Case report: coma due to oxytetracycline

An unusual case is reported of coma of gradual onset in a 67-year old woman being treated with oxytetracycline. Ten hours after the last dose, the patient regained consciousness but remained confused with hallucinations for another 24 hours. The possibility of side-effects should be borne in mind in any patient who develops coma whilst on oxytetracycline.     

Pain Management

Abstract

A case report of a male presenting with a gamma-hydroxybutyrate (GHB) induced coma at a gay-oriented dance event is reported. A friend accompanying the patient reported that when the patient started to become stuporous, he attempted to revive him with intranasally administered aliquots of crystal methamphetamine. Such treatment partially counters the hypotonia of GHB induced coma, resulting in “automatic” movements by the patient; however, it does not reverse the cognitive effects of the drug. The result increases the difficulty of medical management. The a11thors report the physical findings and implications for increased difficulty in managing such patients.     

Poly(lactic acid) microencapsulated oxytetracycline: in vitro and in vivo evaluation

Abstract

Poly(lactic acid) microcapsules of oxytetracycline hydrochloride were prepared by precipitation of the polymer from a solution when a non-solvent was added to a polymer solution in which the drug had been dispersed. Three types of microcapsules were prepared by varying the amount of drug encapsulated, as well as by using two samples of polymer with different molecular weights. The product obtained was of a matrix character consisting of agglomerated capsules. The drug release in vitro, for the best batch, was completed within 12 hours. Serum levels of the drug in rabbits treated by intramuscular injection were prolonged maximally up to 24 hours depending upon the type of microcapsules.     

Truncal Ataxia and Prolonged Coma in an Exploratory Pediatric Perampanel Ingestion

IntroductionSeveral overdoses of the antiepileptic drug perampanel have been reported in adults, but very few have been reported in children. We report the case of an observed exploratory ingestion of perampanel in a 2-year-old child that resulted in ataxia and prolonged coma.Case ReportA previously healthy 2-year-old female patient presented to the emergency department (ED) 30 minutes after the witnessed ingestion of 30 mg of perampanel (2 mg/kg). Within minutes of ingestion, she displayed ataxia and inability to walk. Upon ED presentation, she had normal vital signs but was minimally responsive with physical stimulation. Naloxone was given without response. She was intubated because of profound central nervous system depression and transferred to a pediatric tertiary care facility. She remained intubated with no pharmacological sedation. Physical exam showed a horizontal nystagmus. Detailed neurologic examination of ataxia and coordination was not possible, and she did not demonstrate hyperreflexia, clonus, or rigidity. Her mental status gradually improved, and she was extubated approximately 72 hours after exposure. After extubation, the patient still exhibited truncal ataxia and did not return to baseline until 96 hours post ingestion. Serum drawn approximately 16 hours after exposure showed 870 ng/mL perampanel (ref < 20 ng/mL). She remained hemodynamically stable throughout her hospital course, despite protracted depressed mental status.DiscussionGiven the severity of our patient’s presentation, pediatric patients showing symptoms of perampanel overdose should be triaged to the ED for evaluation in anticipation of a prolonged clinical course with decreased consciousness and hypoventilation.     

Treatment of acute bacterial infections of the upper respiratory tract

Summary

An open comparative study was carried out to assess the effectiveness of 4 antibiotic regimens in eradicating acute bacterial infections of the upper respiratory tract. Patients in each treatment group had similar physical parameters, severity of disease and bacterial pathogens, and were treated for 10 days with either erythromycin estolate, erythromycin stearate, ampicillin or oxytetracycline in the recommended dosage. Each patient was reviewed daily by physical examination and the bacteriological findings from throat swab and salivary washings. The results showed that erythromycin stearate produced more rapid bacterial eradication and clinical resolution of symptoms and fever than with the other antibiotic preparations, and was well tolerated by most patients.     

