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Biomedical subjects

B J Zarowitz

Publications and source records attributed to B J Zarowitz.

At least 37 records · Page 2Linked to original sources
PubMed1995

Vancomycin removal by high-flux polysulfone hemodialysis membranes in critically ill patients with end-stage renal disease.

To define the pharmacokinetics of vancomycin in patients undergoing maintenance hemodialysis in an acute care setting and to characterize the rebound phenomenon occurring after hemodialysis, vancomycin t1/2 during the interdialytic and intradialytic phases and intradialytic clearance were measured in eight critically ill patients undergoing high-flux hemodialysis using F-80 or F-60 polysulfone dialyzers. Intradialytic clearance was determined using the recovery method. In patients dialyzed with F-80 dialyzers, interdialytic and intradialytic t1/2 for vancomycin were 162 +/- 69.8 hours and 4.7 +/- 1.3 hours, respectively. Intradialytic clearance was 108.5 +/- 16.3 mL/min, and 238 +/- 55 mg of vancomycin was recovered in the dialysate. In patients dialyzed with F-60 dialyzers, interdialytic and intradialytic t1/2 were 211.0 +/- 166.8 and 4.6 +/- 0.4 hours, respectively. Intradialytic clearance was 100.6 +/- 18.3 mL/min and the amount of vancomycin recovered was 252 +/- 79 mg. Vancomycin concentrations rebounded by 16% to 37% between 3 and 6 hours in patients dialyzed with the F-80 dialyzer and 15% to 38% between 2 and 3 hours in patient dialyzed with F-60 dialyzers. Hemodialysis with high-flux polysulfone dialyzers removes significant amounts of vancomycin in patients dialyzed in an acute care setting. A suggested scheme for vancomycin dosage adjustments in these patients is presented.

Adult↗
PubMed1995

Proarrhythmic effects of intravenous vasopressors.

OBJECTIVE: To review the electrophysiologic properties and the in vitro, ex vivo, animal, and human data regarding proarrhythmic effects of intravenous vasopressors. DATA SOURCES: A comprehensive (MEDLINE) search (1960-1994) was conducted for dopamine, epinephrine, norepinephrine, phenylephrine, and methoxamine. STUDY SELECTION: In vitro and ex vivo studies and investigations performed in animals or humans reporting electrophysiologic and/or proarrhythmic effects of the above intravenous vasopressors were selected. A comprehensive search of all human studies involving these agents was conducted to reveal any proarrhythmic effects that may have been reported. In addition, case reports of proarrhythmic effects associated with these agents were reviewed. DATA EXTRACTION: Data regarding electrophysiologic and proarrhythmic effects of these agents were extracted from in vitro, ex vivo, animal, and human studies. Because few studies with the specific purpose of investigating proarrhythmic effects of vasopressors have been performed in humans, all studies involving these drugs for evaluation of hemodynamic effects, clinical efficacy, or other endpoints in humans were reviewed. In addition, data were extracted from case reports of proarrhythmic effects associated with these agents. DATA SYNTHESIS: Dopamine increases automaticity in Purkinje fibers and has a biphasic effect on action-potential duration. Dopamine has caused both atrial and ventricular tachyarrhythmias in animals. Human data have revealed dose-related sinus tachycardia, with few reports of clinically significant ventricular arrhythmias. Epinephrine shortens sinus cycle length, increases atrial and ventricular automaticity, promotes atrioventricular nodal conduction, and decreases ventricular effective refractory period (ERP). It is well known to induce ventricular fibrillation and decrease the ventricular fibrillation threshold (VFT) in ex vivo models as well as intact animals. In humans, epinephrine may cause dose-related sinus tachycardia, supraventricular arrhythmias, or, more commonly, ventricular arrhythmias. Norepinephrine increases automaticity of the sinoatrial node, atria, and ventricles; promotes atrioventricular nodal conduction; and decreases ventricular ERP. In vitro/ex vivo and animal data have shown that norepinephrine significantly decreases VFT. Although electrophysiologic studies suggest that norepinephrine may be proarrhythmic, few supporting data exist in humans. Phenylephrine demonstrates differential electrophysiologic effects in atrial and ventricular tissue. Most data suggest that phenylephrine causes prolongation of the ventricular ERP. Rather than being proarrhythmic, phenylephrine may be protective against arrhythmias. The drug elevates VFT in dogs. In humans, phenylephrine effectively terminates supraventricular tachycardias and may be protective against ventricular arrhythmias. Like phenylephrine, methoxamine elevates the repetitive extrasystolic, atrial, and ventricular fibrillatory thresholds. Methoxamine also may have antiarrhythmic effects because of alpha-receptor stimulation and reflex vagal activity. Despite the relatively low risk of arrhythmogenicity associated with intravenous vasopressors, patients should be monitored for potential proarrhythmic effects and appropriate action taken as necessary. Critically ill patients often have concurrent conditions, electrolyte disturbances, and underlying arrhythmias that predispose them to a higher risk of vasopressor proarrhythmic effects. CONCLUSIONS: Controlled data supporting the proarrhythmic potential of intravenous vasopressors in humans are lacking. Sinus tachycardia, asymptomatic ventricular ectopic activity, and other ventricular or supraventricular arrhythmias have been reported in association with dopamine and epinephrine. Phenylephrine and methoxamine have been associated with sinus bradycardia, but otherwise may be antiarrhythmic. Intravenous vasopressors appear relatively safe w

