Anemia and inflammatory bowel diseases.

World J Gastroenterol. 2009 Oct 7;15(37):4659-65

Authors: Gomollón F, Gisbert JP

Too often anemia is considered a rare or unimportant manifestation in inflammatory bowel disease (IBD). However, over the last 10 years a number of studies have been conducted and the most relevant conclusions obtained are: (1) anemia is quite common in IBD; (2) although in many cases anemia parallels the clinical activity of the disease, many patients in remission have anemia, and iron, vitamin B12 and/or folic acid deficiency; (3) anemia, and also iron deficiency without anemia, have important consequences in the clinical status and quality of life of the patient; (4) oral iron can lead to gastrointestinal intolerance and failure of treatment; (5) intravenous iron is an effective and safe way to treat iron deficiency; (6) erythropoietin is needed in a significant number of cases to achieve normal hemoglobin levels. Thus, the clinician caring for IBD patients should have a comprehensive knowledge of anemia, and apply recently published guidelines in clinical practice.

PMID: 19787829 [PubMed - in process]

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Mortality and need for mechanical ventilation in acute exacerbations of chronic obstructive pulmonary disease: development and validation of a simple risk score.

Arch Intern Med. 2009 Sep 28;169(17):1595-602

Authors: Tabak YP, Sun X, Johannes RS, Gupta V, Shorr AF

BACKGROUND: Acute exacerbations of chronic obstructive pulmonary disease (AECOPDs) often require hospitalization, may necessitate mechanical ventilation, and can be fatal. We sought to develop a simple risk score to determine its severity. METHODS: We analyzed 88,074 subjects admitted with an AECOPD between 2004 and 2006. We used recursive partition to create risk classifications for in-hospital mortality. Need for mechanical ventilation served as a secondary end point. We internally validated the model via 1000 bootstrapping on half of patients and externally validated it on the remaining patients. We assessed predictive ability using the area under the receiver operating curve (AUROC). RESULTS: The in-hospital mortality rate was 2%. Three variables had high discrimination of outcomes: serum urea nitrogen level greater than 25 mg/dL (to convert to millimoles per liter, multiply by 0.357); acute mental status change, and pulse greater than 109/min. For those without any of the 3 factors, age 65 years or younger further differentiated the lowest-risk group. In those with all 3 factors, the mortality rates were 13.1% (131 in 1000) and 14.6% (146 in 1000) in the derivation and validation cohorts, respectively, compared with 0.3% (3 in 1000) in both cohorts among patients without any of the 3 factors and age 65 years or younger (P < .001). The AUROC for mortality in the 2 cohorts were 0.72 (95% confidence interval [CI], 0.70-0.74) and 0.71 (95% CI, 0.70-0.73), respectively. For mechanical ventilation, the AUROCs were 0.77 (95% CI, 0.75-0.79) for both cohorts. CONCLUSIONS: A simple risk class based on clinical variables easily obtained at presentation predicts mortality and need for mechanical ventilation. It may facilitate the triage and care of patients with AECOPD.

PMID: 19786679 [PubMed - in process]

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Carriage rate of carbapenem-resistant Klebsiella pneumoniae in hospitalised patients during a national outbreak.

J Hosp Infect. 2009 Sep 25;

Authors: Wiener-Well Y, Rudensky B, Yinnon AM, Kopuit P, Schlesinger Y, Broide E, Lachish T, Raveh D

During a national outbreak of carbapenem-resistant Klebsiella pneumoniae (CRKP) in Israel, we conducted a point prevalence survey to determine the extent of asymptomatic carriage. Subsequently, a retrospective case-control study was done, comparing carriers of CRKP with non-carriers, in order to detect risk factors for carriage. Oral, perianal and rectal swabs were obtained from all hospitalised eligible and consenting patients. Selective media for carbapenem-resistant Gram-negative bacteria were used and pulsed-field gel electrophoresis (PFGE) helped to determine clonal source. Culture was obtained from 298 patients. Sixteen (5.4%) were carriers of CRKP, with a higher carriage rate in medical and surgical wards. Only 18% of carriers were treated with any carbapenem prior to the survey. Five of the 16 carriers had a positive clinical specimen for CRKP, hence a clinical infection versus asymptomatic carriage ratio of 1:3. The rectum was the most sensitive site sampled, detecting 15/16 carriers, and the overall sensitivity of the method was 94% with a negative predictive value of 99.6%. In a multivariate analysis of risk factors for CRKP carriage, three variables were significantly related to carriage state: diaper use, longer duration of hospital stay and vancomycin use. PFGE demonstrated that all 16 isolates were identical, confirming clonal origin. A point prevalence survey performed at a single medical centre during an outbreak of CRKP demonstrated a carriage rate of 5.4%. The clonal origin of these isolates suggests that strict adherence to isolation procedure may contain this outbreak.