轻中度创伤性脑损伤患者记忆受损与血清Tau蛋白的关系

目的 探讨轻中度创伤性脑损伤（TBI）患者记忆受损与血清Tau蛋白的关系。方法 选取安徽医科大学第一附属医院2016年6月至2017年6月收治的TBI患者60例为研究对象,依据患者入院时格拉斯哥昏迷评分（GCS）分为轻度TBI组（30例）与中度TBI组（30例）。另选取20名志愿者为健康对照组。在入院时、伤后第72小时、2周、6周和3个月时,采用ELISA法检测受试对象的血清Tau蛋白浓度,同时运用神经心理学测试量表对受试对象记忆认知特点进行评估。结果 入院时,TBI组患者血清Tau蛋白浓度为（574.3±270.1） pg/mL、健康对照组为（79.9±36.3） pg/mL,两组差异有统计学意义（t=13.807,P<0.05）。伤后第72小时,中度TBI组患者血清Tau蛋白浓度为（1 051.2±333.9） pg/mL、轻度TBI组为（805.2±400.2） pg/mL,两组差异有统计学意义（t=2.585,P=0.012）。伤后3个月,TBI组患者血清Tau蛋白浓度为（100.8±35.6） pg/mL,与健康对照组相比,差异无统计学意义（t=2.001,P=0.051）。TBI组患者记忆受损明显,且伤后第72小时患者记忆认知水平处于最低,至伤后6周,TBI组患者记忆受损逐渐恢复至健康对照组水平,两组差异无统计学意义（P>0.05）。伤后第72小时和伤后2周,TBI组患者血清Tau蛋白浓度与神经心理学测试评分呈负相关（P<0.05）。结论 早期检测TBI患者的血清Tau蛋白浓度不仅可以评估患者的受伤程度,而且能够有效地反映患者记忆受损的程度。     

LGBT cultural competency,patient exposure,and curricular education among student pharmacists

BackgroundPharmacists are positioned in unique and important roles in health care in their ability to care for the lesbian, gay, bisexual, and transgender (LGBT) population. For example, pharmacists are a highly prevalent, accessible provider type, and informal surveys have shown that LGBT patients may be more comfortable asking their pharmacists sensitive medication questions rather than their primary provider.ObjectivesTo demonstrate gaps in LGBT cultural competency among student pharmacists and propose specific recommendations on the number of LGBT patient exposures and educational hours that can significantly improve LGBT cultural competency.MethodsStudent pharmacists (N = 275) at 3 universities in the United States completed a survey comprising demographics, experiential variables (i.e., number of LGBT patients and LGBT hours), and the 7-point Likert LGBT-Development of Clinical Skills Scale (LGBT-DOCSS). LGBT-DOCSS scores were stratified by 1-point increments, and experiential variable means were computed per each stratification to characterize the mean LGBT patients and hours of student pharmacists with higher scores and those with lower scores.ResultsStudent pharmacists reported low numbers of annual LGBT patients (Mean = 3.82, SD = 9.54), annual LGBT curricular hours (Mean = 0.55, SD = 0.95), and annual LGBT extracurricular hours (Mean = 2.50, SD = 15.42). They reported very high attitudinal awareness (Mean = 6.19, SD = 1.02), moderate knowledge (Mean = 5.00, SD = 1.25), and low clinical preparedness (Mean = 3.26, SD = 1.33). Student pharmacists who cared for 25 or more LGBT patients and received 10 or more LGBT total hours reported significantly higher preparedness, knowledge, and overall cultural competency.ConclusionStudent pharmacists have shortcomings in LGBT cultural competency and limited LGBT patient exposure and education. To improve LGBT cultural competency, pharmacy schools and accrediting bodies should consider ensuring that student pharmacists receive at least a total of 25 LGBT patient contacts and 10 LGBT formal education hours across their pharmacy education.     

亚胺培南/西司他丁钠致癫痫的临床分析及治疗

目的：探讨亚胺培南/西司他丁钠致癫痫发作的防治措施。方法：从1例肺癌合并肺部感染患者使用亚胺培南/西司他丁钠临床病例出发,结合文献分析癫痫的发生机制及治疗方案。结果：该例患者用药结束6小时癫痫发作,给予地西泮10 mg肌注及停药处理,癫痫缓解。结论：癫痫为亚胺培南/西司他丁钠神经系统严重不良反应之一,应加强重视。     

临床药师参与1例行腹膜透析的乳腺癌患者使用多西他赛的药物治疗

目的 肾功能不全患者行腹膜透析可能影响各类药物的代谢动力学,本研究拟为长期腹膜透析合并乳腺癌患者多西他赛的使用提供药学指导和建议。方法 临床药师对1例持续非卧床腹膜透析的乳腺癌患者使用多西他赛化疗期间进行血药浓度监测,观察安全性并定期随访。结果 腹膜透析患者多西他赛的清除率并未受到影响,且腹膜透析不影响多西他赛的治疗,治疗4个周期并随访半年,患者未出现复发,化疗期间未出现严重不良反应,安全性高。结论 肾功能不全并非化疗的绝对禁忌,在充分评估患者的不良反应及耐受性后,行腹膜透析的乳腺癌患者可选择75 mg·m^-2多西他赛化疗,化疗期间给药6 h后可常规进行腹膜透析。     

