Atrial Flutter with 1:1 Atrioventricular Conduction Caused by Propafenone

We describe a case of 1:1 atrial flutter in a patient with coronary disease taking propafenone. In atrial flutter, the atrial rate is usually about 300 beciis/min with 2:1 AV conduction and a ventricular rate of 150 beats/min. Class IA antiarrhythmic drugs, especially quinidine and disopyramide, may cause 1:1 AV response because they reduce atrial rate and are vagolytic. However, propafenone is a Class IC agent and has no anticholinergic properties, and the occurrence of 1:1 AV conduction at a rate of about 250 beats/min is an important side, effect that, although uncommon, should be recognized.     

Comparison of effects and plasma concentrations of opioids between elderly and middle-aged patients after cardiac surgery

Background: In elderly patients, opioids may cause prominent postoperative sedation and respiratory depression. We evaluated the influence of age on the effects of opioids and plasma concentrations of fentanyl and oxycodone in cardiac surgery patients.
Methods: Thirty (≥75 years, gender M9/F21) and 20 (≤60 years, gender M20/F0) patients scheduled to undergo cardiac surgery. A standard anesthesia with fentanyl as an opioid was used. Fentanyl plasma concentrations were measured at the end of surgery and 2 h later. After tracheal extubation, when the pain intensity was at least moderate, blood samples for fentanyl and oxycodone plasma concentration measurements were taken. Thereafter, oxycodone hydrochloride 0.05 mg/kg i.v. was administered. After 15 and 45 min, pain intensity, sedation and oxycodone plasma concentration were determined. This test protocol was repeated twice.
Results: The elderly had a higher plasma concentration of fentanyl at the end of surgery than younger patients (5.7±2.2 vs. 3.8±1.2 ng/ml, P =0.001). The plasma concentrations of oxycodone were comparable between the groups. The interval between the second and the third oxycodone dose was longer in the elderly patients ( P =0.036). Pain intensity on the verbal rating scale was lower at the 45-min assessment point after all three oxycodone test doses ( P =0.008) and sedation scores were significantly higher after the third dose in the elderly patients ( P =0.035).
Conclusions: In elderly patients, the plasma concentration of fentanyl was higher but plasma levels of oxycodone were at a similar level compared with middle-aged patients. However, the elderly patients had less pain and were more sedated after doses of oxycodone.     

Evaluation of the impact of recent changes in postgraduate continuing education for community pharmacists in England

Postgraduate continuing education for community pharmacists in England has undergone a radical change since the establishment of the Centre for Pharmacy Postgraduate Education (CPPE) in 1992. The present study was undertaken to assess the impact of the introduction of the CPPE on levels of participation and attitudes towards continuing education. Comparisons are drawn with an analysis made in 1991. Results showed that 76.8 per cent of respondents had participated in CPPE-based continuing education, as either workshops or distance learning. This level of participation is far higher than that previously recorded. Those pharmacists who attended the workshops also tended to request distance learning packages, while a significant proportion of users of distance learning declined to attend workshops. Owners of community pharmacies were significantly more likely than managers to use computer assisted learning material. Attitudes concerning restraints against participation in continuing education focused on the value pharmacists place on their spare time and the absence of a postgraduate education allowance for community pharmacists.     

An audit of adverse events in children sedated with chloral hydrate or propofol during imaging studies

We examined records of sedations provided by the paediatric anaesthesiology staff for 455 children (ages 1 mo-17 yr) undergoing MRI or CT scans at our institution over a twelve-month period with regard to the monitoring of adverse events: excessive sedation, agitation, vomiting, hypoxaemia, and major airway compromise. One hundred-and-thirty-one patients (29%) received chloral hydrate; 324 patients (71%) received propofol. All patients were monitored with continuous noninvasive pulse oximetry and received supplemental oxygen via nasal cannulae. Of the patients who received chloral hydrate, 64 (49%) were over one year of age; of the patients who received propofol, 318 (98%) were one year of age or older. In the chloral hydrate group, 23 patients (19%) were deemed excessively sedated and four patients (3%) were agitated; no patients in the propofol group experienced any of the adverse outcomes reviewed. Furthermore, no patients in either group had significant airway compromise and none was admitted to the hospital as a result of the sedation.     

