Biomedical subjects

R M Reichley

Publications and source records attributed to R M Reichley.

13 recordsLinked to original sources

PubMed1999

Impact of a Web-based clinical information system on cisapride drug interactions and patient safety.

BACKGROUND: Most commercially available drug-interaction screening systems have important limitations that fail to protect patients from dangerous drug combinations. We attempted to overcome the limitations of our commercial program by developing a Web-based clinical information system to serve as a safety net. This system identifies drug interactions with newly marketed medications not screened by our commercial program, and generates a second alert on dangerous interactions that were overridden during order processing. METHODS: The Web-based system uses patient-specific pharmacy, laboratory, and demographic data to generate detailed alerts on patients receiving potentially dangerous drug combinations. The system's impact on the use of dangerous drug combinations and related adverse events was evaluated by a retrospective analysis of patients receiving cisapride with contraindicated medications in the 2 years before and after implementation. RESULTS: The rate of dangerous drug combinations declined by 66% after implementing the system, from 9.0% of cisapride orders in 1994 and 1995 to 3.1% in 1996 and 1997 (P<.001). The mean [SD] duration of contraindicated therapy (4.1 [3.8] vs 1.6 [1.4] days, P<.001) and proportion of patients being discharged under treatment with a dangerous drug combination (36.2% vs 7.7%, P<.001) was also significantly reduced during the study period. Three patients (1.7%) during the control period experienced serious adverse events that may have been related to the targeted drug interactions. No symptomatic cardiac events were identified during the study period (P = .21). CONCLUSIONS: An automated system running as a safety net can be an efficient method of detecting contraindicated drug combinations and serves an important role in the avoidance of potentially serious adverse drug events.

Adverse Drug Reaction Reporting Systems↗

PubMed1999

Notification of real-time clinical alerts generated by pharmacy expert systems.

We developed and implemented a strategy for notifying clinical pharmacists of alerts generated in real-time by two pharmacy expert systems: one for drug dosing and the other for adverse drug event prevention. Display pagers were selected as the preferred notification method and a concise, yet readable, format for displaying alert data was developed. This combination of real-time alert generation and notification via display pagers was shown to be efficient and effective in a 30-day trial.

Clinical Pharmacy Information Systems↗

PubMed1997

Automated system for identifying potential dosage problems at a large university hospital.

A hospital's experience with an automated system for screening drug orders for potential dosage problems is described. DoseChecker was developed by the hospital pharmacy department in collaboration with a local university. Pharmacy, laboratory, and patient demographic data are transferred nightly from the hospital's mainframe system to a database server; DoseChecker uses these data and user-defined rules to (1) identify patients receiving any of 35 targeted medications, (2) evaluate the appropriateness of current dosages, and (3) generate alerts for patients potentially needing dosage adjustments. The alert reports are distributed to satellite pharmacists, who evaluate each patient's condition and make recommendations to physicians as needed. One of the system's primary purposes is to calculate creatinine clearance and verify that dosages are properly adjusted for renal function. Between May and October 1995, the system electronically screened 28,528 drug orders and detected potential dosage problems in 2859 (10%). The system recommended a lower daily dose in 1992 cases (70%) and a higher daily dose in 867 (30%). Pharmacists contacted physicians concerning 1163 (41%) of the 2859 alerts; in 868 cases (75%), the physicians agreed to adjust the dosage. The most common dosage problem identified was failure to adjust dosages on the basis of declining renal function. An automated system provided an efficient method of identifying inappropriate dosages at a large university hospital.

Adolescent↗

PubMed1997

A meta-analysis of extended-interval dosing versus multiple daily dosing of aminoglycosides.

We conducted a meta-analysis of 22 randomized, controlled trials in which extended-interval dosing of aminoglycosides was compared with multiple daily dosing. When we classified intermediate outcomes as successes, we found that patients receiving extended-interval dosing were at significantly reduced risk of clinical treatment failure (risk difference, -3.4%; 95% confidence interval [CI], -6.7% to -0.2%; P = .039) and that there was a trend toward reduced risk of bacteriologic failure (risk difference, -1.7%; 95% CI, -5.4% to +2.1%; P = .38). Reclassification of intermediate outcomes as failures yielded similar results. There was significant heterogeneity among the trials, necessitating cautious interpretation of these outcomes. There were negligible differences in the risk of nephrotoxicity (risk difference, -0.6%; 95% CI, -2.4% to +1.1%; P = .46) and ototoxicity (risk difference, +0.3%; 95% CI, -1.2% to +1.8%; P = .71). We conclude that for many indications, extended-interval dosing of aminoglycosides appears to be as effective as conventional dosing, with similar rates of toxicity. The added convenience of extended-interval dosing makes it an attractive alternative to conventional dosing.

Aminoglycosides↗

PubMed1995

Supporting ad-hoc queries in an integrated clinical database.

