Annals of Pharmacotherapy

Changes in bronchial osmolarity is a well-known factor for bronchoconstriction. Recently, nonisotonic aerosols have begun to be used for the assessment of bronchial hyperreactivity. Hypertonic KCl can cause bronchoconstriction even in non-symptomatic asthmatic patients.

To evaluate the protective role of heparin on hypertonic KCl-induced bronchospasm in asthma.

Thirty-eight asthmatic patients were included in this double-blind, placebo-controlled study. On day 1 of the study, after performing the respiratory function test (RFT), patients had inhaled KCl 10% and RFTs were done after 20 minutes. On day 2 of the study, after the basal RFT, 18 patients inhaled NaCl 0.9% 0.2 mL/kg solution. After the completion of this procedure, patients waited for 20 minutes and inhaled KCl 10% 10 mL, and RFTs were repeated 20 minutes later. The second group consisted of 20 patients who inhaled heparin 1000 units/kg after the RFTs were performed. Twenty minutes later, they inhaled KCl 10% and waited for 20 minutes. Finally, RFTs were done and compared with those from the other group.

In the control group, forced expiratory volume in one second (FEV₁) decreased 17.4% on day 1 and 16.4% on day 2. In the heparin-treated group, FEV₁ decreased 18.6% on day 1, but almost no change occurred after this group was treated with heparin before inhalation of hypertonic KCl on day 2.

Heparin was found to be highly protective against hypertonic KCl—induced bronchospasm in bronchial asthma.

To identify potential adverse drug events (ADEs) in a geriatric ambulatory population using the modified Beers criteria.

This is a cross-sectional study of an indigent and homeless geriatric population served by a network of six primary healthcare clinics with clinical pharmacy services. Medical records of patients ≥65 years old visiting the clinics between December 1999 and April 2000 were retrospectively reviewed by a clinical pharmacist. Medications meeting the modified Beers criteria were evaluated for the most common drug classes involved, severity potential, and dose or disease state restrictions. Following the identification of medications meeting Beers criteria, the pharmacist left a written recommendation regarding use of alternative drugs or doses in the medical record. Physician acceptance of pharmacy recommendations was also evaluated.

Medical records of 146 patients (71.9% women, average age 72.6 ± 6.7 y) were reviewed. Overall, 52 patients (35.6%) had 70 medications with the potential for causing an ADE based on the modified Beers criteria. The most commonly identified medication classes were narcotic analgesics (20.0%), antihypertensives (20.0%), and antihistamines (14.3%). Fifteen of these medications (21.4%) had a high severity potential. Identified medications met the following modified Beers criteria: 41.4% were inappropriate in a specific disease state, 38.6% were inappropriate for the elderly, 10.0% exceeded maximum dosage guidelines, and 10.0% were inappropriate for both the elderly and the patient's disease state. Approximately 60% of pharmacy recommendations were accepted by physicians.

The modified Beers criteria are a useful tool for reviewing medical records to identify potential ADEs in an ambulatory geriatric population.

To explore how well physicians who treat hypertension know the indications and contraindications for particular antihypertensive therapies, and how closely their opinions and practice of hypertension treatment agree with national guidelines.

We surveyed by mail a stratified random sample of 10 000 US cardiologists, internists, and general/family practitioners. This survey explored their knowledge, attitudes, and practices with respect to the treatment of hypertension. Responses were compared with national guidelines and product labeling at the time of the survey. Results were stratified by physician specialty.

A total of 1023 physicians, or 10.2% of the sample, responded to the survey. Only 37.3% answered all four knowledge questions correctly, including 25.7% of general/family practitioners, 38.3% of internists, and 49.5% of cardiologists (p < 0.001). In their attitudes with respect to evaluating high blood pressure and establishing treatment goals, most respondents agreed with established guidelines. However, when asked how they would treat uncomplicated, mild hypertension, only 23% limited their selection to diuretics and β-blockers in accordance with the guidelines. Cardiologists in particular were more likely than internists or general/family practitioners to choose other drug classes, such as angiotensin-converting enzyme inhibitors or calcium-channel blockers.