通顶合剂雾化吸入对中风昏迷患者的疗效及对IL-6、NSE的影响

目的 观察中药通顶合剂雾化吸入对中风昏迷患者的疗效及对患者白细胞介素6（IL-6）、神经特异性烯醇化酶（neuron-specific enolase,NSE）的影响。方法 将52例中风昏迷患者随机分成治疗组和对照组,对照组予西医常规治疗,治疗组在此基础上加用中药通顶合剂雾化吸入治疗。于入院时、治疗后第3,7,14天进行Glasgow昏迷指数评分（Glasgow Coma Scale,GCS评分）、美国国立卫生院神经功能缺损评分（NIH Stroke Scale,NIHSS评分）、检测血清IL-6、NSE含量。结果 治疗后两组GCS评分、NIHSS评分得到改善,IL-6、NSE数值下降,治疗组明显优于对照组（P<0.05）。结论 在西医常规治疗基础上联合中药院内制剂通顶合剂雾化吸入,能有效降低中风患者昏迷程度,并能明显降低患者血清IL-6、NSE含量,促进脑损伤修复,改善预后。     

Efficacy of flurbiprofen 8.75 mg lozenge in patients with a swollen and inflamed sore throat

Objective: Sore throat is often over-treated with antibiotics, therefore there is a need for non-antibiotic treatments that provide effective relief. From the patient’s point of view, symptoms of pharyngeal inflammation such as a “swollen” and “inflamed” throat are often considered the most bothersome; so, a non-steroidal anti-inflammatory drug could be an appropriate treatment. We investigated the efficacy and safety of flurbiprofen 8.75?mg lozenge in adults with a swollen and inflamed throat.

Research design and methods: We enrolled adults with moderate-to-severe sore throat and evidence of tonsillo-pharyngitis into a randomized, double-blind study. Patients received flurbiprofen 8.75?mg or placebo lozenges every 3–6?hours as needed (up to five lozenges in 24?hours) and rated their symptoms (sore throat pain, difficulty swallowing and the sensation of a swollen throat) on standard linear scales regularly over 24?hours. The efficacy of flurbiprofen lozenge was determined in patients reporting a swollen and inflamed throat at baseline, as well as those with relatively severe symptoms.

Clinical trial registration: ClinicalTrials.gov NCT01049334.

Main outcome measures: The main outcome measures were the time-weighted summed differences in patient-reported sore throat pain, difficulty swallowing and swollen throat over 24?hours.

Results: Out of 204 patients, 124 (60.8%) described their throats as swollen and inflamed at baseline. Flurbiprofen lozenges provided greater relief than placebo over 24?hours: 79.8%, 99.6% and 69.3% (for sore throat pain, difficulty swallowing and swollen throat, respectively, all P?≤?0.01). These outcomes were more substantial in patients with relatively severe symptoms. No serious or unexpected adverse events occurred.

Conclusions: Flurbiprofen 8.75?mg lozenge appears to provide effective, well-tolerated relief of sore throat, difficulty swallowing and swollen throat in adults with a swollen and inflamed throat, as well as those with relatively severe symptoms. A limitation of these findings is that, while predetermined, these are secondary outcomes derived from a targeted sub-group of patients, not the entire study population.     

Sublingual,transdermal and intravenous patient-controlled analgesia for acute post-operative pain: systematic literature review and mixed treatment comparison

Objective: To conduct a systematic literature review (SLR) and quantitative analysis to assess the comparative efficacy and safety of the sufentanil sublingual tablet system (SSTS) against other available patient controlled analgesia (PCA) options for post-operative analgesia.

Methods: An SLR was conducted for studies published between 2004 and 2016. Due to study heterogeneity, subgroup analyses were conducted controlling for differences in imputation methods for missing values, baseline pain severity, and type of surgery. Where sufficient data was available, a mixed treatment comparison (MTC) was performed.

Results: The MTC and subgroup analyses used 13 studies. In direct meta-analysis, there was a statistically significant difference in favor of SSTS compared with intravenous (IV) PCA (morphine) at 24?hours for the patient global assessment (PGA) scores of “good” or “excellent”. For the Pain Intensity Score, there were numerical but not statistically significant differences in favor of the SSTS versus IV PCA (morphine) and the patient controlled transdermal system (PCTS) (fentanyl) in the MTC at 6?hours (standardized mean difference ?0.27 [credible interval ?2.78, 2.09] and ?0.36 [?3.89, 3.03], respectively). The onset of pain relief was earlier with the SSTS versus IV PCA (morphine) as shown by the Pain Intensity Difference. Likewise, the onset was earlier compared with PCTS (fentanyl) where data was available. There was a significant difference in favor of SSTS compared with IV PCA (morphine) and with PCTS (fentanyl) for any adverse event, and numerical improvements for withdrawals due to adverse events.