Whether caring for patients or conducting research, medical decision-makers need access to clinical data. To fulfill that need, commercial software developers have produced a wide range of database query tools that differ greatly in functionality and cost. Generally, tools that have a greater ability to conceal database complexity from the user also require more effort for administrative setup. We describe a cost-effective, commercially-available query tool that requires no special setup to perform most simple queries, yet can be customized to satisfy users' more complex querying requirements.

Clinical Pharmacy Information Systems↗

PubMed1995

Vancomycin levels after intravitreal injection. Effects of inflammation and surgery.

OBJECTIVE: Vancomycin hydrochloride for intraocular injection is the drug of choice for the treatment of suspected gram-positive endophthalmitis. To study its intraocular pharmacokinetics, we injected vancomycin into the vitreous cavity of phakic, aphakic, and aphakic-vitrectomized rabbit eyes and determined its rate of clearance. Inflamed eyes were compared to control eyes in each group. METHODS: Three groups of eyes were prepared. The eyes in Group 1 were phakic, the eyes in Group 2 had the lens removed, and the eyes in Group 3 had both the lens and central vitreous removed. Each group was subdivided into a control group and a group made inflamed by injection of heat-killed Staphylococcus epidermidis. Vancomycin hydrochloride 1 mg in 0.1 cc of diluent was injected into the midvitreous cavity and samples obtained at 2 or 3, 8, 24, and 48 hours after injection. Vancomycin concentrations were measured and clearance rates were calculated for each of the groups. RESULTS: Vancomycin was cleared substantially faster from aphakic-vitrectomized eyes (half-life 9.0 hours) and aphakic eyes (half-life 8.9 hours) than phakic eyes (half-life 25.1 hours). Inflammation increased the rate of elimination of vancomycin only in the aphakic group. CONCLUSIONS: Clearance of vancomycin from the phakic eye is prolonged compared to that of beta-lactam antibiotics, an important pharmacokinetic advantage in treating endophthalmitis. Its clearance from aphakic-vitrectomized eyes is dramatically faster than from phakic eyes and is similar to that of other antimicrobial agents.

Animals↗

PubMed1995

Intraocular injection of ceftazidime. Effects of inflammation and surgery.

OBJECTIVE: The clearance of ceftazidime from the rabbit vitreous cavity after injection into phakic, aphakic, and aphakic vitrectomized rabbit eyes was assessed and the duration of concentrations above the minimal inhibitory concentrations for target gram-negative bacteria was determined. To determine the effect of inflammation on the intraocular pharmacokinetics of ceftazidime, each anatomic group was subdivided into inflamed and control eyes. METHODS: Ceftazidime (2.25 mg) was into the vitreous cavity of inflamed and control rabbit eyes and its concentration was assayed 2, 8, 24, and 48 hours later. The half-life for each of the anatomic groups was calculated. RESULTS: The half-life of ceftazidime in control phakic eyes was 13.8 hours. In aphakic eyes the half-life was 11.8 hours and in the aphakic vitrectomized eyes the half-life was 4.7 hours. Inflammation slightly shortened the half-life in phakic (10.1 hours) and aphakic (8.7 hours) eyes. The half-life in aphakic vitrectomized inflamed eyes was 5.1 hours. CONCLUSION: Vitrectomy and lensectomy significantly shorten the half-life of ceftazidime after intravitreal injection. Inflammation increases clearance to a small degree in phakic and aphakic eyes.

Animals↗

PubMed1992

Investigation of a computer virus outbreak in the pharmacy of a tertiary care teaching hospital.

OBJECTIVE: A computer virus outbreak was recognized, verified, defined, investigated, and controlled using an infection control approach. The pathogenesis and epidemiology of computer virus infection are reviewed. DESIGN: Case-control study. SETTING: Pharmacy of a tertiary care teaching institution. RESULTS: On October 28, 1991, 2 personal computers in the drug information center manifested symptoms consistent with the "Jerusalem" virus infection. The same day, a departmental personal computer began playing "Yankee Doodle," a sign of "Doodle" virus infection. An investigation of all departmental personal computers identified the "Stoned" virus in an additional personal computer. Controls were functioning virus-free personal computers within the department. Cases were associated with users who brought diskettes from outside the department (5/5 cases versus 5/13 controls, p = .04) and with College of Pharmacy student users (3/5 cases versus 0/13 controls, p = .012). The detection of a virus-infected diskette or personal computer was associated with the number of 5 1/4-inch diskettes in the files of personal computers, a surrogate for rate of media exchange (mean = 17.4 versus 152.5, p = .018, Wilcoxon rank sum test). After education of departmental personal computer users regarding appropriate computer hygiene and installation of virus protection software, no further spread of personal computer viruses occurred, although 2 additional Stoned-infected and 1 Jerusalem-infected diskettes were detected. CONCLUSIONS: We recommend that virus detection software be installed on personal computers where the interchange of diskettes among computers is necessary, that write-protect tabs be placed on all program master diskettes and data diskettes where data are being read and not written, that in the event of a computer virus outbreak, all available diskettes be quarantined and scanned by virus detection software, and to facilitate quarantine and scanning in an outbreak, that diskettes be stored in organized files.

