Home Medication Regimen Research Articles

In-Home Intravenous Dexmedetomidine Infusion for Treatment of Dystonia: A Pediatric Case Report

The off-label use of an intravenous dexmedetomidine infusion is an option for refractory symptoms in pediatric palliative care with a few published cases of in-home use, most limited to end-of-life care. After an intrathecal baclofen pump malfunction with meningitis and medication withdrawal, a 17-year-old adolescent with quadriparetic cerebral palsy and paroxysmal autonomic instability experienced relief of refractory pain and dystonia with an in-home intravenous dexmedetomidine infusion. His interdisciplinary care team collaborated to establish safety measures and adjust his home medication regimen to further improve quality of life well before his end of life.

Implementation of Pharmacist-Led Medication Review Service for Parkinson's Disease Patients Admitted for Deep Brain Stimulation.

Objective The purpose of this study was to determine the clinical impact of a specialized pharmacist-led medication assessment on the incidence of dopamine antagonists administered for patients with Parkinson's disease after deep brain stimulation (DBS). Methods This was a single-center, Institutional Review Board-approved, two-phase study with pre- and post-implementation cohorts of patients who were 18 years of age or older who underwent DBS for treatment of Parkinson's disease. The primary endpoint was the incidence of dopamine antagonists administered after DBS procedure. Secondary endpoints included the incidence of dopamine antagonists ordered; restarting home Parkinson's disease regimen; rate of tardive dyskinesia; length of hospital stay; and incidence of sitters, restraints, and medications administered for acute agitation. Statistical analysis included Fisher's exact test for categorical data, unpaired t-test for continuous data, and descriptive statistics for all other data. Results The incidence of dopamine antagonists administered was 1 (1.2%) versus 1 (25%) for the pre- and post-implementation groups, respectively (P = 0.09). Restarting of home Parkinson's disease regimen was 30 (36.1%) versus 4 (100%); P = 0.021. The average length of stay was 1.9 days versus 1.3 days. Incidence of sitters was 1 (1.2%) versus 0 (0%), and incidence of restraints was 0 (0%) versus 0 (0%). Incidence of acute agitation medications administered was 9 (10.8%) versus 0 (0%). The secondary endpoints were not significant except for the restarting of home medication regimen. Conclusion The specialized pharmacist-led medication review service identified a single incident of inappropriate medications administered for Parkinson's disease patients status post DBS. However, it did significantly increase the incidence of the restart of Parkinson's disease home regimen.

FREE AIR FROM WHERE? SPONTANEOUS PNEUMOMEDIASTINUM AND SUBCUTANEOUS EMPHYSEMA IN A PATIENT WITH ULCERATIVE COLITIS IN THE ABSENCE OF COLONIC OR ESOPHAGEAL PERFORATION