The results of our survey suggest that national efforts to educate physicians about the increasingly complex armamentarium for hypertension, and to persuade them to base their prescribing on the results of randomized, controlled trials of primary prevention, must be continued.

To compare outcomes of care and antibiotic utilization for community-acquired pneumonia (CAP) throughout a group of not-for-profit hospitals.

A retrospective chart review of patients from community hospitals with a diagnosis of pneumonia at discharge admitted from December 1997 to May 1998. Data were collected based on American Thoracic Society (ATS) criteria.

Medical records of 330 patients were reviewed; mortality was 7%. Using ATS guidelines, 51 (15.5%) patients were not treated with recommended antimicrobial therapy. Of these patients, 14 had nonsevere cases of CAP and 37 cases were severe. Factors found to be associated with in-hospital mortality included nonadherence to ATS guidelines (OR 4.46; 95% CI 1.38 to 14.43), decreased urine output (OR 7.72; 95% CI 1.70 to 35.04), and increasing age (OR 1.06; 95% CI 1.01 to 1.12). Significant predictors of length of stay (LOS) included age, nonadherence to ATS criteria, suspected aspiration, discharge status, low pulse oximetry on admission, decreased urine output, use of vasopressor medications, and interstitial lung disease. More than 80% of patients had at least one culture performed, but only 27.5% of these cultures were positive. The most commonly prescribed antibiotic was cefuroxime injection, representing 25% of the antibiotic orders.

Patients with CAP treated inconsistently with ATS guidelines had a 4.46-fold higher risk of inpatient mortality and had significantly longer LOS.

To determine the cost and benefit of using RSV-IG and palivizumab as prophylactic therapy against respiratory syncytial virus (RSV)–associated illness in high-risk infants.

A nonrandomized, retrospective, cohort control study was conducted comparing the outcomes of patients who received either RSV-IG or palivizumab therapy against RSV during the 1998–1999 RSV season with patients identified from the 1994–1995 RSV season who would have been eligible to receive prophylaxis had either agent been available at that time. Medical record reviews were conducted to gather data regarding the costs associated with both the administration of the prophylactic drugs and the treatment of RSV-associated hospitalizations in both groups. Decision analysis was used to determine the average cost per patient for both groups. A cost—benefit analysis was then conducted to determine the return on investment, if any, for the use of these drugs. A sensitivity analysis was also conducted to determine the robustness of the data.

Patients who received RSV-IG or palivizumab had a hospitalization rate of 1.6% compared with 25% for the group who did not receive prophylactic drugs. The average costs for the RSV prophylaxis group were less per patient: $3733 compared with $4258 in the group who did not receive prophylaxis. The benefit is a 23.4% lower chance of hospitalization for each infant or, in dollar figures, $3985 ($17 031 × 0.234). The benefit—cost ratio is 1.15:1 ($3985:3461). The benefits, therefore, exceed the costs associated with the prophylaxis program. The prophylaxis program saved healthcare dollars by preventing RSV-related hospital-izations.

Results demonstrate that when used according to our institution's criteria, RSV prophylaxis is of benefit to our institution.

To report two cases of seizures following administration of levofloxacin and ciprofloxacin.

A 75-year-old white woman admitted to the hospital was prescribed levofloxacin for ischemic toes. After receiving three doses of oral levofloxacin, the patient experienced a seizure. One month later, the patient was rechallenged with ciprofloxacin and again experienced a seizure. The patient was hypomagnesemic and had elevated serum creatinine at the time of both seizures, and was hyponatremic during the second seizure. A 74-year-old white woman admitted to the hospital was prescribed levofloxacin for bacterial pneumonia. After five doses, the patient experienced a seizure. The woman had no electrolyte imbalances at the time of the seizure and no history of a seizure disorder.

