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Amyotrophic lateral sclerosis (ALS) is a disease that results in the progressive deterioration and loss of function of the motor neurons in the brain and spinal cord, leading to paralysis. ALS affects approximately 16,000 individuals, with a prognosis for survival of 2 to 5 years. There are 2 types of ALS differentiated by genetics: familial and sporadic (idiopathic). Diagnosis is determined by excluding other conditions and utilizing clinical examinations, laboratory tests, and nerve conduction/electromyography studies. Due to the collection of information from the participation of patients with ALS in registries, biomarkers and genes associated with ALS have been discovered. The best practices for the management of ALS include an interdisciplinary approach aimed at addressing the physical and psychological needs and desires of patients and their families and caregivers.

New guidelines have been released for the treatment of skin and soft tissue infections. The updates include recommendations on when to prescribe antibiotics and which antibiotics are effective for each infection. This article will highlight the important changes to practice and provide additional antibiotic clinical pearls.

Objective: To report on the proportion of individuals with alcohol-use disorders who take prescription medications that could interact with alcohol and on the proportion who recall advice to avoid alcohol with their medications., Design: Secondary analysis of a randomized controlled trial of telephone counseling., Setting: 18 primary care practices in south-central and southeastern Wisconsin., Patients: 897 adults with alcohol-use disorders as identified by systematic survey., Intervention: Telephone and mail survey., Main Outcome Measures: Patient-reported prescription medication use, potential for alcohol-drug interactions according to DrugDex, and patient-reported receipt of advice not to take alcohol with their medications., Results: Of the 869 patients who provided usable information on prescription medication use, 348 (40.0%) were taking medications with alcohol interactions or proscriptions; the most frequently reported were bupropion, selective serotonin reuptake inhibitors, and various acetaminophen-containing compounds. Slightly more than 20% of patients were taking medications with moderate to severe alcohol interactions; over one-third of these 184 patients did not recall advice to avoid alcohol., Conclusion: Practitioners who prescribe or dispense medications may need to enhance their efforts to advise patients about alcohol-drug interactions. Prescribing and dispensing medications that interact with alcohol present opportunities to administer alcohol screens and interventions.

This paper describes an approach to instruction for allied health students in screening and brief intervention to assist children and adolescents living with adults who are abusing substances. Substance abuse is a major public health problem in the United States; among its outcomes is damage to children living in the home. Health professionals should screen child and adolescent clients to determine whether adults in the home are substance abusers, and provide help for children living with such adults. An interactive electronic instructional unit, suitable for either independent study or classroom use, was developed to provide this content to allied health students. The unit includes an introductory page, followed by pages focused on the scope of the problem, screening, and brief intervention. Evaluation by means of a pre and post-test suggested that the unit has the potential to increase occupational and physical therapy students' knowledge and modify attitudes regarding their role in providing screening, referral, and brief intervention for this population.

Elementary school staff requested and were provided with strategies for helping students and a resource guide to services for students living with substance-abusing adults.

Objective: To review the laboratory and clinical evidence of the medicinal value of zinc for the treatment of the common cold., Data Sources: Published articles identified through Medline (1980-2003) using the search terms zinc, rhinovirus, and other pertinent subject headings. Additional sources were identified from the bibliographies of the retrieved articles., Study Selection: By the author., Data Extraction: By the author., Data Synthesis: Human rhinoviruses, by attaching to the nasal epithelium via the intracellular adhesion molecule-1 (ICAM-1) receptor, cause most colds. Ionic zinc, based on its electrical charge, also has an affinity for ICAM-1 receptor sites and may exert an antiviral effect by attaching to the ICAM-1 receptors in the rhinovirus structure and nasal epithelial cells. Clinical tests of zinc for treatment of common colds have been inconsistent, primarily because of study design, blinding, and lozenge contents. Early formulations of lozenges also were unpalatable. In three trials with similar study designs, methodologies, and efficacy assessments, zinc effectively and significantly shortened the duration of the common cold when it was administered within 24 hours of the onset of symptoms. Recent reports of trials with zinc gluconate administered as a nasal gel have supported these findings; in addition, they have shown that treatment with zinc nasal gel is effective in reducing the duration and severity of common cold symptoms in patients with established illness., Conclusion: Clinical trial data support the value of zinc in reducing the duration and severity of symptoms of the common cold when administered within 24 hours of the onset of common cold symptoms. Additional clinical and laboratory evaluations are warranted to further define the role of ionic zinc for the prevention and treatment of the common cold and to elucidate the biochemical mechanisms through which zinc exerts its symptom-relieving effects.