Abstract INTRODUCTION The development of Spontaneous Pneumomediastinum and Subcutaneous Emphysema in patients with Inflammatory Bowel Disease (IBD) has often been associated with perforation related to toxic megacolon or prior endoscopic procedures. We describe a case of Ulcerative Colitis complicated by Clostridium difficile (C diff) colitis in which Spontaneous Pneumomediastinum and Subcutaneous Emphysema developed without any evidence of perforation. CASE REPORT A 20-year-old male with a past medical history of recently diagnosed Ulcerative Colitis presented for evaluation of rectal pain, dysphagia, hematochezia, fecal incontinence, and urinary hesitancy. He endorsed dysphagia with the inability to tolerate solids or liquids for 4 days. He was diagnosed with Ulcerative Colitis 5 months prior to presentation and had unintentionally lost 90 lbs over the past 2 months. His home medication regimen included infliximab started 2 weeks prior, mesalamine PO tablets and suppositories, and a prednisone taper initiated at 10 mg TID. Laboratory tests confirmed anemia, leukocytosis, thrombocytosis, and elevated ESR and CRP levels. Chest X-ray and CT scans of the neck and chest showed moderate pneumomediastinum and subcutaneous emphysema. Given the symptoms of dysphagia along with the imaging findings of pneumomediastinum and subcutaneous emphysema, there was concern for esophageal perforation. However, an Esophagram and Upper GI series were both unremarkable. Abdominal CT revealed colitis of the descending and sigmoid colon without any evidence of free air or free fluid. Fecal Occult Blood Test and C diff antigen and toxin assays were positive. He was treated with oral vancomycin, IV fluids, IV methylprednisolone, and total parenteral nutrition (TPN). His symptoms significantly improved with a decrease in stool frequency and bloody stools. TPN was weaned and he was able to tolerate an oral diet. A repeat CT scan of the chest showed a complete resolution of the pneumomediastinum. CONCLUSION There are only a few reported cases in the literature of spontaneous pneumomediastinum and subcutaneous emphysema in patients with IBD in the absence of colonic or esophageal perforation. The spontaneous isolated presentation of air leaking from a chronically diseased hollow organ remains rare. In our patient there was no evidence of perforation, therefore the pneumomediastinum and subcutaneous emphysema likely resulted from the release of free air from colonic micro-perforations caused by the severe inflammation related to his Ulcerative Colitis flare and C. diff infection. CT Chest demonstrating pneumomediastinum and subcutaneous emphysema of the neck CT Neck demonstrating subcutaneous emphysema

Cheiro-oral-pedal syndrome of the pons and the role of imaging in diagnosis and management

The patient is a 58-year-old male who presented with chief complaints of right-sided numbness, tingling, and loss of temperature sensation in the upper and lower extremities. The patient’s symptoms began around the face and right corner of the mouth [maxillary/mandibular (V2/V3) distribution] before descending to the arm, trunk, and followed by the lower leg and foot. His home medication regimen included lisinopril, atorvastatin, long and short-acting insulin, and amlodipine. During the interview, the patient admitted to abstinence from his medications. Upon examination, the patient was found to have a loss of hot and cold touch on the right side and expressed 2+ reflexes (brisk response; normal) on both upper and lower extremities. In the initial work-up of the patient, he received a computed tomography (CT) scan which demonstrated an area of potential ischemic infarct of one of the left sided pontine perforator arteries. Immediately at that time he was given a loading dose of 325 mg aspirin and started on 81 mg daily. Because of the patient’s symptoms and risk factors, he was hospitalized for further additional work-up and eventually discharged on dual antiplatelet therapy. This case is intriguing as both neuroradiological reading and neurological examination helped with localization of the lesion and changing the treatment strategy of the patient. With a pontine perforator ischemic event, the harms of treatment with thrombolytics would have outweighed the benefits. This interprofessional work between neuroradiology, internal medicine, and neurology ensured that the patient received the best care for his specific ailments.

Adherence to a strict medication protocol can reduce length of stay in hospitalized patients with Parkinson's Disease

BackgroundPatients with Parkinson's Disease (PD) are at higher risk of complications when admitted to the hospital. Delays in PD medications and use of contraindicated medications contribute to the increased risk and prolong their lengths of stay (LOS). Using a hospital-wide PD protocol, we aimed to ensure PD medications were placed with “custom” timing to resemble the home schedules, and also to avoid ordering or administering contraindicated medications. Material and methods569 patients admitted in 2017 and 2018, were reviewed retrospectively. Mean age was 76.5 (SD 10.6), 332 were males and 237 were females. Charts were reviewed to assess if A) PD medications were ordered with custom timing, B) if not, were the orders changed to custom timed C) if contraindicated medications were ordered, and D) if they were administered. We also assessed the actual/expected length of stay during this time period. Chi Square and post hoc analyses were done to compare time points. Poisson regression analysis was done to assess relative improvement of variables. ResultsThere was a 2.7 fold increase in orders placed with custom timing in 2018 compared to 2017 (RR = 2.651, 95%CI: 1.860–3.780, p < 0.0001), and a 3.2 fold increase in correction of non-custom orders in the same time period (RR = 3.246, 95%CI: 1.875–1.619, p < 0.0001). We also observed a decrease in the actual/expected LOS ratio from 1.54 to 1.32 (p < 0.05). ConclusionBy utilizing an established platform for quality improvement, we were able to improve adherence to the home medication regimen timing in admitted PD patients. Our findings also suggests that adherence to a strict medication regimen protocol may decrease LOS for this patient population.

