Impact of Clinical Pharmacist Practitioner Management of Chronic Obstructive Pulmonary Disease in the Ambulatory Care Setting

Objectives: To evaluate the impact of clinical pharmacist practitioner (CPP) management on potentially inappropriate use of inhaled corticosteroids (ICS) in the ambulatory care setting. Design: Multicenter, prospective quality assurance/improvement (QA/QI) project. Setting: Erie Veterans Affairs Medical Center (VAMC) and surrounding Ashtabula, Crawford, and Venango County Community-Based Outpatient Clinics (CBOCs). Participants: Thirty-five participants with chronic obstructive pulmonary disease (COPD) who met inclusion criteria were included in the project. Interventions: Participants were contacted to schedule an initial sixty-minute telephone visit with a CPP. Exacerbation history, rescue inhaler use, and symptom burden were assessed using the COPD Assessment Test (CAT) and Modified Medical Research Counsel Breathlessness Scale (mMRC) scales. Medication regimens were optimized based on guideline recommendations with an emphasis on appropriate use of ICS. Participants were scheduled for follow-up telephone visits with the CPP every 4 weeks. Main Outcome Measures: The primary project outcome was potentially inappropriate use of ICS without a long-acting muscarinic antagonist (LAMA)/long-acting beta agonist (LABA). Secondary project outcomes included ICS de-escalation, vaccinations, and smoking cessation. Results: The primary outcome of reducing use of ICS without a LAMA/LABA was achieved in thirty-one (88.6%) participants. ICS de-escalation was achieved in twenty-three (65.7%) participants. Rates of recommended vaccinations and smoking cessation with nicotine replacement therapy increased as a result of pharmacist intervention. Conclusion: Pharmacist management of COPD in the ambulatory care setting was associated with a decrease in potentially inappropriate use of ICS and an increase in preventative care measures.

Liver disease in neonatal lupus erythematosus

We report the cases of neonatal lupus erythematosus associated with significant hepatic involvement in three living infants and in one infant who died 3 hours after delivery. The three living infants had neonatal cholestasis as a major component of their clinical findings. Pathologic changes included giant cell transformation, ductal obstruction, and extramedullary hematopoiesis. Liver involvement has been noted incidentally in children with neonatal lupus erythematosus, but it has generally been attributed to hemodynamic compromise as a result of congenital heart block or systemic toxic reactions. We speculate that neonatal hepatitis proceeding to hepatic fibrosis may occur in neonatal lupus erythematosus, analogous to the occurrence of "idiopathic" congenital heart block. The neonatal hepatitis associated with neonatal lupus erythematosus is a form distinguishable from the "idiopathic" group. Liver involvement may be more common than was previously recognized, and prospective studies to look for maternal autoantibodies in idiopathic neonatal liver disease should be undertaken.

Maternal autoantibodies and fetal disease

We have examined the relationships between maternal connective tissue disease (CTD), fetal and neonatal health, and the presence of specific autoantibodies: antinuclear antibodies (ANA), anti-Ro, antiLa, anti-Sm, anti-RNP, anti-DNA, and anticardiolipin (ACL) in 27 mothers with CTD (Group A), and 10 asymptomatic mothers of babies with complete congenital heart block (CCHB), or cardiac arrhythmias (Group B). Compared to 100 normal pregnant controls, autoantibodies were significantly more common in both Group A (96.3%, p less than 0.0005) and Group B (70%, p less than 0.0005), although the prevalence of autoantibodies in the Group A mothers having abnormal babies compared with those who had normal babies did not differ. Anti-La was present only in mothers with abnormal babies (7 of 17 compared to 0 of 10, p less than 0.025). Anti-La did not occur without anti-Ro, but anti-Ro occurred in 9 mothers without anti-La. Anti-Ro was present in the serum of all mothers of infants with CCHB and occurred alone in 3 of 4 instances. Titers of anti-Ro did not differ between abnormal and normal infants or their mothers. ACL occurred alone in the serum of 10 of 38 mothers, and was present in 7 mothers who had infants with cardiac abnormalities other than CCHB.

Pneumococcal vertebral osteomyelitis presenting with an aseptic knee effusion in a child

An 11 year-old girl developed a sterile knee effusion in association with vertebral osteomyelitis. Blood cultures grew Streptococcus Pneumoniae. Sterile joint effusions and vertebral osteomyelitis are both rare complications of pneumococcal infection although this organism is a frequent cause of bacteremia in childhood.

Intraarticular triamcinolone hexacetonide in the management of chronic arthritis in children

The use of intraarticular triamcinolone hexacetonide in the management of persistent arthritis of the knee joint that is unresponsive to nonsteroidal anti-inflammatory drugs was prospectively evaluated in 40 children with chronic arthritis. Of 49 knees that were injected, 63.3% maintained complete resolution of effusion and other signs of inflammation at the 6-month followup. This favorable outcome correlated with a young age, a short disease duration, and a higher dose of triamcinolone hexacetonide. At the 12-month followup, 45% of the injected knees remained in remission.