Quinolone antibiotics vary in their ability to induce seizures, with trovafloxacin having the greatest potential and levofloxacin possibly having the least potential. Neither patient had a history of a previous seizure disorder. Electrolyte imbalances are common with previous reports of fluoroquinolone-induced seizures.

Although levofloxacin monotherapy has not been implicated in inducing seizures, it appears to be the causative agent in the second case. In the first case, the quinolones may have been a necessary, but not sufficient, cause in a patient with electrolyte abnormalities. Risk factors for fluoroquinolone-induced seizures may include seizure history, electrolyte imbalances, dose unadjusted for renal insufficiency, and concomitant treatment with agents that lower the seizure threshold.

To describe a patient who was stabilized on warfarin and developed an elevated international normalized ratio (INR) after drinking a concentrated Chinese herbal tea. Additionally, to determine the effect of the tea on CYP2C9, the isoenzyme responsible for the metabolism of S-warfarin.

An elevated INR of 4.1 was observed in a 61-year-old Chinese woman, previously stabilized on anticoagulation therapy (INR 2–3). With no changes in her other medications or lifestyle, a review of her dietary habits revealed four days of drinking a concentrated Chinese herbal tea made from Lycium barbarum L. fruits (3–4 glasses daily) prior to her clinic visit. Warfarin was withheld for one day and then resumed at a lower weekly dose. She discontinued the tea, while maintaining consistency with medications and dietary habits. A follow-up INR seven days later was 2.4, and seven subsequent INR values were in the 2.0–2.5 range.

L. barbarum L. (family Solanaceae) is a commonly used Chinese herb considered to have a tonic effect on various organs. Any impact of an herbal product on the metabolism of S-warfarin, the enantiomer responsible for most of the anticoagulant activity, could alter the INR values. An herbal—drug interaction was suspected in this case. In vitro evaluation showed inhibition of S-warfarin metabolism by CYP2C9 by the tea of L. barbarum L.; however, the inhibition observed was weak, with a dissociation constant (K_i) value of 3.4 mg/mL, suggesting that the observed interaction may be caused by factors other than the CYP450 system.

There is a potential herbal—drug interaction between warfarin and L. barbarum L., based on an increased INR value noted with concurrent use. Thus, combination of L. barbarum L. and warfarin should be avoided. Vigilance is needed with other herbal combinations taken with drugs of narrow therapeutic indices.

To report a case of increased international normalized ratio (INR) in a geriatric patient receiving warfarin and ropinirole.

A 63-year-old African-American man with a history of Parkinson disease, Alzheimer disease, and status postcardio-vascular accident was evaluated for symptoms of progressing stiffness and rigidity. Ropinirole was added to his current therapy for Parkinson disease, with a corresponding decrease in the dose of levodopa/carbidopa to allow levodopa sparing. On laboratory evaluation, he was noted to have an increased INR nine days after these adjustments; the INR had previously been stable. No other significant medication, social, or diet changes were noted. Warfarin was withheld for four days and restarted at approximately 75% of the previous weekly dose. The patient had no obvious signs of bleeding. Furthermore, the warfarin dose was again increased after discontinuation of ropinirole due to common gastrointestinal adverse effects.

Warfarin is an oral anticoagulant whose narrow therapeutic index and potential for drug interaction is well documented. It is always possible that a change in blood coagulability can occur without an obvious contributable cause; however, an acute change in a previously stable INR with the addition of other medications always raises questions as to the possible mechanism of adverse reaction. No previously documented interaction of this precise nature has been identified.

Ropinirole may elevate the anticoagulant effects of warfarin. Patients receiving warfarin should be considered for more frequent INR monitoring when ropinirole is added, adjusted, or discontinued from their medical regimen.

To report a patient developing hypertension following the use of testosterone gel.

A 65-year-old white man who was placed on topical testosterone therapy to increase libido developed hypertension and increased hematocrit simultaneously. After discontinuation of the testosterone, the hematocrit returned to mid-normal reference range and blood pressure returned to normal; he had been normotensive prior to topical testosterone use.