Animals↗
PubMed1994

Prophylaxis for stress-related gastric hemorrhage in the medical intensive care unit. A randomized, controlled, single-blind study.

OBJECTIVE: To determine the efficacy and safety of cimetidine and sucralfate prophylaxis for stress-related gastrointestinal hemorrhage in patients admitted to a medical intensive care unit. SETTING: Medical intensive care unit of a nonprofit, university-affiliated teaching hospital. PATIENTS: 300 patients admitted to the medical intensive care unit during a 10-month period. DESIGN: Randomized, controlled, single-blind clinical trial. INTERVENTION: Patients were assigned to receive no prophylaxis (control), 1 g sucralfate given orally every 6 hours, or continuous intravenous cimetidine titrated to maintain gastric pH at 4.0, intervention was maintained until the occurrence of clinically severe hemorrhage, onset of drug-related complications, death, or discharge from the medical intensive care unit. OUTCOME MEASURES: The primary outcome measure was the incidence of clinically severe hemorrhage from endoscopically verified stress-related gastritis. Other outcome measures were transfusion requirements, duration of medical intensive care unit stay, incidence of nosocomial pneumonia, adverse drug reactions, and death. RESULTS: 100 patients were randomly assigned to each treatment. The three groups were similar with regard to demographic characteristics, intensive care unit admission diagnoses, and APACHE II scores. Stress-related hemorrhage was seen in 6% of control participants and in 5% of those receiving sucralfate or cimetidine (relative risk compared with control, 0.83 for each group; 95% CI, 0.26 to 2.64; P = 0.75). No statistically significant differences were found for transfusion requirements, duration of medical intensive care unit stay, and mortality rates among the three groups. Nosocomial pneumonia was diagnosed in 6%, 12%, and 13% of controls, sucralfate recipients, and cimetidine recipients, respectively (sucralfate: relative risk, 2.0 [CI, 0.79 to 5.01], P = 0.14; cimetidine: relative risk, 2.2 [CI, 0.88 to 5.33], P = 0.09). Prophylaxis caused no definite adverse drug reactions. CONCLUSIONS: The observed effects of cimetidine and sucralfate on the incidence and severity of hemorrhage from stress-related gastritis were not significant when compared with no treatment. Routine prophylaxis with these agents for patients entering the medical intensive care unit does not seem warranted.

Adult↗
PubMed1994

Estimation of total body and extracellular water using single- and multiple-frequency bioimpedance.

