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Gentamicin sulfate remains an important antibiotic in the treatment of gram-negative infections. The drug is most effective when particular attention is paid to proper dosing and monitoring of both serum [...], To assess the effects of implementing a standardized order form on the prescribing and monitoring of gentamicin sulfate at a nonteaching Veterans Affairs Medical Center, we prospectively evaluated the prescribing and monitoring of gentamicin for 14 months after the use of such a form was implemented. The data collected included dosing, initial serum gentamicin concentrations, and serum creatinine measurements. These data were compared with similar data obtained during a period of 6 months before the order form was used. A total of 76 patient records were reviewed, 39 before the use of the order form and 47 after the order form was implemented. Gentamicin peak concentrations were statistically higher in the group treated after the order form was implemented. No differences were seen in gentamicin trough concentrations. The timely measurement of serum gentamicin concentrations and serum creatinine levels was improved in the group for whom the order form was used. The order form was completed satisfactorily in 44 patients (94%). We conclude that implementing a standardized order form improved the use of gentamicin. (Smith K, Rindone JR A gentamicin order form improves its use. West J Med 1998; 168:494-498)

Background: Fluconazole has been reported to interact with many medications. This study examined the effect of low-dose fluconazole therapy on the hypoprothrombinemic response of warfarin sodium in patients. Methods: Patients receiving low-intensity anticoagulation therapy with warfarin were recruited. All patients were taking stable doses of warfarin and had two baseline prothrombin times (PTs) within 10% of each other. Each patient received 100 mg of fluconazole daily for 7 days. Prothrombin times were measured on days 2, 5, and 8 during fluconazole administration. Results: All patients had a progressive increase in PTs. Mean ([+ or -] SD) of PTs increased from 15.8 [+ or -] 1 seconds before the administration of fluconazole to 18.9 [+ or -] 1.9 seconds on day 5 and 21.9 [+ or -] 2.2 seconds on day 8. Fluconazole therapy was stopped early in three patients due to high PTs. The largest change in PT was 9.7 seconds. No bleeding was noted during the study. Conclusion: Fluconazole predictably potentiates the hypoprothrombinemic response of warfarin. Prothrombin times must be monitored when fluconazole is administered to patients taking warfarin. (Arch Intern Med. 1993;153:102-104)

Glucosamine sulfate is widely purported in the media and on the Internet to be an effective treatment for osteoarthritis. Its popularity can be traced, in part, to the success of [...], * Objective To determine the effectiveness of glucosamine in reducing pain from osteoarthritis of the knee. * Design Randomized, double-blind parallel trial of glucosamine 500 mg three rimes daily or a placebo for 2 months. * Setting Veterans Affairs Medical Center, Prescott, AZ. * Participants Ninety-eight patients aged 34 to 81 being treated for osteoarrhritis of the knee. * Main outcome measures Pain intensity both at rest and while walking as assessed by a visual analog scale at baseline and after 30 and 60 days of treatment. * Results Forty-nine patients were randomly allocated to each group. There was no statistical difference between the two groups in scores on the visual analog scale at 30 days for resting (mean [SD] score placebo group 3.5 [2.7] vs 3.3 [2.4] glucosamine group, P=0.66) or walking (5.1 [2.6] vs 5.3 [2.4], P=0.69); there was also no difference at 60 days for resting (3.4 [2.5] vs 3.2 [2.5], P=0.81) or walking (4.9 [2.2] vs 4.9 [2.8], P=0.90). There was also no statistical difference between groups in the mean change from baseline in scores on the visual analog scale (mean [SD] change for walking at 60 days placebo group -1.5 [2.5] vs glucosamine group -1.4 [3.0], P=0.77). Two participants, raking glucosamine and 4 raking placebo withdrew from the study due to adverse side effects (P=0.67). * Conclusion Glucosamine was no better than placebo in reducing pain from osteoarrhritis of the knee in this group of patients.

Background: Observational studies have suggested an increased risk of nephrotoxicity when piperacillin-tazobactam is added to vancomycin, although the data are confliciting. Objective: To perform a meta-analysis of identified studies to assess if adding piperacillin-tazobactam to vancomycin increases the incidence of nephrotoxicity. Method: A systematic review of PubMed, EMBASE, Cochrane Central, and Google Scholar was conducted to identify studies. Studies selected for meta-analysis were full length reports, retrospective or prospective, and designed specifically to assess if the combining piperacillin-tazobactam with vancomycin increases nephrotoxicity. Results: Six observational trials involving 963 patients were identified and analyzed. Five trials were retrospective and one was prospective. Vancomycin/piperacillin-tazobactam was compared to vancomycin alone in 2 trials, to vancomycin/cefepime in 3 trials, and vancomycin/cefepime or meropenem in one. Meta-analysis showed a statistical increase in the incidence of nephrotoxicity when piperacillin-tazobactam/vancomycin is compared to the control group (2.26 95% CI 1.41-3.63, p= 0.0007). No differences were noted between groups in patients requiring renal replacement. Conclusion: Adding piperacillin-tazobactam to vancomycin increases the risk of nephrotoxicity when compared to vancomycin alone or vancomycin with either cefepime or meropenem.

Since the introduction of ophthalmic timolol solution in 1978 there have been numerous reports of systemic toxicity associated with its use. The majority of the systemic side effects reported are the same as those associated with oral timolol. Several cases of respiratory distress have been described generally in patients with underlying restrictive airway disease. Cardiovascular effects range from effects on resting pulse rate to the development of overt bradycardia and heart failure. Central nervous system effects reported include fatigue, confusion, depression, and hallucinations. A variety of other systemic effects have also been described. Caution should be used when ophthalmic timolol is administered to elderly patients or those patients with contraindications to systemic β-blockers.