PMID: 19783067 [PubMed - as supplied by publisher]

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Office management of deep venous thrombosis in the elderly.

Am J Med. 2009 Oct;122(10):904-6

Authors: Jacobs LG, Billett HH

Deep venous thrombosis is common in the elderly. Diagnosis and management are now a part of office practice. As signs and symptoms are inconsistent and nonspecific, diagnostic testing is necessary. For patients with a low clinical probability, a normal D-dimer result can rule out disease. For patients with a high clinical suspicion or an elevated D-dimer, duplex ultrasonography may confirm the diagnosis. Anticoagulation, usually with low-molecular-weight heparin, should begin on suspicion and continue, along with warfarin, until the international normalized ratio is therapeutic. Arrangements for the initial daily injections can be made with a visiting nurse. Treatment should continue for at least 3 months, when a risk-versus-benefit analysis for continuing anticoagulation should be undertaken. Therapy may be discontinued for thromboses associated with a reversible risk factor or for patients in whom anticoagulant management was unstable or complicated by bleeding. A persistently high D-dimer result or evidence of residual clot on repeat duplex ultrasonography may support continuation. For all patients, the use of compression stockings to prevent the post-thrombotic syndrome is recommended.

PMID: 19786156 [PubMed - in process]

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Molecular epidemiology of Clostridium difficile over the course of 10 years in a tertiary care hospital.

Clin Infect Dis. 2009 Oct 15;49(8):1141-7

Authors: Belmares J, Johnson S, Parada JP, Olson MM, Clabots CR, Bettin KM, Peterson LR, Gerding DN

BACKGROUND: The molecular epidemiology of endemic and outbreak Clostridium difficile strains across time is not well known. METHODS: HindIII restriction endonuclease analysis (REA) typing was performed on available clinical C. difficile isolates from 1982 to 1991. RESULTS: The annual incidence of C. difficile infection (CDI) ranged from 3.2 to 9.9 cases per 1000 discharges and was significantly higher in 1982, 1983, 1985, and 1991 (high-incidence years) than in other years (mean standard deviation number of cases for the high- vs the low-incidence years, 121.8 +/-20.4 and 70.0 +/-15.0; P =.002). A total of 696 (76.6%) of 908 C. difficile isolates were available for REA typing over the 10-year period. Large clusters (>or=10 CDI cases in consecutive months) were caused by REA types B1 and B2 in 1982 and 1983, F2 and B1 in 1985, and K1 in 1991 (high-incidence years). Small clusters of 4-9 CDI cases in consecutive months were caused by REA types G1 (1984), Y4 and Y6 (1987), Y2 (1988), L1 (1989), Y1 (1990), and K1 (1991). Current epidemic REA group BI (unrelated to type B1) was isolated 6 times, twice in 1984, 1988, and 1990. CONCLUSIONS: Years with a high incidence of CDI were associated with large clusters of specific REA types that changed yearly. The molecular epidemiology of CDI in this hospital was characterized by a wide diversity of C. difficile types and an ever-changing dominance of specific C. difficile types over time. The current epidemic BI group was found sporadically on 6 occasions. A changing CDI molecular epidemiology should be expected in the future.

PMID: 19780659 [PubMed - in process]

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Related Articles

Acute effects of statin therapy on coronary atherosclerosis following an acute coronary syndrome.