OBJECTIVE: To determine the precision and bias of single- and multiple-frequency bioimpedance estimates of total body water (TBW) and extracellular water (ECW) volumes in comparison with the true values for these volumes established by gold standard dilution techniques. DESIGN: Controlled, prospective, open-label investigation. SETTING: Private, not-for-profit university-affiliated, acute care hospital. PARTICIPANTS: Normal, healthy men (n = 8) and women (n = 6) volunteers, 25-46 years of age. INTERVENTIONS: A single oral dose of a mixture of deuterium oxide 10 g and bromine 30 mmol; bioimpedance analysis pre- and three hours postmixture administration. MAIN OUTCOME PARAMETERS: TBW and ECW volumes established by deuterium oxide and bromine dilutional spaces (gold standards), respectively, and single- and multiple-frequency bioimpedance estimates of those same volumes. RESULTS: The mean multiple-frequency bioimpedance (MFB) and single frequency bioimpedance (SFB) estimates of TBW, 41.2 and 42.1 L, respectively, were not statistically different (NS) from the 41.2 L deuterium oxide value. Although the two methods had similar precision (NS), MFB was less biased. For ECW, the mean MFB and SFB values of 19.5 and 24.8 L, respectively, were significantly different from the bromine value of 18.8 L (p = 0.013 and p = 0.001, respectively). MFB was the more precise and less biased predictor of ECW. CONCLUSIONS: Compared with SFB, the MFB approach is a more precise and less biased predictor of TBW and ECW volumes in young, healthy adults, and may offer more accurate assessment in subjects with aberrant physiology.

Adult↗
PubMed1994

Changing perspectives of stress gastritis prophylaxis.

OBJECTIVE: To present recent advances in stress gastritis prophylaxis in the critically ill and review considerations in selection of a prophylactic agent. DATA SOURCES: Information was obtained from MEDLINE search, reference lists from articles identified in search, and from review articles. STUDY SELECTION: Emphasis was placed on controlled trials conducted within the last 5 years. DATA EXTRACTION: All literature was assessed for methodology, results, and conclusions. Results of prospective, randomized trials, and meta-analyses are summarized. DATA SYNTHESIS: Histamine2-receptor antagonists, antacids, and sucralfate appear equally effective in preventing stress gastritis in the critically ill. A definitive cause-effect relationship between histamine2-receptor antagonists and increased incidence of nosocomial pneumonia has not yet been established. The indications for using a prophylactic agent and consideration in selecting an agent should include an evaluation of the following: risk factors for gastritis including the type of intensive care patient, comparative efficacy, adverse effects, drug interactions, cost, and ease of administration. The least expensive, safest agent requiring minimal monitoring is sucralfate. Prevention of stress gastritis has never been shown to reduce morbidity or mortality significantly. CONCLUSIONS: Controversies still exist regarding the need to provide prophylaxis, the choice of an agent, and the relative importance of previously identified risk factors. Further well-designed studies are needed before consensus can be reached.

Antacids↗
PubMed1993

Influence of digoxin immune Fab therapy and renal dysfunction on the disposition of total and free digoxin.