Objectives: To review unmet medical needs associated with irritable bowel syndrome (IBS), to discuss factors that contribute to these unmet needs, and to provide an overview of advancements in IBS diagnosis and treatment options that may influence treatment strategies., Summary: IBS is characterized by a multiple symptom complex of abdominal pain or discomfort and altered bowel habits (i.e., constipation, diarrhea, or both in alternation) and is associated with a large unmet medical need. IBS symptoms are chronic and bothersome, and they have a profound negative impact on patients. quality of life (i.e., affecting sleep, personal relationships, travel, diet, and sexual functioning). IBS imposes a substantial economic burden in direct medical costs and in indirect social costs such as absenteeism from work and school and lost productivity, along with the less-measurable costs of a decreased quality of life. The annual cost of IBS treatment in the United States has been estimated to be between $1.7 billion and $10 billion in direct medical costs (excluding prescription and over-the-counter [OTC] drug costs) and $20 billion for indirect costs. The goals of IBS therapy are to provide global relief of the multiple symptoms of IBS and to relieve single IBS symptoms. Although traditional IBS therapies (e.g., laxatives, antidepressants, antispasmodics, and bulking agents) are useful for some patients in relieving single IBS symptoms, patients generally are dissatisfied with their overall efficacy and tolerability. These agents have not been proven in randomized, controlled clinical trials to be more effective than placebo in providing global relief of the multiple symptoms of IBS. Over the past 2 decades, numerous advancements in the diagnosis and management of IBS have provided hope for the future, including research strides in our understanding of the underlying pathophysiology of IBS; new diagnostic and management recommendations based on a stepwise, symptom-based approach; and the development of novel pharmacologic agents., Conclusion: IBS imposes a high socioeconomic burden on its sufferers and on society. Research strides in the underlying pathophysiology of this disorder have enhanced our understanding of IBS, but many questions remain to be answered. Development of evidence-based guidelines on the stepwise, symptom-based approach to IBS diagnosis and the continuing efforts to develop unique pharmacologic classes targeted at the multiple symptoms of this disorder are steps in the right direction. Though cost-effectiveness data on specific pharmacologic classes are not yet available, these ongoing efforts may help promote timely IBS diagnosis and patient satisfaction with care, optimally decreasing the use of health care resources., (Copyright 2004 Academy of Managed Care Pharmacy)

Objective: To define the incidence and severity of thrombocytopenia in a mixed medical-surgical population of critically ill patients and to examine factors that may be related to the development of thrombocytopenia., Design: Retrospective chart review of 314 critically ill patients requiring at least 3 days of critical care., Setting: A 17-bed combined medical-surgical intensive care unit (ICU) in a 560-bed tertiary care community hospital., Patients: Medical and surgical patients admitted to the ICU., Interventions: All medical records over the duration of the ICU stay were reviewed. All scheduled medications, including dosage and start/stop dates, were recorded. All platelet counts, placement of pulmonary artery catheters, liver function test results, and admission serum creatinine concentrations were collected., Measurement and Main Results: Thrombocytopenia (platelet count less than 200 x 10(9)/L) was observed frequently, but rarely reached a severe stage (7 patients). No single diagnostic category was significantly associated with thrombocytopenia alone, although the combination of sepsis syndrome/septic shock and respiratory failure was strongly correlated (p < 0.0001) with thrombocytopenia. Liver function abnormalities were correlated strongly with thrombocytopenia, and the majority of patients (5 of 7) with severe thrombocytopenia (less than 20 x 10(9)/L) were found to have concurrent severe alterations in liver function test results. Pulmonary artery catheter placement and heparin exposure were associated strongly with thrombocytopenia (p < 0.0001). Drug therapies that were correlated with thrombocytopenia included heparin and vancomycin (p < 0.05). Hemodynamic instability was correlated strongly with the presence and severity of thrombocytopenia. In a stepwise linear regression model, the admission platelet count accounted for the largest proportion of the variance (43%), followed by hemodynamic instability (8%) and the requirement for inotropic agents (2%)., Conclusions: Thrombocytopenia in the critically ill occurs frequently, rarely reaches severely depressed concentrations, and primarily represents a manifestation of disease processes initiated prior to admission. Hemodynamic instability and/or heparin exposure appear to be the strongest identifiable correlates with thrombocytopenia. Although these may cause infrequent isolated cases, other specific drug causes of thrombocytopenia are not responsible for the majority of cases of thrombocytopenia in the critically ill.