Comparison of the effect of intravenous ketoprofen, ketorolac and diclofenac on platelet function in volunteers

Background : Nonsteroidal anti–inflammatory drugs (NSAIDs) inhibit prostaglandin synthesis which may result in impaired platelet function. Because NSAIDs have different abilities to inhibit cyclo–oxygenases we compared the effect of intravenous ketoprofen, ketorolac and diclofenac on platelet function in volunteers. Methods : Ten healthy male volunteers were given ketoprofen 1.4 mg kg^-1, ketorolac 0.4 mg kg^-1 and diclofenac 1.1 mg kg^-1 in saline i.v. on three different occasions, at more than one–week intervals, in a randomized double–blind crossover study. Platelet function was evaluated before (sample 0), 2 (sample 2) and 24 h (sample 3) after the beginning of the infusion. Results : Two of the volunteers had no secondary platelet aggregation in their aggregation curves before the experiment (sample 0, studied three times) and their results were excluded from the final analysis. Diclofenac inhibited adrenaline (0.9 μg–ml^-1) induced platelet aggregation less (median maximal aggregation 22.5%) than ketoprofen (18.3%) and ketorolac (15.7%) (P<0.05) in sample 2. In the ketorolac group in sample 3 an impairment of adrenaline (0.9 ng ml^-1) induced platelet aggregation was still seen (26.7%) (P<0.05) but not in the other groups. Diclofenac did not affect adenosine diphosphate (ADP) induced platelet aggregation. However, ketorolac caused an impairment in ADP (3 μM and 6 μM) induced platelet aggregation and ketoprofen in ADP (6 μM) induced platelet aggregation in sample 2. Bleeding time was prolonged (P<0.05) after ketoprofen and ketorolac (sample 2) but not after diclofenac. Platelet retention on glass beads was unaffected by the tested drugs. Conclusion : Ketoprofen, ketorolac and diclofenac caused a reversible platelet dysfunction. Diclofenac had the mildest effect, while platelet dysfunction was still seen 24 h after the beginning of ketorolac.     

Rate-Related and Autonomic Effects on Atrioventricular Conduction Assessed Through Beat-to-Beat PR Interval and Cycle Length Variability

Atrioventricular Conduction Variability. Introduction: Atrioventricular AV) conduction time varies on a beat-by-beat basis in response to the influences of cardiac efferent autonomic activity and rate-dependent electrical recovery processes. The goals of this study were to distinguish these effects on AV conduction time and to compare the variability in sinoatrial and AV nodal function. Methods and Results: The PR interval on the surface ECG served as an index of AV conduction time in this study of 14 adult human subjects undergoing a random interval breathing protocol. P and R waves were located by a template-matching algorithm. Spectral analysis allowed frequency-domain comparisons between PR and RR interval variability. Spectra of PR and RR intervals had similar power distributions, although the power of the RR interval spectra was much greater. Autonomic blockade with atropine plus propranolol reduced the power of both spectra. Standing significantly decreased the spectral power from 0.15 to 0.5 Hz for PR and RR spectra, and introduced a peak near 0.1 Hz in the mean PR and RR spectra, although the latter finding was significant only for the RR interval spectra. Propranolol had no significant effects on the PR and RR interval spectra. Linear regression analysis allowed quantification of the autonomic and recovery effects on AV conduction and showed which effect predominated. Simple linear regression confirmed in adults a previous finding in children that conduction time may be either positively or negatively correlated with cycle length. By multiple regression and transfer function analysis, the inverse relation seen in some subjects was attributed to the effect of recovery from the preceding cycle. With the preceding recovery period accounted for, the conduction time and cycle length of the current beat were positively correlated, presumably due to the parallel autonomic effects on the sinoatrial and AV nodes. The magnitude of the recovery effect predicted by the regression analysis was similar to published values. Conclusion: A noninvasive evaluation of the surface ECG can be used to compare variability in AV conduction time and cycle length and characterize the effects of autonomic efferent activity and rate-related recovery on AV nodal function.     

General medical practitioners' attitudes towards the use of patient medication records

A survey was conducted to ascertain general medical practitioners' (GPs') attitudes to community pharmacists' use of patient medication records (PMRs) and to assess whether GPs envisage a role for family health service authorities (FHSAs) in maintaining records of patients' data. The survey questionnaire was sent by post to all 1,257 GPs in contract with Avon and Devon FHSAs. A total of 811 questionnaires was returned, an overall response rate of 64.5 per cent. A majority (59 per cent) of GPs considered that community pharmacists should keep patient medication records and there was strong support for pharmacists holding PMRs for the elderly and confused, and also for patients with diabetes, asthma, epilepsy, and those patients who had experienced major adverse drug reactions or allergies. Some GPs, however, remained unconvinced of the usefulness of a pharmacy PMR. Seventy four per cent of respondents considered that patients should keep their own medication records. In contrast, only 4 per cent were in agreement with patient medication data being stored by FHSAs. The community pharmacist's role in maintaining PMRs received less support from doctors in dispensing practices than from their non-dispensing counterparts. Some 80 per cent of respondents were in favour of pharmacists providing PMR system-generated patient information leaflets with dispensed medicines. Most GPs considered that such leaflets had a positive effect on patient compliance. Recently registered GPs were found to be more supportive than their older colleagues of community pharmacists recording patients' clinical conditions and providing information leaflets.