OBJECTIVE: To characterize the disposition of total and free serum digoxin following the administration of digoxin Fab antibody in patients with varying degrees of renal function. DESIGN: Observational study of pharmacokinetics and pharmacodynamics. SETTING: Critical care and telemetry units of two university-affiliated teaching institutions, Hartford Hospital and Henry Ford Hospital. PATIENTS: Fourteen digoxin-intoxicated patients (baseline total digoxin > 3.2 nmol/mL) with mean (+/- SD) serum creatinine of 380.1 +/- 212.2 mumol/L who received digoxin Fab antibody therapy. MEASUREMENTS: Serum was drawn every 12 to 24 hours for 80 to 327 hours after Fab administration. Total and free digoxin were assayed in serum by fluorescence polarization immunoassay or modified immunofluorometric assay. RESULTS: Before Fab was administered, total digoxin ranged from 3.5 to 10.5 nmol/mL. After treatment with Fab, total digoxin increased rapidly to a mean (+/- SD) maximum of 51.8 +/- 22.7 nmol/mL and decreased to 7.2 +/- 4.7 nmol/mL at the last measurement. Total digoxin was eliminated in a two-phase fashion. The half-life of the initial phase of total digoxin decline was 11.6 +/- 4.1 hours, and the half-life of the second or terminal elimination phase was 118 +/- 57 hours. Free digoxin levels decreased rapidly following Fab therapy, to a mean nadir of 0.6 +/- 1.1 nmol/mL, but rebounded to a mean maximum free digoxin concentration of 1.7 +/- 1.3 nmol/mL in 77 +/- 46 hours. The time to maximum free digoxin rebound occurred later in patients with end-stage renal disease (n = 4) compared with other patients (127 +/- 40 hours compared with 55 +/- 28 hours). CONCLUSION: Elimination of digoxin following Fab therapy is prolonged in digoxin-toxic patients with renal dysfunction. In addition, rebound of free digoxin is delayed in anephric patients. Monitoring free digoxin following the administration of Fab may be of value in selected patients to guide additional Fab dosing, confirm possible rebound toxicity, or guide the reinitiation of digoxin therapy.

Adult↗
PubMed1993

Determination of gentamicin pharmacokinetics by bioelectrical impedance in critically ill adults.

This investigation compares the accuracy of calculating gentamicin pharmacokinetic parameters by a noninvasive body composition technique (bioelectrical impedance analysis; BIA) with an empiric method, against the two-point method as the criterion standard. A prospective concurrent open label design was used. The 32 medical and surgical intensive care unit beds at Henry Ford Hospital, a not-for-profit, university-affiliated teaching hospital, served as the setting. Twenty critical ill adults, Therapeutic Index Scoring System (TISS) = 4, who required gentamicin as part of their normal course of therapy for gram-negative bacillary infections, were evaluated. Gentamicin Vd and k were calculated by three methods. After measurement of body composition parameters by BIA, previously derived gentamicin dosing equations were used to predict gentamicin volume of distribution (Vd) and elimination rate constant (k) (BIA method). Empiric estimates of these parameters (Vd = 0.3L/kg and k derived from creatinine clearance) were compared with the BIA parameters against a criterion standard Vd and k determined from a two-point sampling of gentamicin serum concentrations. Measurements of BIA parameters and gentamicin serum concentrations were made in duplicate with coefficients of variation, < or = 2% and < or = 3%, respectively. The BIA and empiric methods produced resultant pharmacokinetic parameters (Vd and k) not different than those measured by the two-point method. There were no statistically significant differences in mean error (bias), or mean squared error (precision) for both Vd and k assessed by the empiric or BIA methods.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1993

Disposition of digoxin immune Fab in patients with kidney failure.

Digoxin and digoxin immune Fab, its antidote, are eliminated renally. However, the disposition of Fab in severe kidney disease is poorly described. Therefore, the disposition of Fab and its relationship to total and free digoxin were studied in five digoxin-toxic patients with end-stage renal disease (n = 4) or severe renal dysfunction (n = 1) with a mean (+/- SD) serum creatinine of 5.9 +/- 1.2 mg/dl (four patients were receiving long-term hemodialysis). Serum was drawn after a clinically neutralizing Fab dose (80 to 160 mg) every 12 to 24 hours for 204 to 327 hours. Fab concentrations were assessed by radioimmunoassay, whereas total digoxin concentrations were assessed with a modified radioimmunoassay or fluorescence polarization immunoassay. The concentration-time profile of Fab appeared to be similar to the concentration-time profile of total digoxin. The mean (+/- SD) half-lives of the alpha and beta disposition phases of Fab were 13 +/- 5 hours and 96 +/- 31 hours, respectively, which were similar to the alpha and beta parameter estimates of total digoxin (14 +/- 4 and 123 +/- 16 hours, respectively). Steady-state volume of distribution and systemic clearance of Fab were 0.29 +/- 0.11 L/kg and 0.057 +/- 0.022 ml/min/kg, respectively. Thus, in comparison to values reported in patients with normal renal function, the elimination of Fab and total digoxin are markedly delayed in patients with end-stage renal disease, which may necessitate prolonged clinical monitoring.