Am J Cardiol. 2009 Sep 15;104(6):750-7

Authors: Rodés-Cabau J, Tardif JC, Cossette M, Bertrand OF, Ibrahim R, Larose E, Grégoire J, L'allier PL, Guertin MC

No data exist on the acute effects of statin therapy on human coronary atherosclerotic plaques. The objective of our study was to evaluate the early (<2 months) effects of newly initiated statin therapy on coronary atherosclerosis as evaluated by intravascular ultrasonography. The study population consisted of 74 patients (mean age 58 +/- 8 years) who had been included in the ERASE trial (evaluating the effects of reconstituted high-density lipoprotein infusions). All patients underwent serial intravascular ultrasonographic (IVUS) evaluation at baseline (3 +/- 2 days after an acute coronary syndrome [ACS]) and after 6 +/- 1 weeks of follow-up. Statin therapy was initiated after ACS in 36 patients who received < or =1 dose of statins before baseline IVUS examination (newly initiated statin therapy group), and 38 patients were already on a stable statin dose before the ACS (long-term statin therapy group). Atorvastatin at a dose of 40 mg/day was the most common regimen in the 2 groups. Percent changes in atheroma volume (prespecified primary efficacy parameter) were -4.71 +/- 0.96% in the newly initiated statin therapy group (p <0.0001) and -0.54 +/- 0.89% in the long-term statin therapy group (p = 0.546; p = 0.002 for comparison between groups). Median nominal changes in atheroma volume were -9.10 mm(3) (interquartile range -12.56 to -3.73, p <0.0001 vs baseline) and 1.21 mm(3) (interquartile range -6.41 to 3.76, p = 0.429 vs baseline) in the newly initiated and long-term statin therapy groups, respectively (p = 0.003 for comparison between groups). Greater decreases in total cholesterol (r = 0.25, p = 0.035), ratio of total to high-density lipoprotein cholesterol (r = 0.28, p = 0.018), and high-sensitivity C-reactive protein (r = 0.31, p = 0.046, for patients with high-sensitivity C-reactive protein measurements within 7 days after IVUS examination) were associated with larger percent changes in atheroma volume. In conclusion, newly initiated statin therapy is associated with rapid regression of coronary atherosclerosis within 2 months. This effect was in part associated with decreases in atherogenic lipid and inflammatory parameters. These results provide insight into the rapid clinical benefits of statin therapy after an ACS.

PMID: 19733706 [PubMed - indexed for MEDLINE]

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Related Articles

Errors and omissions in hospital prescriptions: a survey of prescription writing in a hospital.

BMC Clin Pharmacol. 2009;9:9

Authors: Calligaris L, Panzera A, Arnoldo L, Londero C, Quattrin R, Troncon MG, Brusaferro S

BACKGROUND: The frequency of drug prescription errors is high. Excluding errors in decision making, the remaining are mainly due to order ambiguity, non standard nomenclature and writing illegibility. The aim of this study is to analyse, as a part of a continuous quality improvement program, the quality of prescriptions writing for antibiotics, in an Italian University Hospital as a risk factor for prescription errors. METHODS: The point prevalence survey, carried out in May 26-30 2008, involved 41 inpatient Units. Every parenteral or oral antibiotic prescription was analysed for legibility (generic or brand drug name, dose, frequency of administration) and completeness (generic or brand name, dose, frequency of administration, route of administration, date of prescription and signature of the prescriber). Eight doctors (residents in Hygiene and Preventive Medicine) and two pharmacists performed the survey by reviewing the clinical records of medical, surgical or intensive care section inpatients. The antibiotics drug category was chosen because its use is widespread in the setting considered. RESULTS: Out of 756 inpatients included in the study, 408 antibiotic prescriptions were found in 298 patients (mean prescriptions per patient 1.4; SD +/- 0.6). Overall 92.7% (38/41) of the Units had at least one patient with antibiotic prescription. Legibility was in compliance with 78.9% of generic or brand names, 69.4% of doses, 80.1% of frequency of administration, whereas completeness was fulfilled for 95.6% of generic or brand names, 76.7% of doses, 83.6% of frequency of administration, 87% of routes of administration, 43.9% of dates of prescription and 33.3% of physician’s signature. Overall 23.9% of prescriptions were illegible and 29.9% of prescriptions were incomplete. Legibility and completeness are higher in unusual drugs prescriptions. CONCLUSION: The Intensive Care Section performed best as far as quality of prescription writing was concerned when compared with the Medical and Surgical Sections.Nevertheless the overall illegibility and incompleteness (above 20%) are unacceptably high. Values need to be improved by enhancing the safety culture and in particular the awareness of the professionals on the consequences that a bad prescription writing can produce.

PMID: 19439066 [PubMed - indexed for MEDLINE]

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Antioxidant therapy in the management of acute, chronic and post-ERCP pancreatitis: A systematic review.