Incidence of Cytomegalovirus Infection in Hospitalized Adult Patients With IBD Treated With a Drug Regimen Containing Mercaptopurine

Introduction: Immunocompromised patients are known to be at increased risk of CMV infection. Patients with IBD may be at higher risk of developing CMV disease often affecting various organ systems. This can lead to life-threatening systemic illness. The increased risk for opportunistic disease is likely multifactorial and is thought to be due to malnourishment, immunosuppressive therapy and poor NK cell function. We sought to further investigate the effect of immunosuppressive therapy contributing to an increased risk of developing active CMV viremia in the hospitalized IBD population at our tertiary center. Methods: We conducted a single-center, retrospective review of 85 patients tested for CMV from October 2014 through November 2017. Inclusion criteria included adults age 18 and older with a known IBD diagnosis. CMV testing modality included DNA and/or immunoglobulin testing of plasma, CSF and tissue biopsy specimens. Home medication regimen at the time of CMV testing was also assessed to further evaluate the relationship between immunosuppressive and biologic therapy to CMV viremia. Results: Of 85 patients who were tested for CMV, 41 (48%) had a confirmed IBD diagnosis (UC or Crohn's disease). Four (9.7%) patients with IBD tested positive for CMV viremia (two had Crohn's disease and the other two had UC). The patients with CMV presented uniquely, two had hematochezia and ileocolitis/colitis, one had dyspnea and was found to have CMV pneumonia and one presented with chronic sore throat and was noted to have active CMV viremia. Ten out of 41 (24%) patients were on anti-TNF therapy (including infliximab, adalimumab and certolizumab) and only one (10%) tested positive for CMV infection in this group. Another ten (24%) patients were on a regimen containing mercaptopurine and of these, three (30%) tested positive for CMV. The patients who tested positive denied a smoking history and ranged in age from 22 to 67 years. Conclusion: Immunomodulators and biologics are widely used in the treatment of moderate to severe IBD and are associated with side effects including bone marrow suppression and infections, particularly opportunistic infections like CMV. Our data suggests that patients receiving a mercaptopurine-containing regimen have a higher risk of acquiring active CMV infection when compared to those receiving biologics alone. We plan to expand the present study using a larger patient population to further identify correlations between treatment regimen and development of CMV in the setting of IBD.

Patient and Family Partnership for Safer Health Care.

Annually, thousands of children in the United States experience serious preventable health care harm.1 Although children are at an increased risk of health care harm compared with adults, they also have an important protective factor: their families. Cognizant of this, we believe that improvements in pediatric safety could be accelerated through better utilization of patient and family partnerships. Patients and families play an important role in health care safety in the hospital and the community as contributors to, detectors of, and mitigators of medical error.2 Parents may not understand or have the skills to manage their children’s home medication regimen, resulting in errors. Families are, however, well placed to detect errors and are equipped with extensive knowledge and astute observations of the child and their conditions. Finally, informed and empowered families can be important advocates for their children and can prevent errors from reaching and subsequently harming their children, acting as error safety nets.3–5 In this article, we will discuss how unsafe health care continues to harm children and how families can influence care safety, giving both parent (J.W.) and health care professionals’ (P.R. and K.E.W.) perspectives. We will discuss promising examples of family partnership for safety in hospital, outpatient, and community settings for children with varying health needs. Additionally, we will discuss barriers to optimal partnering and how we might build on positive examples and better tap into families’ unique potential to coproduce safer care. Thousands of children in the United States continue to suffer … Address correspondence to Philippa Rees, BSc (Hons), MPhil, MBBCh, Institute of Child Health University College London, 1st Floor, 30 Guilford St, London WC1N 1EH. E-mail: p.rees{at}ucl.ac.uk