Aged↗
PubMed1993

Bioelectrical impedance assessment of nutritional status in critically ill patients.

The objective of this study was to assess the utility of bioelectrical impedance analysis (BIA) in determining nutritional status in critically ill patients in the intensive care unit (ICU). Data were collected prospectively in 33 mechanically ventilated medical and surgical ICU patients requiring nutrition as part of their care. BIA, with subsequent calculation of body-composition indexes, was performed every other day for the duration of ICU stay. Body cell mass (BCM) changes correlated with energy and protein intakes (r2 = 0.87, P < 0.001 and r2 = 0.67, P < 0.001, respectively). Maintenance of BCM was achieved by a daily provision of 125.5 kJ.kg-1.d-1 (30 kcal.kg-1.d-1) and 1.5 g protein/kg whereas greater intakes allowed restoration of BCM. The mean ratios of exchangeable sodium to potassium (Nae:Ke) improved only in patients achieving positive nitrogen balance (P = 0.013). Body-composition changes determined by BIA represent a feasible adjunctive method for evaluating and monitoring nutritional status in ICU patients.

Adult↗
PubMed1993

Predictability of creatinine clearance estimates in critically ill patients.

OBJECTIVES: a) To evaluate the predictive ability of different creatinine clearance methods as compared with the criterion standard, inulin clearance; and b) to determine which of the predictive methods yields the most accurate estimation of creatinine clearance. DESIGN: Prospective study. SETTING: Medical intensive care unit (ICU) of a university-affiliated tertiary care hospital. INTERVENTIONS: Glomerular filtration rate was measured by the criterion standard, inulin clearance. PATIENTS: Twenty mechanically ventilated adults. MEASUREMENTS: Renal function was assessed by the following procedures: inulin clearance using a standard protocol, 30-min creatinine clearance, 24-hr creatinine clearance, and creatinine clearance estimates by the Cockcroft-Gault equation. Ideal body weight, total body weight or lean body mass with actual serum creatinine or serum creatinine concentration corrected to 1 mg/dL (85 mumol/L) in cachectic patients were sequentially incorporated into the Cockcroft-Gault equation. RESULTS: The Cockcroft-Gault equation, using ideal body weight and the corrected serum creatinine concentration, was the best predictor of inulin clearance with the smallest bias (9.7 +/- 8.6, 95% confidence interval 5.7 to 13.8). The bias encountered with the 30-min creatinine clearance was not different from that value with the 24-hr creatinine clearance (21.6 +/- 33.0, 95% confidence interval 6.2 to 37.1 vs. 25.4 +/- 28.3, 95% confidence interval 11.8 to 42.9). Good correlations existed between inulin clearance and the Cockcroft-Gault equation, using ideal body weight and the corrected serum creatinine concentration (r2 = .81; p = .0001), as well as between inulin clearance and the Cockcroft-Gault equation, using the lower of ideal or total body weight and the higher of the actual serum creatinine concentration or corrected serum creatinine (r2 = .75; p = .0001). The 30-min creatinine clearance and the 24-hr creatinine clearance had poorer agreement with inulin clearance. The incorporation of a corrected serum creatinine value into the Cockcroft-Gault equation consistently led to better predictions and higher correlation coefficients. CONCLUSIONS: The utilization of the Cockcroft-Gault equation as used clinically (the lower of ideal or total body weight and the higher of actual serum creatinine or corrected serum creatinine concentration to 1 mg/dL [85 mumol/L]) results in more accurate predictions of glomerular filtration rate in the medical, critically ill patient than urine creatinine clearance measures. If creatinine clearance measures are used, the 30-min collection provided results not different from those results obtained with 24-hr urinary collections.