World J Gastroenterol. 2009 Sep 28;15(36):4481-90

Authors: Mohseni Salehi Monfared SS, Vahidi H, Abdolghaffari AH, Nikfar S, Abdollahi M

We systematically reviewed the clinical trials which recruited antioxidants in the therapy of pancreatitis and evaluated whether antioxidants improve the outcome of patients with pancreatitis. Electronic bibliographic databases were searched for any studies which investigated the use of antioxidants in the management of acute pancreatitis (AP) or chronic pancreatitis (CP) and in the prevention of post-endoscopic retrograde cholangio-pancreatography (post-ERCP) pancreatitis (PEP) up to February 2009. Twenty-two randomized, placebo-controlled, clinical trials met our criteria and were included in the review. Except for a cocktail of antioxidants which showed improvement in outcomes in three different clinical trials, the results of the administration of other antioxidants in both AP and CP clinical trials were incongruent and heterogeneous. Furthermore, antioxidant therapy including allopurinol and N-acetylcysteine failed to prevent the onset of PEP in almost all trials. In conclusion, the present data do not support a benefit of antioxidant therapy alone or in combination with conventional therapy in the management of AP, CP or PEP. Further double blind, randomized, placebo-controlled clinical trials with large sample size need to be conducted.

PMID: 19777606 [PubMed - in process]

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A double-blind, delayed-start trial of rasagiline in Parkinson’s disease.

N Engl J Med. 2009 Sep 24;361(13):1268-78

Authors: Olanow CW, Rascol O, Hauser R, Feigin PD, Jankovic J, Lang A, Langston W, Melamed E, Poewe W, Stocchi F, Tolosa E,

BACKGROUND: A therapy that slows disease progression is the major unmet need in Parkinson's disease. METHODS: In this double-blind trial, we examined the possibility that rasagiline has disease-modifying effects in Parkinson's disease. A total of 1176 subjects with untreated Parkinson's disease were randomly assigned to receive rasagiline (at a dose of either 1 mg or 2 mg per day) for 72 weeks (the early-start group) or placebo for 36 weeks followed by rasagiline (at a dose of either 1 mg or 2 mg per day) for 36 weeks (the delayed-start group). To determine a positive result with either dose, the early-start treatment group had to meet each of three hierarchical end points of the primary analysis based on the Unified Parkinson's Disease Rating Scale (UPDRS, a 176-point scale, with higher numbers indicating more severe disease): superiority to placebo in the rate of change in the UPDRS score between weeks 12 and 36, superiority to delayed-start treatment in the change in the score between baseline and week 72, and noninferiority to delayed-start treatment in the rate of change in the score between weeks 48 and 72. RESULTS: Early-start treatment with rasagiline at a dose of 1 mg per day met all end points in the primary analysis: a smaller mean (+/-SE) increase (rate of worsening) in the UPDRS score between weeks 12 and 36 (0.09+/-0.02 points per week in the early-start group vs. 0.14+/-0.01 points per week in the placebo group, P=0.01), less worsening in the score between baseline and week 72 (2.82+/-0.53 points in the early-start group vs. 4.52+/-0.56 points in the delayed-start group, P=0.02), and noninferiority between the two groups with respect to the rate of change in the UPDRS score between weeks 48 and 72 (0.085+/-0.02 points per week in the early-start group vs. 0.085+/-0.02 points per week in the delayed-start group, P<0.001). All three end points were not met with rasagiline at a dose of 2 mg per day, since the change in the UPDRS score between baseline and week 72 was not significantly different in the two groups (3.47+/-0.50 points in the early-start group and 3.11+/-0.50 points in the delayed-start group, P=0.60). CONCLUSIONS: Early treatment with rasagiline at a dose of 1 mg per day provided benefits that were consistent with a possible disease-modifying effect, but early treatment with rasagiline at a dose of 2 mg per day did not. Because the two doses were associated with different outcomes, the study results must be interpreted with caution. (ClinicalTrials.gov number, NCT00256204.)

PMID: 19776408 [PubMed - in process]

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Renal failure in cirrhosis.

N Engl J Med. 2009 Sep 24;361(13):1279-90

Authors: Ginès P, Schrier RW

PMID: 19776409 [PubMed - in process]

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Quality of care for atrial fibrillation among patients hospitalized for heart failure.