Conclusions: This meta-analysis shows that SSTS is an option for non-invasive management of moderate-to-severe post-operative pain which can be more effective, faster in onset and better tolerated than IV PCA (morphine) and PCTS (fentanyl).     

Clean intermittent catheterization rates after initial and subsequent treatments with onabotulinumtoxinA for non-neurogenic overactive bladder in real-world clinical settings

Objective: Previous randomized controlled trials have reported a 6.1–6.9% incidence of clean intermittent catheterization (CIC) following treatment with onabotulinumtoxinA in non-neurogenic overactive bladder (OAB) patients who were inadequately managed by ≥1 anticholinergic. A multi-center retrospective chart review assessed the real-world rate of voiding dysfunction requiring catheterization.

Methods: Patients received onabotulinumtoxinA 100?U (approved dose) administered by experienced injectors between January 2013 and June 2015. Patients using CIC or an indwelling catheter for ≥24?hours for voiding dysfunction prior to onabotulinumtoxinA injections were excluded. The primary outcome was post-treatment CIC (lasting >24?hours; per individual physician’s clinical judgment considering patient’s voiding symptoms, post-void residual [PVR] urine volumes and patient bother). Potential baseline predictors of CIC (history of pelvic prolapse, cystocele, diabetes, PVR urine volume and age) were assessed using multivariable logistic regression.

Results: Overall, 299 patients received their first treatment with onabotulinumtoxinA 100?U. Mean age was 66.4 years; 98.3% were female. The incidence of CIC was 2.7% in the total study population after the first treatment with onabotulinumtoxinA. The de novo CIC rate in treatments 2 and 3 combined was similarly low (3.2%). None of the evaluated baseline characteristics were significant predictors of CIC initiation due to the low CIC incidence.

Conclusions: This real-world study of non-neurogenic OAB patients treated with onabotulinumtoxinA suggests that the CIC rate is lower than the rates reported in previous studies. There were no significant correlations between baseline predictors and CIC initiation, although statistical significance may not have been reached because of the low incidence of CIC.     

Use of Labor Economic Theory to Examine Hours Worked by Male and Female Pharmacists

Purpose. The objectives of this study were to develop a theoretically derived model of hours worked by pharmacists and estimate the model separately for male and female pharmacists. Methods. A systematic random sample of 1,600 pharmacists from four states was mailed a survey asking about current and past employment information. Two dependent variables were studied: weekly hours worked and annual hours worked. Independent variables were categorized as economic variables (hourly wage rate, other income, total debt) and demographic variables (employment position, age, degree earned, marital status, number of children at home). A two equation multiple regression model was estimated with two-stage least squares regression. Results. A total of 541 pharmacists responded to the survey and data from 442 of the respondents were used in the analysis. Hourly wage rates were negatively associated with weekly hours worked for males. Other income and total debt were significantly negatively and positively associated, respectively, with annual hours worked by female pharmacists. The number of young children at home significantly reduced weekly and annual hours worked by female pharmacists. Female pharmacists earning a Pharm.D. degree worked significantly more hours weekly and annually. Age was significantly negatively associated with male pharmacists weekly and annual hours worked. Conclusions. Economic variables had a relatively small effect on hours worked by male and female pharmacists suggesting that increased wage rates may not increase hours worked. Strategies to increase hours worked by females likely should focus on benefits to help females handle childcare issues.     

Once-a-Day Oral Dosing Regimen of Cyclosporin A: Combined Therapy of Cyclosporin A Premicroemulsion Concentrates and Enteric Coated Solid-State Premicroemulsion Concentrates