Adult↗
PubMed1993

Labetalol: response and safety in critically ill hemorrhagic stroke patients.

OBJECTIVE: To observe and characterize the blood pressure (BP)-lowering and adverse hemodynamic and/or central nervous system effects of intravenous bolus doses of labetalol in hemorrhagic stroke patients. DESIGN: Observational, prospective, pilot survey conducted over an eight-week period. SETTING: Surgical intensive care unit. PARTICIPANTS: Patients admitted with an intracerebral or subarachnoid hemorrhage. MAIN OUTCOME PARAMETERS: Absolute decline in systolic BP (SBP) and diastolic BP (DBP), time to peak reduction in SBP and DBP, and adverse hemodynamic and mental status changes. RESULTS: Labetalol at doses between 5 and 25 mg lowered SBP by 6-19 percent (baseline 152-184 mm Hg) and DBP by 3-26 percent (baseline 50-99 mm Hg). Adverse hemodynamic or mental status changes were not detected following labetalol administration. CONCLUSIONS: Small (< or = 25 mg) intravenous bolus doses of labetalol produce mild decreases in BP in hemorrhagic stroke patients.

Adult↗
PubMed1993

Vasopressor-resistant hypotension following a massive ingestion of theophylline.

OBJECTIVE: To report the unusual and poorly understood occurrence of vasopressor-resistant hypotension following a suicidal ingestion of theophylline. DESIGN: Single case report. SETTING: Eight-bed, respiratory intensive care unit in a 937-bed teaching hospital. PATIENT: A 52-year-old man with a past medical history significant only for hypertension. RESULTS: The additive influence of markedly elevated theophylline serum concentrations, status epilepticus, and vasopressor-resistant hypotension was associated with the patient's death. Intravenous dosages of epinephrine, norepinephrine, and phenylephrine (ranges 160-210, 32-105, and 200-250 micrograms/min, respectively) were ineffective in controlling the patient's dramatic hypotension. CONCLUSIONS: In addition to the usual metabolic abnormalities and central nervous system effects seen in theophylline poisoning, severe hypotension can occur and prove resistant to commonly used vasopressors. Early identification and treatment of theophylline poisoning is warranted to prevent the development of severe sequelae.

Critical Care↗
PubMed1993

Bar-code technology applied to drug-use evaluation.

Bar-code technology was used to determine: (1) patterns in histamine H2-receptor antagonist use and (2) the occurrence of adverse drug effects and drug interactions associated with the use of these agents in critically ill patients. Patients at Henry Ford Hospital (Detroit) receiving histamine H2-receptor antagonists over a two-month period were evaluated. Clinical information was collected in the intensive care units by using a bar-code system. The data-capture menu was based on drug-use-evaluation criteria for H2-receptor antagonists. Data collected in the scanning wands were uploaded into a computer database and were analyzed at the end of the study. Data were collected for 207 patients. Cimetidine was the predominant H2-receptor antagonist used, and the predominant indication was stress-ulcer prophylaxis. Dosing trends followed accepted guidelines for cimetidine dosage adjustment in renal and hepatic failure. Two drug interactions and six adverse drug reactions occurred. Pharmacists made 92 recommendations to the medical staff regarding modification in therapy, involving 32% of the patients. Data collection required an average of 10 minutes per day each for three pharmacists. H2-receptor antagonist use patterns were evaluated in intensive care units through the application of bar-code technology. The speed and efficiency of this automated tool facilitated collection of a large amount of data.

Clinical Pharmacy Information Systems↗
PubMed1993

Epidemiology of atrial fibrillation in patients hospitalized in a large hospital.