The popularity of hormone replacement for women for the maintenance of appearance and lifestyle and the prevention of complications such as osteoporosis has been established over several decades, and the complications and risks and benefits of this therapy have been well described. More recently, and particularly with the availability of topical preparations of testosterone, hormone replacement for men is becoming popular with both older male patients and their physicians. We describe a case of hypertension as a complication of the application of topical testosterone and link this adverse effect to the known anabolic effects of testosterone.

Clinicians should be cautious in prescribing topical preparations of testosterone for the proper administration by the patient and alert to the development of hypertension in this population at increased risk for cardiovascular events due to their age.

To report a case of Cushing syndrome associated with megestrol acetate therapy in a patient with renal insufficiency.

A 17-year-old boy with renal insufficiency due to unilateral renal agenesis developed Cushing syndrome and worsening of his renal function after megestrol acetate therapy. The diagnosis was based on clinical and analytical evaluation.

Megestrol acetate is indicated for the treatment of cachexia associated with AIDS and malignancy. Due to its glucocorticoid activity, megestrol use has resulted in the occurrence of Cushing syndrome in both patient groups. We report the case of a young patient with renal insufficiency due to unilateral renal agenesis who developed Cushing syndrome two months after administration of high-dose (900-mg/d) megestrol acetate for an eating disorder.

The risk of megestrol-induced Cushing syndrome, especially with high doses of the medication, should be considered as a possible adverse effect in patients with renal insufficiency.

To describe an adverse effect with intravenous codeine in a child diagnosed with sickle cell anemia.

A seven-year-old boy with sickle cell anemia was admitted to the emergency department with severe pain unresponsive to high doses of oral acetaminophen; subsequently, intravenous codeine phosphate was administered. The patient immediately developed a tonic—clonic seizure, which was treated with intravenous diazepam and naloxone.

Seizures associated with the intravenous administration of codeine phosphate have not been extensively reported in the literature, and special precautions for using the parenteral route for this drug have been vague and limited. Because of the frequent need for acute pain control in children with sickle cell crisis, they may be exposed to this type of reaction when intravenous narcotics are administered. The need for clear guidelines regarding the drug's appropriate parenteral dosing and administration is essential.

Codeine phosphate—induced seizures are not common. The need for special instructions for its intravenous administration may prevent this type of reaction, especially in patients in need of acute pain control requiring intravenous narcotics.

To report a case of inflammatory bowel disease (IBD) associated with use of isotretinoin.

A 17-year-old boy presented with new-onset rectal bleeding after completion of a five-month course of isotretinoin. A diagnosis of ulcerative colitis was made. His condition worsened despite therapy with 5-aminosalicylic acid, steroid retention enema, iron supplement, and prednisone. Five months after the onset of rectal bleeding, he had lost 11.4 kg and developed bilateral pitting edema of the hips and profound anemia. A subtotal colectomy and ileostomy was performed.

Rectal bleeding has been reported to occur during or up to several years after treatment with isotretinoin. The mechanism by which isotretinoin may induce IBD is unknown. Proposed mechanisms include inhibition of epithelial cell growth resulting in ulceration and inflammation of the gut mucosa, inhibition of glycoprotein synthesis affecting the integrity of the mucosal wall, and stimulation of killer T cells, leading to epithelial cell injury and a resultant inflammatory response.

This case of probable isotretinoin-induced IBD suggests that patients with suspected IBD should be asked about current or past use of isotretinoin to improve documentation of this serious adverse event.

To document a case of serotonin syndrome associated with the combined use of fluvoxamine and mirtazapine, and to discuss the pharmacodynamic and pharmacokinetic interactions that were the likely causes of this potentially serious adverse drug reaction (ADR).

A 26-year-old white woman with a 12-year history of anorexia nervosa was being treated with fluvoxamine. After mirtazapine was added to her therapy, she developed tremors, restlessness, twitching, flushing, diaphoresis, and nausea, symptoms that are consistent with serotonin syndrome.