Probable Rivaroxaban-Induced Full Body Rash: A Case Report

Introduction: Rivaroxaban is a novel oral anticoagulant with several indications, one of which is for stroke prevention in nonvalvular atrial fibrillation. We present a case of probable rivaroxaban-induced rash. Case Summary: A 79-year-old female with a medical history of atrial fibrillation experienced a stroke, after which she was prescribed rivaroxaban 20 mg. After several days, she developed a rash requiring admission to the emergency department and several days of treatment. The rash resolved and she was switched from rivaroxaban to apixaban and did not experience any adverse drug events. Discussion: Onset of symptoms occurred within days of rivaroxaban initiation. The patient had no allergy history and never reported a similar reaction while on concurrent home medication regimen. The resolution of rash and toleration of apixaban suggest a rivaroxaban-specific reaction. The mechanism of this rash is currently unclear. Conclusion: We report one of the first cases of probable rivaroxaban-induced rash, whereas the patient tolerated apixaban. Further investigation is warranted, but prescribers should be cognizant of this potential issue when choosing a factor Xa inhibitor for anticoagulation.

Ergotomine-Induced Ulcerative Colitis

Migraine headaches are commonly treated with ergotamines. Serotonin-1 5-hydroxytryptamine (5-HT 1) receptor agonists are first line agents for migraines. Intravenous dihydroergotamine (DHE) is sometimes used for refractory migraines. Previously published case report have suggested an association between 5-HT 1 receptors and onset of ulcerative colitis, however, this was dismissed as an unlikely cause. We report a case of a new diagnosis of ulcerative colitis associated with intravenous DHE use for refractory migraine. A 45-year-old female with a past medical history of severe migraines presented with a two month history of bloody diarrhea and abdominal pain. Her home medication regimen included naproxen and naratriptan. She was admitted to the Dartmouth-Hitchcock Medical Center (DHMC) a month prior for intractable migraines, where she received seven treatments of IV dihydroergotamine (DHE). During her second infusion of DHE, she developed severe abdominal cramps with associated bloody diarrhea. Infectious workup including stool for C. Difficile was negative. She was subsequently treated for infectious colitis with ciprofloxacin/metronidazole and discharged home. Two month post-discharge, she represented to DHMC for ongoing symptoms of abdominal pain, and bloody diarrhea (10-12 bloody bowel moments daily). In the Emergency Department she had a hemoglobin of 11 and C-reactive protein of 18.5 without an associated leukocytosis. An extensive infectious stool evaluation was negative. Sigmoidoscopy was performed and showed mild to moderate colitis extending from anal-rectal verge to 40 cm (the extent of the examination). The mucosa was characterized by diffuse erythema, edema, complete loss of the normal vascular pattern, granularity, contact friability and superficial ulceration (figure 1). Histopathology confirmed mildly active chronic colitis consistent with ulcerative colitis, without evidence of infection (Figure 2). She was treated with hydrocortisone 100mg IV q8hr with a rapid dramatic improvement in her symptoms. She was subsequently transitioned to prednisone with a planned taper and mesalamine 4.8g daily. Repeat colonoscopy four months later showed complete mucosal healing (Figure 3).Figure 1Figure 2There has being one case report of ergotamine induced ulcerative colitis in the literature. Since ergotamines are used wildly for the treatment of migraines, it is important to understand if there is a true association with inflammatory bowel disease. The mechanism of ergotamine inducing ulcerative colitis is not completely understood. However, the hypothesis is that vasoconstriction leads to ischemia triggering a pro-inflammatory state. We report this case to raise awareness of this possible association so that it can be identified and studied further in the future.Figure 2

The effect on potential adverse drug events of a pharmacist-acquired medication history in an emergency department: a multicentre, double-blind, randomised, controlled, parallel-group study.