Objective: To compare gastric pH control using intravenous famotidine as a primed, continuous infusion versus intermittent infusion., Methods: In a prospective, double-blind study, 40 ICU patients at risk for stress ulceration were randomly assigned to receive either famotidine 20 mg intravenous bolus followed by 1.67 mg/h infusion or famotidine 20 mg intravenously every 12 h. Intraluminal gastric pH was recorded at baseline and every 4 h using a glass electrode. Clinical outcome indicators were also monitored. Subjects were studied for a minimum of 24 h and a maximum of 6 days. Continuous variables were analyzed by ANOVA and nominal variables by Fisher's exact test (alpha = 0.05)., Results: Nineteen patients were randomized to the continuous infusion group, and 21 were randomized to the intermittent group. Using gastric pH greater than 4.0 as an endpoint, the continuous group exhibited better pH control, both in terms of percentage of total measurements (83% versus 63%, p < 0.001) and time spent above pH 4.0 (91% versus 76%, p < 0.01). Similar results were found at pH greater than 5.0 (78% versus 56% for all measurements for the continuous and bolus groups, respectively (p < 0.001), and 88% versus 72% for the time spent above pH 5.0 (p < 0.01). Clinical outcomes, including evidence for gastrointestinal bleeding and hospital mortality, did not differ significantly between groups., Conclusion: Famotidine infusion at 1.67 mg/h, when preceded by a bolus dose of 20 mg, provides a greater and more sustained increase in gastric pH than intermittent administration of famotidine 20 mg every 12 h.

A 72-year-old woman attempted suicide with thioridazine 3000 mg and 60 tablets of acetaminophen 325 mg plus codeine 30 mg. She was semicomatose and had persistent third-degree atrioventricular block, progressive hypotension, and an episode of torsade de pointes. Heart block, arrhythmias, and hypotension resolved within 48 hours, and the patient recovered without adverse sequelae.

Objective: To review published reports of hepatotoxicity associated with angiotensin-converting enzyme (ACE) inhibitors and to explore possible mechanisms of injury., Data Sources: Published reports of hepatotoxicity associated with use of ACE inhibitors and investigations that suggest potential mechanisms of injury., Data Synthesis: Nineteen cases of ACE-inhibitor-associated hepatotoxicity are presented. Early theories regarding mechanisms are reviewed. Laboratory investigations of hepatic effects of eicosanoids on hepatic function are reviewed and a novel mechanism by which ACE inhibitors may cause hepatic injury is postulated., Conclusions: Hepatotoxicity, usually cholestatic in nature, has been reported with captopril, enalapril, and lisinopril use. Apparent cross-reactivity has been reported twice. Potential mechanisms of injury include idiopathic hypersensitivity and modulation of eicosanoid metabolism by inhibition of kininase II and subsequent increased hepatic bradykinin activity. Mediation via altered eicosanoid metabolism provides a plausible explanation for cross-reactivity among ACE inhibitors. Hepatotoxicity resolves if ACE inhibitors are stopped but may progress to liver failure if treatment is continued.

The administration of intermittent intravenous infusions of cimetidine is infrequently associated with the development of bradyarrhythmias. A 40-year-old man with leukemia and no history of cardiac disease developed recurrent, brief episodes of apparent sinus arrest while receiving continuous-infusion cimetidine 50 mg/hour. The arrhythmias were temporally related to cimetidine administration, disappeared after dechallenge, and did not recur during ranitidine treatment. This is the first reported case of sinus arrest associated with continuous-infusion cimetidine.