The possible causes of this ADR are discussed, including the effects of fluvoxamine and mirtazapine alone, the possible pharmacodynamic and pharmacokinetic interactions of these two drugs, and the patient's underlying anorexia nervosa.

An increasing number of drugs that affect serotonin are available and are indicated for various disorders. Since there is a significant likelihood of these agents being prescribed concomitantly, clinicians must be aware of possible interactions that could lead to serotonin syndrome.

To report two cases of interaction between fluvoxamine and mirtazapine.

A 17-year-old boy was treated with mirtazapine 30 mg/d. The addition of fluvoxamine 100 mg/d to the regimen caused a threefold increase in the mirtazapine concentration. This interaction was associated with increased anxiety. A second patient, a 43-year-old woman, was treated with mirtazapine 15 mg/d. There was a fourfold increase in her mirtazapine concentration and simultaneous mood improvements after augmentation with fluvoxamine 50 mg/d.

This is the first report of any interaction between fluvoxamine and mirtazapine. Mirtazapine is mainly metabolized by cytochrome P450 isoenzymes CYP1A2, CYP2D6, and CYP3A4. Fluvoxamine and cimetidine inhibit the same isoenzymes, but fluvoxamine is probably the only agent that causes a clinically significant interaction.

Adding fluvoxamine to treatment with mirtazapine may cause a significant increase in mirtazapine concentration. This interaction may necessitate adjustment of the mirtazapine dosage.

To assess the current evidence of the value of cycling of antimicrobials to control the emergence of resistance or to reverse existing resistance to antimicrobials.

Articles were obtained through a MEDLINE search of the English-language literature from 1966 to January 2000. Additionally, references from retrieved publications were reviewed to identify further articles.

All investigations of switching between or cycling among antimicrobials were evaluated. Studies switching between or cycling among specific drugs or classes of drugs within institutional settings were included in this review.

Studies involving cycling among different aminoglycosides suggest that, although temporary decreases in resistance can be documented, resistance usually rebounds rapidly on completion of the cycle and return to the original agent. Switching between classes of antimicrobials has produced inconsistent results and has been shown to replace resistance to one agent with resistance to another. Mathematical models using both in vitro and clinical data have suggested that, due to residual resistance in the population, cycling among drug classes is unlikely to yield long-term reductions in antimicrobial resistance, especially if a high level of antimicrobial resistance exists.

Cycling among different antimicrobials to reverse resistance trends is currently not supported by published literature. Cycling to prevent the emergence of resistance may ultimately be more useful; however, no studies have evaluated this concept. Well-designed prospective studies are needed to evaluate the potential clinical value of antimicrobial cycling.

To describe the pharmacology, pharmacokinetics, efficacy, and safety of tenecteplase in reducing mortality associated with acute myocardial infarction (AMI).

Published articles were identified from MEDLINE (from 1966 to December 2000) and Current Contents (all sections) searches.

Dose-ranging and pivotal studies were included for analysis in the clinical trials section.

Tenecteplase is a third-generation thrombolytic indicated for the reduction of mortality associated with AMI. Tenecteplase has a longer half-life that allows for single-dose, intravenous bolus administration. Data from clinical trials support that tenecteplase is similar to alteplase in reducing 30-day mortality rates in patients who have had an AMI. In the ASSENT-2 (Assessment of the Safety and Efficacy of a New Thrombolytic) trial, patients treated with tenecteplase required fewer blood transfusions and experienced fewer episodes of noncerebral bleeding compared with those treated with alteplase.

Tenecteplase is an effective thrombolytic agent for the treatment of AMI. It can be given as a single weight-based dose; however, it appears to offer no significant advantage over other agents in terms of its efficacy or rate of intracranial hemorrhage.

To review and summarize the efficacy, mechanisms of action, and cost of the options available when choosing antiplatelet agents for secondary stroke prevention.

This article is based on a review of the literature found with MEDLINE, CINAHL, and Cochrane Reviews (1980–June 2000) and abstracts from relevant international scientific meetings. We searched for the terms aspirin, ticlopidine, dipyridamole, antiplatelet, and clopidogrel.