Clinical Pharmacy Information Systems↗

PubMed1986

Vancomycin pharmacokinetics in small, seriously ill infants.

Twenty vancomycin pharmacokinetic studies were performed on 17 small infants who were receiving the antibiotic for treatment of documented infections. Fourteen patients were less than or equal to 41 weeks' postconception. In this group there was no statistical difference in mean elimination rate, volume of distribution, or clearance between neonates and infants 4 to 8 weeks of age. However, they had significantly lower clearance and prolonged mean beta-half-life than infants who were 3 to 6 months old (greater than 43 weeks' postconception). Vancomycin clearance was directly related to postconceptional age by linear regression analysis. beta-Half-life was influenced by the weight of the patient, volume of distribution, and gestational age. In view of the interpatient variability observed in the prematurely born infants, pharmacokinetic studies should be performed to determine the appropriate dose and intervals in vancomycin therapy.

Age Factors↗

PubMed1979

Antibiotic usage in a pediatric medical center.

Antibiotic usage in a large pediatric teaching hospital was evaluated during a three-month period. A total of 1,067 patients received antibiotics and 295 patient records were reviewed. One hundred sixty-nine courses of antibiotics were administered to surgical patients, 77% for surgical prophylaxis. One hundred forty-seven antibiotic courses administered to medical patients were therapeutic in 61.2% and in 35.3% were given because of suspicion of infection. Ampicillin was the most commonly used antibiotic; cephalosporins were used for surgical prophylaxis. Aminoglycosides were used commonly for suspected infection in medical patients. Antibiotic management was inappropriate in 66% of surgical patients and in 21% of medical patients. Not obtaining appropriate studies prior to and during therapy were common infractions on all services. Surgical prophylaxis was freqently inappropriate by reason of no indication, wrong drug or dose, or inappropriate timing.

Adolescent↗

PubMedDate not supplied

Analysis of various creatinine clearance formulas in predicting gentamicin elimination in patients with low serum creatinine.

Predicted gentamicin elimination rate constants (kelS) using creatinine clearance (Clcr) estimates from seven equations were compared with kelS calculated from steady-state serum gentamicin concentrations in 186 hospitalized patients. In predicting kel, the equations varied significantly in precision (mean absolute percentage error), and were particularly imprecise among patients with serum creatinine values of 71 mumol/L or less. Significant differences in bias (mean prediction error) were also observed. All equations using serum creatinine as an element showed improved precision, and most showed reduced bias when a minimum value of 71 mumol/L was used. The Cockcroft-Gault normalized to 72 kg and the Hull equations are among the simplest to calculate and, when using a minimum serum creatinine of 71 mumol/L, had significantly greater precision and less bias than several of the equations. We recommend one of these two methods for predicting gentamicin kel in patients with low serum creatinine values.

Adult↗

PubMedDate not supplied

Evaluation and financial impact of imipenem/cilastatin dosing in elderly patients based on renal function and body weight.

OBJECTIVE: To evaluate the financial impact of adjusting imipenem/cilastatin (IC) dosages in elderly patients based on estimated creatinine clearance (Cl cr) and body weight. DESIGN: Retrospective cost-savings analysis. SETTING: A 500-bed, university-affiliated, tertiary-care hospital. MAIN OUTCOME MEASURES: All courses of IC administered to patients over age 60 during a four-month period were retrospectively assessed for appropriateness based on both dosing interval and dosage. Manufacturer's guidelines for adjusting the IC dosage based on estimated CL cr and body weight were used to define appropriate dosing. The cost savings that could have been realized by appropriately adjusting IC dosage was calculated for the study period and extrapolated to project an annual cost savings. RESULTS: Only 37 percent of patient days of therapy and 32 percent of therapy courses were judged as appropriate based on both dose amount and interval. The projected annual cost savings that could have been realized by appropriately adjusting IC dosage based on estimated Cl cr and body weight was $11,500. CONCLUSIONS: Adjustment of IC dosages in elderly patients based on estimated Cl cr and body weight can result in significant cost savings.

Age Factors↗

PubMedDate not supplied

A randomized, prospective evaluation of an interventional program to discontinue intravenous antibiotics at two tertiary care teaching institutions.

To evaluate a program to discontinue intravenous antibiotics at two teaching hospitals, 102 inpatients meeting eligibility criteria were randomly assigned to two groups. In one group, patients' physicians were contacted by pharmacists with recommendations to discontinue intravenous antibiotic therapy; in the other, patients were simply observed. Measured outcomes were antibiotic costs, length of stay, need to restart intravenous antibiotics, in-hospital mortality, and 30-day readmissions. The intervention significantly reduced mean antibiotic costs per patient ($19.82 vs $35.84, p = 0.03), but related labor costs exceeded this benefit. Readmissions were significantly more frequent in the intervention group than in the control group (29% vs 9.8% p = 0.02), but they were not infection related. No impact was demonstrated on the other measured outcomes. Institutions considering such programs or with one in place should conduct similar evaluations.

Administration, Oral↗