BACKGROUND: Atrial fibrillation (AF) affects a significant proportion of the American population and increases ischemic stroke risk by 4- to 5-fold. Oral vitamin K antagonists, such as warfarin, can significantly reduce this stroke risk but can be difficult to dose and monitor. Previous research on the effects of setting (e.g., randomized controlled trials, anticoagulation management by specialty clinics, usual care by community physicians) on the proportion of time spent within therapeutic range for the international normalized ratio (INR) has not specifically examined anticoagulation in AF patients. OBJECTIVES: Use traditional meta-analytic and meta-regressive techniques to evaluate the effect of specialty clinic versus usual care by community physicians on anticoagulation control, measured as the proportion of time spent in therapeutic INR range, for AF patients that received warfarin anticoagulation in the United States. METHODS: Studies included in a previously published meta-analysis (van Walraven et al., 2006), which systematically searched reports between

https://www.jmcp.org/doi/pdf/10.18553/jmcp.2009.15.3.244

Meta-Analysis to Assess the Quality of Warfarin Control in Atrial Fibrillation Patients in the United States

The formation of a bezoar is a relatively infrequent disorder that affects the gastrointestinal system. Bezoars are mainly classified into four types depending on the material constituting the indigestible mass of the bezoar: phytobezoars, trichobezoars, pharmacobezoars, and lactobezoars. Gastric bezoars often cause ulcerative lesions in the stomach and subsequent bleeding, whereas small intestinal bezoars present with small bowel obstruction and ileus. A number of articles have emphasized the usefulness of Coca-Cola® administration for the dissolution of phytobezoars. However, persimmon phytobezoars may be resistant to such dissolution treatment because of their harder consistency compared to other types of phytobezoars. Better understanding of the etiology and epidemiology of each type of bezoar will facilitate prompt diagnosis and management. Here we provide an overview of the prevalence, classification, predisposing factors, and manifestations of bezoars. Diagnosis and management strategies are also discussed, reviewing mainly our own case series. Recent progress in basic research regarding persimmon phytobezoars is also briefly reviewed.

Review of the diagnosis and management of gastrointestinal bezoars

verrue c., mehuys e., boussery k., remon j.-p. & petrovic m. (2010) Tablet-splitting: a common yet not so innocent practice. Journal of Advanced Nursing 67(1), 26–32.

Abstract
Aim.  This paper is a report of a study conducted to quantify (i) the mean deviation from theoretical weight and (ii) the mean weight loss, after tablet-splitting with three different, commonly used splitting methods.

Background.  Tablet-splitting is a widespread practice among all sectors of health care for different reasons: it increases dose flexibility, makes tablet parts easier to swallow and allows cost savings for both patients and healthcare providers. However, the tablet parts obtained are often not equal in size, and a substantial amount of tablet can be lost during splitting.

Method.  Five volunteers were asked to mimic the situation in nursing homes and to split eight tablets of different sizes and shapes using three different routine methods: (i) with a splitting device (Pilomat®), (ii) with scissors for unscored tablets or manual splitting for scored tablets and (iii) with a kitchen knife. Before and after splitting, tablets and tablet parts were weighed using an analytical balance. The data were collected in 2007.

Results.  For all tablets, method 1 gave a statistically significantly lower mean deviation from theoretical weight. The difference between method 2 and method 3 was not statistically significant. When pooling the different products, method 1 also induced significantly less weight loss than the two other methods.

Conclusion.  Large dose deviations or weight losses can occur while splitting tablets. This could have serious clinical consequences for medications with a narrow therapeutic-toxic range. On the basis of the results in this report, we recommend use of a splitting device when splitting cannot be avoided.