English-language articles, both reviews and original studies, were evaluated, and all information considered relevant was included in this review. In addition, guidelines from the American Heart Association are included.

Aspirin is a relatively inexpensive and effective agent for secondary stroke prevention, and lower doses of aspirin appear as effective as higher doses. Ticlopidine has been used alone or in combination with aspirin, but serious adverse effects have limited its use. Clopidogrel has emerged as a safe and effective alternative to ticlopidine and lacks some of the serious adverse effects associated with ticlopidine, but is not superior to aspirin in secondary stroke prevention. Unlike previous studies, one recent trial showed that dipyridamole in combination with aspirin is superior to aspirin alone.

Antiplatelet therapy is a key component of secondary prevention strategies in ischemic stroke. While aspirin has been the cornerstone in the management of stroke, other classes of antiplatelet drugs present new opportunities to optimize antiplatelet therapy.

To delineate amiodarone's role in the new American Heart Association guidelines for ventricular tachyarrhythmias, review the literature that supports the use of amiodarone in ventricular tachyarrhythmias, describe the pharmaceutical properties of amiodarone and elucidate their clinical implications, and discuss the dosing, preparation, and administration of amiodarone.

A search of MEDLINE (1966–October 2000) database and EMBASE Drugs and Pharmacology database (1980–October 2000) was performed. References from published articles and tertiary references were used to gather additional data.

All articles were screened, and pertinent studies were identified and evaluated.

Recent trials have demonstrated amiodarone's usefulness in the setting of ventricular tachyarrhythmias. Based on these investigations and contrary to past guidelines, amiodarone is included in the 2000 advanced cardiovascular life support guidelines as a possible agent for hemodynamically stable monomorphic ventricular tachycardia (VT), non-QT prolonged polymorphic VT, and ventricular fibrillation (VF)/pulseless VT. Although not specifically evaluated in the setting of hemodynamically stable monomorphic VT and non-QT prolonged polymorphic VT, investigations by the Intravenous Amiodarone Multicenter Trial Group and other clinical trials make amiodarone an acceptable choice for these arrhythmia categories. The results of the ARREST (Resuscitation of Refractory Sustained Ventricular Tachyarrhythmias) trial prove amiodarone to be the antiarrhythmic of choice for VF/pulseless VT.

Amiodarone is classified as a IIb therapeutic intervention for all three arrhythmia categories, which makes it an acceptable, safe, and useful agent with fair to good evidence to support its use. In addition, amiodarone requires careful preparation and delivery to achieve safe and effective outcomes.

To review the literature regarding the prevention of catheter colonization and catheter-related bloodstream infections (CRBIs) with the use of antimicrobial-coated/bonded and -impregnated intravascular catheters.

Primary and review English-language literature were identified using MEDLINE (1966–September 2000) pertaining to the key terms antibiotic, antimicrobial, antiseptic, silver, and bonded, coated, impregnated catheters. In addition, textbooks and relevant reference lists were reviewed.

All articles identified through the data sources were evaluated. Information deemed relevant to the objectives of the review was included.

Significant morbidity and mortality are associated with the development of CRBIs. Preventative measures such as modification of these catheters with antimicrobial coating/bonding have produced varying results. Trials evaluating cefazolin, teicoplanin, vancomycin, silver, and chlorhexidine—silver sulfadiazine (C-SS) used for coated/bonded intravascular catheters have not demonstrated a consistent decrease in the incidence of CRBIs. However, a meta-analysis of trials evaluating C-SS intravascular catheters demonstrated a statistically significant reduction in CRBIs. A larger reduction in CRBIs has been reported with minocycline—rifampin (M-R) versus C-SS intravascular catheters. Use of the M-R and C-SS catheters may result in a cost savings of $100 million and reduce as many as 12 000 CRBI-related deaths annually when used short term (<7 d).