J Am Coll Cardiol. 2009 Sep 29;54(14):1280-9

Authors: Piccini JP, Hernandez AF, Zhao X, Patel MR, Lewis WR, Peterson ED, Fonarow GC,

OBJECTIVES: This study sought to examine quality of care and warfarin use at discharge in patients with atrial fibrillation (AF) and heart failure (HF). BACKGROUND: Atrial fibrillation is common in HF, and national guidelines recommend discharge on warfarin for stroke prophylaxis. However, the frequency and factors associated with the guideline adherence are poorly described. METHODS: We analyzed 72,534 HF admissions from January 2005 through March 2008 at 255 hospitals participating in the American Heart Association's Get With The Guidelines HF program. Multivariable logistic regression was used to identify independent factors associated with warfarin use at discharge. RESULTS: In this HF population, 20.5% (n=14,901) had AF on admission, whereas another 13.7% (n=9,918) had a prior history of AF but were in a regular rhythm at admission. Contraindications to warfarin therapy were documented in 9.2%. Among eligible HF patients without contraindications, the median prevalence of warfarin therapy at discharge was 64.9% (interquartile range 55.5 to 73.4) and did not improve during the 3.5 years of study. After adjustment, major factors associated with no warfarin use at discharge included increasing age, nonwhite race, anemia, and treatment in the south. Warfarin use also varied inversely with CHADS2 (congestive heart failure, hypertension, age>75, diabetes, and prior stroke or transient ischemic attack) risk (70.9% to 59.5% for CHADS2 score 1 to 6, p<0.0001). CONCLUSIONS: Guideline-recommended warfarin use in patients with AF and HF is less than optimal, has not improved over time, and varies significantly according to age, race, risk profile, region, and hospital site.

PMID: 19778670 [PubMed - in process]

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Gastrointestinal bleeding in patients with acute coronary syndromes: incidence, predictors, and clinical implications: analysis from the ACUITY (Acute Catheterization and Urgent Intervention Triage Strategy) trial.

J Am Coll Cardiol. 2009 Sep 29;54(14):1293-302

Authors: Nikolsky E, Stone GW, Kirtane AJ, Dangas GD, Lansky AJ, McLaurin B, Lincoff AM, Feit F, Moses JW, Fahy M, Manoukian SV, White HD, Ohman EM, Bertrand ME, Cox DA, Mehran R

OBJECTIVES: We assessed the incidence, predictors, and outcomes of gastrointestinal bleeding (GIB) in patients with acute coronary syndromes (ACS). BACKGROUND: GIB is a potential hemorrhagic complication in patients with ACS treated with antithrombotic and/or antiplatelet medications. The clinical outcomes associated with GIB in this setting have not been systematically studied. METHODS: In the ACUITY (Acute Catheterization and Urgent Intervention Triage Strategy) trial, 13,819 patients with moderate- and high-risk ACS, enrolled at 450 centers in 17 countries between August 2003 and December 2005, were randomized to the open-label use of 1 of 3 antithrombin regimens (heparin plus a glycoprotein IIb/IIIa inhibitor, bivalirudin plus a glycoprotein IIb/IIIa inhibitor, or bivalirudin monotherapy). RESULTS: GIB within 30 days occurred in 178 patients (1.3%). Older age, baseline anemia, longer duration of study drug administration before angiogram, smoking, ST-segment deviation>or=1 mm, and diabetes were identified as independent predictors of GIB. On multivariable analysis, GIB was strongly associated with 30-day all-cause mortality (hazard ratio [HR]: 4.87 [interquartile range (IQR) 2.61 to 9.08], p<0.0001), cardiac mortality (HR: 5.35 [IQR 2.71 to 10.59], p<0.0001), and composite ischemia (HR: 1.94 [IQR 1.14 to 3.30], p=0.014), as well as with 1-year all-cause mortality (HR: 3.97 [IQR 2.64 to 5.99], p<0.0001), cardiac mortality (HR: 3.77 [IQR 2.14 to 6.63], p<0.0001), myocardial infarction (HR: 1.74 [IQR 1.01 to 3.02], p=0.047), and composite ischemia (HR: 1.90 [IQR 1.37 to 2.64], p=0.0001). Patients who experienced GIB had significantly higher rates of stent thrombosis compared with patients without GIB (5.8% vs. 2.4%, p=0.009). CONCLUSIONS: GIB is a serious condition in the scenario of ACS and is independently associated with mortality and ischemic complications.