The effect of polycythemia and hyperviscosity on bowel ischemia

Recent clinical reports suggest that newborn infants with polycythemia and other causes of hyperviscosity may be at risk for developing necrotizing enterocolitis (NEC). This study evaluates the relationship of polycythemia and increased blood viscosity on survival and bowel integrity and an ischemic bowel model in rats. Ninety-nine weanling Sprague Dawley rats underwent one-minute occlusion of the superior mesenteric artery. Animals were divided into five treatment groups. Group 1 (n = 40) ischemic controls had a mean hematocrit (HCT) of 44.3 +/- 3.3%. Group 2 (n = 19) rats were transfused with whole blood from donor rats followed by a dose of lasix (2mg/kg) intravenously (IV) 20 hours prior to ischemic injury, raising the HCT to 53.6 +/- 3.2%. Group 3 (n = 19) animals were transfused with whole blood X 2 and given lasix at 20 and 4 hours before operation, raising the HCT to 63.0 +/- 1.6%. Group 4 (n = 16) (HCT 68.6 +/- 2.55%) and group 5 (n = 15) rats (HCT 71.6 +/- 2.07%) were prepared with multiple blood transfusions and given lasix as group 3 animals to achieve those hematocrit levels. Animals were kept in individual cages and fed rat chow and water ad libitum. Survival, length of survival, and evidence of bowel perforation or necrosis were recorded at seven days following the ischemic insult. Blood viscosity was determined in each group. Survival at one week was 65% in group 1, 63% in group 2, and 63% in group 3.(ABSTRACT TRUNCATED AT 250 WORDS)

Superoxide: a critical oxygen-free radical in ischemic bowel injury

The radical anions of molecular oxygen reduction, superoxide (O2), hydrogen peroxide (H2O2), and hydroxyl radical (OH), have been implicated in a number of disease processes, including ischemic bowel injury. This report evaluates the effect of superoxide dismutase (SOD), catalase (CAT), dimethyl sulfoxide (DMSO), selenium treatment, and selenium deficiency on bowel integrity and survival in experimental intestinal ischemia in rats. Ischemic bowel injury was produced in 204 male Sprague-Dawley rats (wt 90 to 100 g) by a one-minute occlusion of the superior mesenteric artery (SMA) with a microaneurysm clip. Experiment I treatment animals (n = 20) received 2.5 mg/kg SOD dissolved in Ringer's lactate, and control animals (n = 71) received Ringer's lactate alone. Experiment II treatment animals (n = 16) received 1 cc of 100% DMSO gavage, and control animals (n = 11) received no treatment. Experiment III treatment animals (n = 17) received 25 mg/kg CAT dissolved in phosphate buffered saline, and control animals (n = 11) received nothing. Experiment IV treatment animals (n = 14) received 300 micrograms of sodium selenate by gavage dissolved in deionized water, and control animals (n = 15) receiving nothing. Experiment V treatment animals (n = 20) were raised from 35 to 50 g size on a selenium deficient diet, and control animals were raised (n = 20) on a normal rat chow diet, until they weighed 100 g when ischemia was induced. At seven days, survival, incidence of bowel perforation or necrosis, and length of survival were compared in each experiment between control and treatment groups using chi 2 analysis.(ABSTRACT TRUNCATED AT 250 WORDS)

Laboratory basis for the medical management of necrotizing enterocolitis (NEC)

Necrotizing enterocolitis (NEC) is a serious condition affecting the neonate that may be responsive to medical management. This study evaluates the efficacy of supplemental oxygen (FiO2 40% and 50%), systemic antibiotics (ampicillin and gentamicin, cephamandole) and oral antibiotics (trimethoprim-sulfamethoxazole, neomycin and gentamicin) in a weanling rat bowel ischemia model induced by a transient (one minute) occlusion of the superior mesenteric artery. Animals were evaluated for overall survival, duration of survival, presence of bowel necrosis or perforation at seven days. Mortality in ischemic controls was 83.8%. This was reduced to 52% by FiO2 of 50%, and 40% with systemic ampicillin and gentamicin (with or without FiO2 50%) (P less than .001). Length of survival was 3.4 days in controls and increased from 5.4 to 5.9 days in rats given FiO2 50% and/or ampicillin and gentamicin (P less than .001). The incidence of bowel necrosis in controls was 60% and was reduced to 25% in rats given systemic ampicillin and gentamicin and 23.3% with 50% FiO2 and the same antibiotics (P less than .001). Systemic cephamandole and oral antibiotics had no beneficial effects.