BackgroundPotential adverse drug events (PADEs) are defined as being potentially harmful unintentional medication discrepancies. Discrepancies regarding medication history (MH) often occur when a patient is being admitted to a hospital’s emergency department (ED); they are clinically important and represent a significant source of data regarding adverse drug events occurring during emergency admission to hospital. This study sought to measure the impact of pharmacist-acquired MH during admission to an ED; it focused on whether a patient’s current home medication regimen being available for a doctor when consulting a patient in an ED would have reduced potential adverse drug events.MethodA multicentre, double-blind, randomised, controlled parallel-group study was carried out at 3 large teaching hospitals in Bogota, Colombia. Two hundred and seventy patients who had been admitted to an ED were enrolled; each had a standardised, comprehensive MH interview, focusing on a patient’s current home medication regimen prior to being seen by a doctor. Data recorded on the admission medication order form was available to be used by a doctor during consultation in the ED. The main outcome dealt with comparing the intervention and control groups regarding the percentage of patients having at least 1 potential adverse drug event.ResultsThere were 811 PADE (3.35 per patient), 528 (65 %) on the standard care arm and 283 (35 %) on an intervention arm. Most PADEs were judged to have had the potential to cause moderate discomfort (42.6 %), 33.4 % were deemed unlikely to have caused harm and 23.9 % were judged to have had the potential to cause clinical deterioration.ConclusionMany patients suffer potentially adverse drugs events during the transition of care from home to a hospital. Patient safety-focused medication reconciliation during admission to an ED involving a pharmacist and drawing up a history of complete medication could contribute towards reducing the risk of PADES occurring and improve follow-up of patients’ medication-based therapy.Trial registration28/10/2012, ISRCTN63455839.

Medication reconciliation in patients hospitalized in a cardiology unit.

ObjectivesTo compare drugs prescribed on hospital admission with the list of drugs taken prior to admission for adult patients admitted to a cardiology unit and to identify the role of a pharmacist in identifying and resolving medication discrepancies.MethodThis study was conducted in a 300 bed university hospital in Brazil. Clinical pharmacists taking medication histories and reconciling medications prescribed on admission with a list of drugs used prior to admission. Discrepancies were classified as justified (e.g., based on the pharmacotherapeutic guidelines of the hospital studied) or unintentional. Treatments were reviewed within 48 hours following hospitalization. Unintentional discrepancies were further classified according to the categorization of medication error severity. Pharmacists verbally contacted the prescriber to recommend actions to resolve the discrepancies.ResultsA total of 181 discrepancies were found in 50 patients (86%). Of these discrepancies, 149 (82.3%) were justified changes to the patient's home medication regimen; however, 32 (17.7%) discrepancies found in 24 patients were unintentional. Pharmacists made 31 interventions and 23 (74.2%) were accepted. Among unintentional discrepancies, the most common was a different medication dose on admission (42%). Of the unintentional discrepancies 13 (40.6%) were classified as error without harm, 11 (34.4%) were classified as error without harm but which could affect the patient and require monitoring, 3 (9.4%) as errors could have resulted in harm and 5 (15.6%) were classified as circumstances or events that have the capacity to cause harm.ConclusionThe results revealed a high number of unintentional discrepancies and the pharmacist can play an important role by intervening and correcting medication errors at a hospital cardiology unit.

Clinical Reasoning: A 68-year-old man with a first presentation of status epilepticus

A 64-year-old man with transfusion-dependent myelodysplastic syndrome (MDS), hypertension, chronic obstructive pulmonary disease, hypothyroidism, blindness from treated syphilitic chorioretinitis, and no prior seizure history presented in generalized status epilepticus. His daily home medication regimen included prednisone 20 mg (chronic therapy for MDS), diltiazem 120 mg, digoxin 250 μg, tiotropium 80 μg, and levothyroxine 112 μg. On admission he was febrile to 39.9 °C and in atrial fibrillation with rapid ventricular rate. Initial hematologic profile showed 11,910 leukocytes/mm(3) (12% immature forms, 46% neutrophils, 32% lymphocytes), hematocrit of 30.8%, and platelet count of 215,000/mm(3), with an otherwise normal serum chemistry.