Objective: To present evidence that enalapril and captopril may produce hepatotoxicity by a common mechanism., Data Sources: A case report and review of pertinent literature., Data Synthesis: A patient developed hepatotoxicity once while taking enalapril and again while taking captopril. Hepatotoxicity resolved with cessation of therapy. Hepatotoxicity has been reported with use of captopril, enalapril, and lisinopril. Apparent cross-reactivity has been reported on just one other occasion., Conclusions: Because hepatotoxicity is uncommon with angiotensin-converting enzyme (ACE) inhibitors, our observations suggest the possibility that these agents produce hepatotoxicity by a common mechanism. In patients who develop hepatotoxicity while taking one ACE inhibitor, other agents in this class probably should be avoided.

Objective: To review the potential for anaphylactoid reactions to intravenously administered acetylcysteine when used in the treatment of acetaminophen overdose. This case is unique in that electrocardiographic changes, including ST segment depression and T-wave inversion were associated with the episode and complicated the diagnosis., Data Sources: Reference articles and letters are identified in the text., Data Synthesis: Intravenous administration of acetylcysteine has been used in the treatment of acetaminophen overdose. This route may be considered in some clinical situations where oral therapy is complicated. Anaphylactoid reactions, including cutaneous eruptions, flushing, chest pain, tachycardia, and fever have been reported in up to three percent of patients receiving intravenous acetylcysteine. The nature of these reactions and evidence concerning their etiology suggest a histamine-release phenomenon. Response to intervention with antihistamines and the safety of further acetylcysteine administration are discussed., Conclusions: This case illustrates a variant anaphylactoid reaction to intravenously administered acetylcysteine and emphasizes the need for practitioners to consider the potential for these reactions prior to initiation of therapy and indicates appropriate treatment of these reactions.

We chose to conduct this study because neuroleptic use has not been well defined in nursing homes. To our knowledge, it represents the only attempt at implementing the AIMS procedure in a group of nursing homes. We have provided evidence for what appears to be reasonably typical use of antipsychotic medication in skilled and intermediate care facilities. Senility and dementia were the most common diagnoses noted for neuroleptic recipients. Inservice education had little, if any, impact on antipsychotic drug use. Efforts to reduce the incidence of inappropriate use of neuroleptics should be aimed at physicians. We do feel that nursing and administrative staff are now more aware than previously of the dangers of indiscriminate use of these drugs. We feel that, because of our efforts, nursing staffs are better able to detect the presence of TD in their geriatric residents. If our sample of patients is representative of the entire population of institutionalized elderly, the overall rate of neuroleptic-induced TD may be lower than once thought. Similarly, the use of regularly scheduled neuroleptics in this population may be lower.

Concurrent administration of both ciprofloxacin and norfloxacin with sucralfate leads to a decrease in quinolone bioavailability. It is unknown whether this decrease is clinically significant because studies have focused primarily on pharmacokinetics and not therapeutic outcomes. A reasonable recommendation may be to avoid using sucralfate and norfloxacin concurrently, or avoid administration of norfloxacin and ciprofloxacin within two hours of sucralfate administration. Magnesium- and aluminum-containing antacids may also interfere with quinolone absorption. Calcium carbonate and H2 receptor antagonists do not appear to interact with quinolones and may be considered as an alternative to sucralfate or magnesium- and aluminum-containing antacids when quinolones are administered. Concurrent administration of ciprofloxacin and theophylline may precipitate theophylline toxicity if not monitored carefully. Some clinicians recommend a 30% empiric reduction in theophylline dosage when ciprofloxacin therapy is initiated. Because the drug interaction is not completely predictable, the patient's theophylline levels should be monitored and signs and symptoms of toxicity noted, adjusting the dose as needed. Decreased theophylline clearance may persist for as long as five days following discontinuation of ciprofloxacin. Some potential for slight increases in serum theophylline concentrations secondary to norfloxacin administration may exist. However, it is unlikely to be clinically significant, based on currently available information.