Tablet‐splitting: a common yet not so innocent practice

Biotechnology: Pharmaceutical Aspects

Anecdotal reports of adverse drug reactions are generally regarded as being of poor evidential quality. This is especially relevant for postmarketing drug safety surveillance, which relies heavily on spontaneous anecdotal reports. The numerous limitations of spontaneous reports cannot be overemphasised, but there is another side to the story: these datasets also contain anecdotal reports that can be considered to describe definitive adverse reactions, without the need for further formal verification. We have previously defined four categories of such adverse reactions: (i) extracellular or intracellular tissue deposition of the drug or a metabolite; (ii) a specific anatomical location or pattern of injury; (iii) physiological dysfunction or direct tissue damage demonstrable by physicochemical testing; and (iv) infection, as a result of the administration of an infective agent as the therapeutic substance or because of demonstrable contamination. In this article, we discuss the implications of these definitive ('between-the-eyes') adverse effects for pharmacovigilance.

Gold standards in pharmacovigilance: the use of definitive anecdotal reports of adverse drug reactions as pure gold and high-grade ore.

Beta-lactamase inhibitors enhance the activity of beta-lactam antibacterials against beta-lactamase-producing bacteria. These agents cause irreversible inhibition of many plasmid-mediated and some chromosomal beta-lactamases. They result in successful inhibition of beta-lactamases produced by gram-positive bacteria including Staphylococcus aureus, and gram-negative bacteria including H. influenzae, Neisseria gonorrhoeae, Moraxella catarrhalis, Bacteroides fragilis, and some Enterobacteriaceae. Because the beta-lactamase inhibitors are generally less effective against chromosomally mediated type 1 beta-lactamases, many Citrobacter, Enterobacter, Morganella, and Serratia spp., and Pseudomonas aeruginosa are resistant to them. Clavulanic acid, sulbactam, and tazobactam are beta-lactamase inhibitors. Whereas clavulanic acid is used in combination with amoxicillin and ticarcillin, sulbactam sodium is used in combination with ampicillin and cefoperazone, and tazobactam in combination with piperacillin …

Beta-Lactamase Inhibitors

Cefaclor

OBJECTIVE:To evaluate the effects of tablet splitting on low-density lipoprotein (LDL) cholesterol and total cholesterol values in patients taking simvastatin and atorvastatin.DESIGN:A retrospective chart review of total cholesterol and LDL cholesterol values of patients instructed to split simvastatin or atorvastatin between January 1999 and November 2000.SETTING:Veterans Affairs Medical Center in Huntington, WV.PATIENTS:Patients were included if they were taking simvastatin or atorvastatin with regular lipid management and follow-up laboratory results. Patients were required to remain on the same milligram-per-day dose at least 6–8 weeks before and after tablet-splitting initiation and have cholesterol values drawn at least 6 weeks after initiation of both whole-tablet and half-tablet dosing. Patients were excluded if they had a triglyceride level >400 mg/dL or were noncompliant on the basis of pharmacy records and provider notes.MEASUREMENT OUTCOMES:The primary end points were changes in total choleste...

Effect of Tablet Splitting on Serum Cholesterol Concentrations

OBJECTIVE:To describe a case of a medication bezoar and to review the clinical presentation, diagnosis, risk factors, pathogenesis, complications, and treatment of medication bezoars.DATA SOURCES AND STUDY SELECTION:A MEDLINE search (January 1966–December 1997) of the English-language literature pertaining to bezoars was performed. These articles were scanned, and literature specifically discussing medication bezoars was selected. Additionally, the reference sections of pertinent review and case reports were scanned for additional relevant literature.DATA SYNTHESIS:Bezoars are concretions of foreign material within the body. In the case of medication bezoars, these concretions occur within the digestive tract and are composed of medications and/or medication vehicles. Rarely, however, is bezoar formation solely due to a medication. In nearly all reported cases the patient had one or more significant risk factors that contributed to bezoar formation. The exact method by which medication bezoars form is dep...

Medication Bezoars: A Literature Review and Report of a Case

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Beta-Lactamase Inhibitors

Cefaclor

Effect of Tablet Splitting on Serum Cholesterol Concentrations

Medication Bezoars: A Literature Review and Report of a Case