Violaceous Necrotic Plaques on the Leg of an Immunosuppressed Patient

A61-year-oldmanwithacute lymphocytic leukemiawas seenwith plaquesonhis right legatday148afterallogeneicbonemarrowtransplantation. Three weeks earlier, he had fallen outdoors on his right knee, landing in apile of leaves. Thepatient reported increasederythemaof thekneeandnew lesionsappearingdistallydownthe right leg.Hisposttransplantationcoursehadbeencomplicatedby thedevelopment of chronic graft-vs-host disease, Aspergillus pneumonia, and vancomycin-resistant Enterococcus, for which his home medication regimen includedmethylprednisoloneacetate, voriconazole, and daptomycin, respectively. Physical examination revealed a marker-outlined, welldemarcated 8 × 4-cm violaceous hyperkeratotic plaque with a central 2-cm round area of dark necrotic crusted ulceration overlying the right knee (Figure, A). Distal to this were 3 welldemarcated plaques with similar morphologic findings. The lesions had not progressed beyond marked outlines from the previous day. Punch biopsy of the knee was performed, and tissue was sent for pathological analysis (Figure, B and C) and culture. What is your diagnosis?

Tamoxifen and Depression: Drug Interactions in Breast Cancer

This case describes a 76-year-old African-American female with a history of depression, breast cancer, and hypothyroidism admitted to the inpatient geriatric psychiatry unit for an electroconvulsive therapy (ECT) evaluation. She had one previous episode of depression, which began after a lumpectomy in 2007. Her home medication regimen included tamoxifen 20 mg daily. This case highlights the incidence of depression in persons with breast cancer, examines the controversy of tamoxifen-induced depression, and evaluates antidepressant considerations regarding potentially efficacy-reducing cytochrome P450 2D6 drug interactions with tamoxifen. The pharmacy team played an active role in educating the medical team regarding tamoxifen drug interactions. After many discussions, the patient was ultimately treated with mirtazapine 15 mg at bedtime, in addition to ECT.

A multicentre, double-blind, randomised, controlled, parallel-group study of the effectiveness of a pharmacist-acquired medication history in an emergency department

BackgroundAdmission to an emergency department (ED) is a key vulnerable moment when patients are at increased risk of medication discrepancies and medication histories are an effective way of ensuring that fewer errors are made. This study measured whether a pharmacist-acquired medication history in an ED focusing on a patient’s current home medication regimen, and available to be used by a doctor when consulting in the ED, would reduce the number of patients having at least 1 medication discrepancy related to home medication.MethodsThis multicentre, double-blind, randomised, controlled parallel-group study was conducted at 3 large teaching hospitals. Two hundred and seventy participants were randomly allocated to an intervention (n = 134) or a standard care (n = 136) arm. All consecutive patients >18 years old admitted through the ED were eligible. The intervention consisted of pharmacists conducting a standardised comprehensive medication history interview focusing on a patient’s current home medication regimen, prior to being seen by a doctor. Data recorded on the admission medication order form was available to be used by a doctor during consultation in the ED. The admission medication order form was given to doctors at a later stage in the control arm for them to amend prescriptions. The effect of the intervention was assessed primarily by comparing the number of patients having at least 1 admission medication discrepancy regarding medication being taken at home. Secondary outcomes concerned the characteristics and clinical severity of such medication discrepancies.ResultsThe intervention reduced discrepancies occurring by 33% (p < 0.0001; 0.1055 odds ratio, 0.05-0.24 95% confidence interval), despite recall bias. Regarding total discrepancies, omitting medication occurred most frequently (55.1%) and most discrepancies (42.7%) were judged to have the potential to cause moderate discomfort or clinical deterioration.ConclusionsA pharmacist-acquired medication history in an ED focusing on a patient’s current home medication regimen available to be used by a doctor at the time of consulting in the ED reduced the number of patients having at least 1 home medication-related discrepancy.Trial registrationCurrent Controlled Trials ISRCTN63455839.