When used for short-term catheterization, M-R catheters appear to be superior to the currently available C-SS catheters at preventing CRBIs. Significant cost savings and reduction in mortality can be anticipated with the use of M-R catheters.

To review the effectiveness data on the use of gabapentin in bipolar disorders.

Clinical literature was accessed through MEDLINE (January 1985–November 2000). Key search terms included gabapentin, mood stabilizer, and bipolar disorder.

Bipolar disorder is a complex condition that can be difficult to treat effectively. Mood stabilizers are increasingly being used to manage bipolar disorder. Studies that used gabapentin in bipolar disorders are evaluated.

From the data presented, gabapentin cannot be recommended for treatment of bipolar disorder. Further studies are required to determine whether gabapentin has any role in the management of bipolar disorder.

To evaluate ondansetron as a treatment for bulimia nervosa.

Literature was accessed through MEDLINE (1966–November 2000). Key terms included ondansetron, bulimia nervosa, binge eating, and eating disorders.

Treatment of bulimia nervosa includes cognitive behavioral therapy and antidepressants. Fluoxetine is approved by the Food and Drug Administration for binge eating and vomiting behaviors in moderate to severe bulimia nervosa. An evaluation of ondansetron for bulimia nervosa was conducted.

Ondansetron for bulimia nervosa was reported to be effective in three small trials by one group of investigators, and may be an option after failure of traditional therapies. Further studies will define the role of serotonin (5-HT₃) receptor antagonists in the management of bulimia nervosa.

To review the literature examining the clinical use of leukotriene receptor antagonists in the treatment of allergic rhinitis.

Biomedical literature accessed through MEDLINE (1990–November 2000) and Current Contents (week 35 of 1999 to week 48 of 2000). Key terms included leukotriene antagonists, montelukast, zafirlukast, and rhinitis (allergic).

Preliminary evidence on the clinical use of either montelukast or zafirlukast as monotherapy is equivocal, with one study noting benefit and another noting lack of benefit in symptom amelioration. A third study suggests that these agents may have a role in further modifying allergic rhinitis symptoms when used in combination with standard treatments.

Future large-scale studies should assess the efficacy of these agents in the treatment of allergic rhinitis, in particular, to identify subsets of patients likely to derive the most benefit. Available data suggest it is reasonable and safe to add these agents to standard therapy if symptomatology remains unresolved.

To examine the role of fenoldopam in prevention of contrast media—induced acute renal failure (ARF).

A literature search of MEDLINE (from 1966 to October 2000) was performed using the following title search terms: fenoldopam, contrast, and renal failure.

English-language human studies, abstracts, and pertinent animal data were reviewed.

Small trials using animals with artificially induced ARF receiving fenoldopam demonstrated improvement in renal function. Preliminary trials in healthy humans have also demonstrated similar results using doses not affecting systemic blood pressure.

Fenoldopam may have a role in the management of ARF induced by contrast dye. However, due to the lack of a large-scale study, it cannot be routinely recommended.

To investigate the knowledge and practice among private pharmacy staff in Hanoi regarding case management of mild acute respiratory infection (ARI) in children.

Sixty private pharmacies in Hanoi were randomly selected. Knowledge was assessed through interviews with pharmacy staff using a questionnaire; practice was assessed through the Simulated Client Method.

In the questionnaire, 20% of the pharmacy staff stated that they would dispense antibiotics. In practice, 83% of the pharmacies dispensed antibiotics. Only 36% of the cases were handled according to guidelines. In the questionnaire, 81% of interviewees stated that antibiotics are not effective in short therapeutic courses. In practice, 48% of the antibiotics were dispensed in courses less than five days. Traditional herbal medicines were dispensed in 41% of the encounters. In the questionnaire, 53% of the pharmacy staff stated that they would ask the patient about difficulty of breathing. In practice, questions related to difficulty of breathing were asked in less than 10% of the encounters.

Dispensing of antibiotics for mild ARI was common practice among private pharmacies, and there was a significant difference between knowledge and practice. Interventions are needed to improve pharmacy practice in Hanoi.