The prevalence of atrial fibrillation varies widely depending on the population studied. To understand the incidence of atrial fibrillation and its significance in relation to other diseases, 3 years (1989 through 1991) of consecutive hospital discharges from the neurology and internal medicine services at Henry Ford Hospital were studied. Of the 26,964 patients who qualified for analysis, 1346 (5%) had atrial fibrillation as 1 of their 5 recorded discharge diagnoses. Comparing the group without atrial fibrillation to those with atrial fibrillation, there were 51% males in both groups (p = 0.88). African-Americans comprised 33% of the patients with atrial fibrillation and 50% of the patients without atrial fibrillation (p < 0.001). The average age of those with atrial fibrillation was 72 +/- 13 years, and 58 +/- 18 years for those without atrial fibrillation (p < 0.001). Length of hospital stay was 9.6 +/- 8.6 days with atrial fibrillation and 7.6 +/- 9.2 days for those without atrial fibrillation (p < 0.001). After adjusting for the effects of age, significant positive associations were noted in those patients with atrial fibrillation whose co-existing condition was either stroke, heart failure, myocardial infarction, hyperthyroidism, or mitral valve disease. There was also a significant negative relationship between hypertension and atrial fibrillation. The most common of the 5 discharge diagnoses observed in patients with atrial fibrillation was congestive heart failure (40%), followed by hypertension (23%) and ischemic heart disease (21%). The existence of a comorbid disease in patients with atrial fibrillation is important, as it can influence medical management and prognosis.(ABSTRACT TRUNCATED AT 250 WORDS)

Age Factors↗
PubMed1993

Pharmacy technicians and computer technology to support clinical pharmacy services.

Use of pharmacy technicians, computer-assisted patient-selection algorithms, and bar-code technology to increase efficiency of clinical pharmacy staff is described. Workload assessment showed that clinical pharmacists at Henry Ford Hospital (Detroit) were spending two thirds of their time with data collection, patient selection, and documentation and only one third of their time intervening to improve drug therapy. To increase pharmacist efficiency, two technicians were hired to perform the clerical functions associated with clinical pharmacy services. Also, a bar-code data-collection system was implemented to help pharmacists document their clinical activity. Computerized algorithms helped pharmacists target patients whose therapy should be most carefully reviewed. Reports generated by the system summarized workload distribution and provided information about the types of problems identified and corrected. After these changes were implemented, the fraction of time that pharmacists spent intervening to improve drug therapy increased to one half. Use of technicians to perform clerical tasks, computerized algorithms to help identify patients in need of pharmacist assistance, and bar-code technology to facilitate data collection has helped clinical pharmacists improve their time management.

Algorithms↗
PubMed1992

Review of randomized trials of digoxin therapy in patients with chronic heart failure.

Although digitalis glycosides were introduced in the treatment of cardiac maladies greater than 200 years ago, controversy persists regarding the precise role of digoxin in any multidrug approach to the treatment of congestive heart failure (CHF). Despite its widespread use for more than 2 centuries, only recently have double-blind, randomized, placebo-controlled trials of digoxin therapy been conducted in patients with moderate CHF and sinus rhythm. These trials demonstrate that digoxin is superior to placebo in improving left ventricular (LV) ejection fraction, increasing exercise capacity, and preventing CHF worsening. Digoxin produces benefits similar to those seen with angiotensin converting enzyme (ACE) inhibitors with regard to clinical compensation and improvement in LV function. However, improved survival is demonstrated only in response to ACE inhibitors. The recently completed RADIANCE study addresses the value of combining digoxin with ACE inhibitor therapy in patients with mild-to-moderate CHF. Because increased mortality has been reported with the newer oral inotropic agents, it currently appears that digoxin is the only oral inotropic agent useful in clinical practice in the treatment of CHF. However, the effects of digoxin on mortality in patients with CHF remain unknown. In the large, double-blind, randomized trial conducted by the National Heart, Lung, and Blood Institute, the effects of digoxin on mortality in patients with CHF and already being treated with ACE inhibitors are currently being evaluated. Presently, based on the results of placebo-controlled studies, it appears that digoxin, alone or in combination with ACE inhibitors, is beneficial in patients with any signs or symptoms of CHF due to systolic LV dysfunction.

Angiotensin-Converting Enzyme Inhibitors↗