinations than students from a less structured course and employing a more generalized checklist. Both medical schools benefited from participation in the study.

Induction of L-forms of Haemophilus influenzae in vitro

The induction of L-forms of Haemophilus influenzae by penicillin, amoxycillin and glycine has been studies in vitro on a nutrient-agar medium. The minimal inducing concentrations of the antibiotics were generally the same as their minimal inhibitory concentrations, but the addition of a sub-inducing concentration of glycine lowered the minimal inducing concentration of penicillin. Preliminary observations have shown that L-forms are induced by penicillin or amoxycillin on a medium in which mucoid sputum forms the sole source of nutrients, and that they remain viable for at least 48 h in the absence of added osmotic stabiliser. The minimal inducing concentration on "sputum agar" is within the range of concentrations measured in sputum from patients receiving amoxycillin therapy. The implications of these observations in relation to bactericidal therapy of haemophilus infections of the respiratory tract are discussed.

Osmotically stable L forms of Haemophilus influenzae and their significance in testing sensitivity to penicillins

The sensitivity of Haemophilus influenzae to penicillins in vitro, determined either by serial antibiotic dilution in broth or by the disc method on agar, is apparently profoundly influenced by inoculum size if the results are read by macroscopic inspection. Microscopic inspection of the growth, however, reveals that the turbidity in heavily inoculated broth containing concentrations higher than the minimal inhibitory concentration is the product of L forms which have failed to succumb to osmotic lysis. Similarly, minute colonies appearing in the ;inhibition zone' of disc tests are composed of L forms. In both broth and agar tests reduction of the osmolality of the medium from 340 to 144 mOsm per kg failed to bring about lysis of organisms exposed either to ampicillin or amoxycillin. The significance of this remarkable osmotic stability of haemophilus L forms is discussed in relation both to testing of sensitivity of this organism to penicillins and to persistence of chronic haemophilus infections of the lower respiratory tract.

An improved test for Haemophilus influenzae precipitins in the serum of patients with chronic respiratory disease

The detection of antibacterial precipitins in the serum of patients with chronic lower respiratory infections has been shown to be of great value in the assessment of pathogenicity of the corresponding bacterial species in the sputum. The test used hitherto, however, is time-consuming and cumbersome owing to the need to distinguish, by immunoelectrophoresis, between antibodies specific to the organism in question and those which react with antigens common to various Gram-negative species. A method has now been devised for the preparation of an extract of Haemophilus influenzae containing species-specific antigens only. Use of this extract obviates the need for immuno-electrophoresis and improves the sensitivity of the test.