Quantifying home medication regimen changes and quality of life in patients receiving nocturnal home hemodialysis

Medication regimen simplification may improve adherence in end-stage kidney disease. The effect of nocturnal home hemodialysis (NHHD) on medication burden is unknown. A retrospective pilot study of NHHD patients was conducted. Medication information was collected at baseline, NHHD start, and at 3, 6, 12, 18, and 24 months. SF-36 scores were collected at baseline, 6, 12, and 24 months. The number of medications, pill burden, and number of administrations per day were determined. Medication Regimen Complexity Index was used at each time point as a comparator. Medications for anemia, mineral and bone disorders (MBD), cardiovascular (CV) disease, infection, and vitamins were analyzed for number of medications and pill burden. Thirty-five patients were included. Patients used 10.5 ± 4.4 medications at baseline and 11.8 ± 4.7 at the end of the study (P=NS). Regarding the number of medications, anemia medications, anti-infectives, and vitamins increased; MBD and CV medications decreased by the end of the study. Total pill burden did not change over 24 months, nor did anemia pill burden. Mineral bone disorder and CV pill burden decreased, and vitamins and anti-infective pill burden increased. Daily medication administration times decreased significantly from 5.0 ± 1.5 to 3.6 ± 1.5 by 24 months. Switching to NHHD was associated with a significant increase in Medication Regimen Complexity Index at 24 months (P<0.05). SF-36 scores increased significantly once patients began on NHHD. No measure of medication regimen complexity was correlated with the SF-36 score. Medication burden changes over time after starting NHHD. It is unknown what effect NHHD has on adherence or medication costs, and warrants further study in a prospective comparative investigation.

Gabapentin Withdrawal Syndrome in a Post–Liver Transplant Patient

ABSTRACTA 41-year-old male with a previous orthotopic liver transplant began experiencing insomnia, anxiety, diaphoresis, headaches, and palpitations that progressed over a 2-day period. As part of his home medication regimen, the patient was taking gabapentin for peripheral neuropathy. His acute onset of increasing symptoms coincided with an inadvertent discontinuation of gabapentin. After reinitiation of gabapentin therapy, the symptoms slowly improved over the next 24 hours and the episode of gabapentin withdrawal syndrome resolved.

Persistent Increase of Cardiac Troponin I in Plasma without Evidence of Cardiac Injury

A 69-year-old man with diabetes mellitus type II, hypertension, dyslipidemia, and prior ischemic strokes presented to the emergency department with complaints of balance difficulties and inability to stand unassisted of 2 weeks’ duration. The patient’s home medication regimen included atenolol, lisinopril, amlodipine, metformin, and glipizide. He is a retired chef and a former smoker (20 pack-years). He has 2 brothers, both of whom had myocardial infarctions in their 50s. The patient’s physical examination was remarkable for frequent premature contractions, left lower extremity weakness, and impaired coordination. His electrocardiogram revealed sinus rhythm with frequent premature ventricular contractions and diffuse nonspecific T-wave abnormalities. Results of a comprehensive metabolic chemistry panel were within the reference intervals except for increases in glucose (158 mg/dL; reference interval, 74–99 mg/dL) and creatinine (1.5 mg/dL; reference interval, 0.7–1.3 mg/dL). The hemoglobin A1c value was 7.4% (reference interval, <6.0%). Cardiac troponin I (cTnI)1 concentrations were increased at 0.27, 0.22, and 0.25 μg/L (Abbott Architect assay; 99th percentile, <0.03 μg/L) over a span of approximately 8 h. The patient was admitted to the cardiology service on the basis of these abnormal results. A transthoracic echocardiogram revealed a preserved left ventricular systolic function with evidence of impaired diastolic filling. A cardiac catheterization evaluation revealed an ulcerated plaque in the left anterior descending artery with >70% stenosis, which was treated with a bare-metal stent. The presenting symptom of balance difficulty failed to resolve after the coronary intervention, and the patient remained unable to stand unassisted. A neurologic evaluation included magnetic resonance imaging, which found no evidence of an acute stroke. He was discharged with a diagnosis of orthostatic hypotension. Three months later, the patient presented to the emergency department with several days of balance difficulty. The initial cTnI value was increased at 0.10 μg/L, prompting admission to the cardiology …