Purpose. To develop once-a-day oral dosing regimen that provides the blood levels of cyclosporin A (CsA) in the therapeutic ranges over 24 hours. Methods. CsA premicroemulsion concentrates (preME) were formulated from phase diagrams. Enteric-coated solid-state premicroemulsion concentrates (sME) were prepared by coating preME with enteric-coating matrials and solidifying them. CsA was measured using high-performance liquid chromatography or radioimmunoassay. Results. PreME consisted of CsA, oil, and mixture of surfactants and a cosurfactant. PreME spontaneously formed microemulsions in aqueous medium and showed oral absorption profiles similar to Sandimmune Neoral® in dogs. Dispersion of sME in aqueous medium also formed microemulsions. Release rates of CsA from sME depended on pH and the type of enteric-coating materials and highly correlated with the extent of oral absorption. The co-administration of preME and sME (200 mg CsA) showed the maximum blood level of CsA not significantly different from that of preME (100 mg CsA) and the concentration of CsA close to the minimum therapeutic level at 24 hours. Conclusions. The combined treatment of preME and sME provided controlled oral absorption of CsA over a 24-hour period. Such once-a-day dosing regimens will lead to increased patient compliance and reduced episodes of organ rejection after transplantation.     

糖尿病低血糖昏迷45例临床分析

目的血糖检查可以有效避免糖尿病低血糖患者误诊的产生。方法回顾性分析糖尿病低血糖昏迷45例患者的临床资料,其中进行血糖检查后紧急处置的44例,未行血糖检查仅给予一般急救处理1例。结果 44例患者在5～20min内慢慢苏醒,症状缓解及消失。留院观察24～48h,血糖控制正常范围内出院。1例患者本有癫痫史,入院前3h出现昏迷、抽搐现象,家属以癫痫发作送诊,急诊室先后考虑癫痫史、脑血管意外、糖尿病高渗性昏迷,测定血糖才知属低血糖昏迷。治疗后,25min神志逐渐清醒。结论对于昏迷患者,常规检测血糖是很有必要的。可有效避免因低血糖昏迷时间长,发生不可逆转的脑组织损害的可能性。     

Investigating the provision,nature and associated costs of unfunded pharmacy services: A nationwide study

BackgroundThere is increasing evidence of pharmacists providing free or partially subsidised patient-focused services in order to meet healthcare needs. Limited information exists about the types of unfunded services and their value.Objectives(1) Identify the types of unfunded services provided nationally in New Zealand (NZ) and (2) Determine the costs associated with service provision.MethodsA continuous observation time-motion study was conducted across New Zealand to characterise the provision of unfunded pharmacy services and the labour costs associated with their provision. The time-motion study spanned one business day (between seven to eight hours) in each participating pharmacy. The primary investigator (YA) spent one business day in each participating pharmacy (n = 51) and recorded details about the patient-focused services that were provided. Details included the type of service provided, approximate duration of the service and out-of-pocket costs borne by the patient.ResultsA total of 660 observations of unfunded services were recorded across the 51 pharmacies where 360 observation hours were carried out. Twenty-three types of unfunded services were identified, where minor ailments accounted for over half of the total observations. Labour costs associated with service provision were variable.ConclusionPharmacies across New Zealand are providing patient-focused services for which no funding is being provided.     

Inhaled loxapine for the urgent treatment of acute agitation associated with schizophrenia or bipolar disorder

Background: Acute agitation is a serious complication of schizophrenia and bipolar disorder, which may escalate quickly to aggressive behavior. Rapid treatment is therefore important to calm and stabilize the patient, reducing the potential for harm to the patient and others, and allowing further assessment. Current guidelines suggest that where pharmacologic intervention is indicated, medication should preferably be non-invasive, should have a rapid onset and should control aggressive behavior in the short term without compromising the physician–patient relationship in the long term.

Objectives: This article presents an overview of a new inhaled formulation of the established antipsychotic loxapine, which aims to provide a more rapidly acting agent for the treatment of acute agitation without the disadvantages of intramuscular or intravenous injection.

Discussion: Inhaled loxapine is rapidly absorbed with intravenous-like pharmacokinetics, with a time to maximum plasma concentration of 2?minutes and a plasma half-life of approximately 6?hours. In phase III studies, loxapine reduced agitation within 10?minutes of inhalation; agitation was decreased at all subsequent assessments during a 24-hour evaluation period. Inhaled loxapine was generally well tolerated with no undue sedation. The most common adverse events were dysgeusia, mild sedation, and dizziness. Inhaled loxapine is contraindicated in patients with asthma, COPD or other pulmonary disease associated with bronchospasm.

Conclusions: Inhaled loxapine rapidly reduces acute agitation in patients with schizophrenia or bipolar disorder and is generally well tolerated. The non-invasive route of delivery respects the patient’s autonomy, reducing the perception of coercion or forced medication. Inhaled loxapine is therefore an effective and appropriate option for use in the emergency setting in patients with acute agitation.