PMID: 19778672 [PubMed - in process]

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Performance of rapid influenza diagnostic tests during two school outbreaks of 2009 pandemic influenza A (H1N1) virus infection – Connecticut, 2009.

MMWR Morb Mortal Wkly Rep. 2009 Sep 25;58(37):1029-32

Authors:

During May 2009, a few weeks after 2009 pandemic influenza A (H1N1) infection was first detected in the United States, outbreaks among students from two schools were detected in Greenwich, Connecticut. Staff members from Greenwich Hospital and the Connecticut Department of Public Health collected data on symptoms for 63 patients and submitted nasopharyngeal washings for testing using a rapid influenza diagnostic test (RIDT) for influenza A and B and real-time reverse transcription–polymerase chain reaction (rRT-PCR) assay, thereby affording an opportunity to assess the field performance of the RIDT. A total of 49 patients had infections with pandemic influenza A (H1N1) confirmed by rRT-PCR. This report summarizes the findings from this performance assessment, which indicated that, compared with rRT-PCR, the sensitivity of the RIDT for detecting infection in patients with 2009 pandemic influenza A (H1N1) was 47%, and the specificity was 86%. Sensitivity and specificity did not vary substantially by the presence or absence of CDC-defined influenza-like illness (ILI) or by time from symptom onset to specimen acquisition. In this group of patients, although positive RIDT results performed well in predicting confirmed infection with pandemic H1N1 virus (positive predictive value: 92%), negative tests did not accurately predict the absence of infection (negative predictive value: 32%). These results affirm recent CDC recommendations against using negative RIDT results for management of patients with possible 2009 pandemic influenza A (H1N1) infection.

PMID: 19779397 [PubMed - in process]

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For whom the bell commission tolls: unintended effects of limiting residents’ hours.

Ann Emerg Med. 2009 Oct;54(4):A25-9

Authors: Millard WB

PMID: 19780220 [PubMed - in process]

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Impact of a Renal Drug Dosing Service on Dose Adjustment in Hospitalized Patients with Chronic Kidney Disease(October).

Ann Pharmacother. 2009 Sep 23;

Authors: Hassan Y, Al-Ramahi RJ, Aziz NA, Ghazali R

BACKGROUND: Appropriate drug selection and dosing for patients with chronic kidney disease (CKD) is important to avoid unwanted drug effects and ensure optimal patient outcomes. OBJECTIVE: To assess the rate of inappropriate dosing in patients with CKD in a nephrology unit and to evaluate the impact on dose adjustment, adverse drug events (ADEs), and drug cost of having a pharmacist accompany a team of physicians on their rounds. METHODS: This was a comparative study with a preintervention and post-intervention design. The preintervention phase served as the control; it was prospective and observational only and was conducted from the beginning of February to the end of May 2007. The second phase (intervention phase) was conducted from the beginning of March to the end of June 2008. Two random samples of 300 patients with an estimated creatinine clearance less than or equal to 50 mL/min were included. During the intervention phase, a clinical pharmacist made rounds with the nephrology unit team and gave dosing adjustment recommendations when needed. A collection of reliable and up-to-date drug information references that are commonly used globally were used during the intervention. RESULTS: In the preintervention group, drug dosage adjustment or avoidance, based on renal function, was necessary in 607 of 2814 (21.6%) prescriptions. Of these, 322 (53.0%) did not comply with guidelines. In the intervention group, adjustment was necessary for 640 of 2981 (21.5%) prescriptions. The pharmacist made 388 recommendations related to dosing adjustment, 212 (54.6%) of which were accepted by physicians. Clinicians' noncompliance with dosing guidelines decreased to 176 (27.5%) (p < 0.001). In the preintervention group, 64 (21.3%) patients had a suspected ADE, with a total of 73 events. In the intervention group, this number was significantly lower with 49 events in 48 (16.0%) patients (p < 0.05). The intervention resulted in drug cost savings of $2250 US. CONCLUSIONS: A renal drug dosing service for patients hospitalized with CKD can increase the proportion of drug dosing that is adjusted to take into account renal function. This can save drug costs and may prevent ADEs.

PMID: 19776297 [PubMed - as supplied by publisher]

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