Medication Adherence in Cardiovascular Disease

A 66-year-old woman presents to the emergency department with crushing chest pain and ST-segment elevations on ECG. She has left ventricular systolic dysfunction (ejection fraction, 35%) after recent (6 days earlier) non–ST-segment elevation myocardial infarction treated with percutaneous coronary intervention, including 2 drug-eluting stents. She is sent for emergent cardiac catheterization, is found to have in-stent thrombosis, and subsequently is revascularized. After being transferred to the coronary care unit, she undergoes further workup. Before her previous admission, her home medication regimen included aspirin, lisinopril, atenolol, atorvastatin, spironolactone, furosemide, potassium, and sublingual nitroglycerin. At the time of her latest discharge, her medication regimen consisted of an increased dose of aspirin, the addition of clopidogrel, and a change in atenolol dose, in addition to all other previous medications. During the history and physical examination, it is discovered that she had not filled any of her new prescriptions after discharge from the hospital 5 days ago. She explains, “I already had all my drugs in my medicine cabinet at home.” Nonadherence to medications has been documented to occur in >60% of cardiovascular patients.1 Self-reported adherence to cardiovascular medications in patients who have coronary artery disease is <40% for the combination of aspirin, β-blocker, and a lipid-lowering agent in both isolated and long-term follow-up surveys2 (Table 1). View this table: Table 1. Adherence Rates to Common Cardiovascular Medications The immediate discharge period is a time of high risk for nonadherence. Nearly 1 in 4 patients is partially or completely nonadherent in filling prescriptions after discharge.3 Of the patients who are initially adherent, up to 50% will discontinue antihypertensive medications within …

Prevalence and Clinical Significance of Medication Discrepancies at Pediatric Hospital Admission

To quantify admission medication discrepancies in a tertiary-care, general pediatric population, to describe their clinical importance and associated factors, and to assess a screening approach to pharmacist involvement. A total of 272 patients were studied prospectively at hospital admission. The study pharmacist performed a medication history and compared it to physicians' admission medication orders. Discrepancies between the 2 were coded as intentional but undocumented or unintentional. Unintentional discrepancies were rated for potential to cause harm by 3 physicians. Additional data collected included patients' reason for admission and presence of chronic conditions, whether physicians used a medication reconciliation form, the characteristics of patients' home medication regimen, and the time required to perform a pharmacist history and reconciliation. Interrater reliability and associations between baseline characteristics and discrepancy rates were explored. Eighty patients (30%) had at least one undocumented intentional discrepancy (range, 0-7). At least one unintentional discrepancy (range, 0-9) was found in 59 patients (22%). Of the unintentional discrepancies, 23% had moderate and 6% had severe potential to cause discomfort or deterioration. Ratings were similar among the 3 physicians. Characteristics associated with higher risk of clinically important discrepancies were: use of the medication reconciliation form, > or =4 prescription medications, and antiepileptic drug use. Logistic regression revealed that only the variable > or =4 medications was independently associated with clinically important discrepancies. Admission medication errors are common in this tertiary-care, general pediatric population, and nearly a third represent potential adverse events. The use of a medication reconciliation form by physicians without pharmacist involvement does not appear to reduce errors. A cutoff of > or =4 prescription medications is highly sensitive for identifying patients at risk of clinically important discrepancies.