Hi-Tech patch for migraine relief

ZelrixZelrix is a transdermal patch containing sumatriptan for the treatment of acute migraine headache developed by NuPathe, a pharmaceutical company specializing in the treatment of neurological and psychiatric disorders. The patch is based on NuPathe’s proprietary SmartRelief™ platform, which according to the manufacturer’s website is “a non-invasive technology that utilizes low-level electrical energy to transport drugs through the skin in a safe and effective manner. The rate and amount of drug delivered is controlled electronically, so that the patient receives consistent therapy each and every time. Iontophoresis is an established drug delivery technology with multiple applications currently being used by physicians.” The SmartRelief™ iontophoresis utilizes pre-programmed, embedded electronics in the patch to provide consistent therapeutic drug levels. This is very interesting technology with many potential applications. Imagine the uses in professional sports where iontophoresis is frequently utilized to administer NSAIDS and corticosteroids for the treatment of inflammation

Deaths caused by postoperative hydration

ASHP: “ Standards Needed for Postoperative Hydration Therapy, ISMP Says – BETHESDA, MD 13 August 2009—Investigations into the deaths of two six-year-old children have prompted the Institute for Safe Medication Practices (ISMP) to call for the establishment of standards of practice for i.v. hydration therapy in postoperative patients.

According to today’s issue of ISMP Medication Safety Alert!, a six-year-old girl who underwent tonsillectomy and adenoidectomy died after receiving 5% dextrose in water at 200 mL/hr for 12 hours. The postoperative orders had stated “1000 cc D5W – 600 cc q8h,” but the pharmacist entered an incorrect infusion rate into the electronic medication administration record. This error was not noticed until a pediatrician, consulted by the surgeon because the girl had a grand mal seizure, recognized that the patient had signs of hyponatremia and water intoxication. The patient had had seizure-like activity earlier in the day, but the surgeon, contacted by telephone, attributed those episodes to a reaction to promethazine even though the nurses had expressed doubt.

In the other case, according to ISMP, a six-year-old boy who underwent surgery to correct a malformation in his aorta died after nurses dismissed his parents’ concerns about their son becoming increasingly less responsive on the second postoperative day. The physician had prescribed an infusion of a sodium chloride solution because the boy’s serum sodium concentration had dropped subsequent to treatment with diuretics. No sodium chloride infusion was documented in the medication administration record, however. The nurses attributed signs of hyponatremia to the patient receiving hydromorphone for pain relief and being “fidgety” from pain.”

Hyponatremia is basically the result of excess water (case #1 above) relative to sodium and is one of the most common electrolyte abnormalities in hospitalized patients. The condition can cause significant morbidity and mortality. Unfortunately incorrectly treating the condition can be dangerous as well (case #2 above).

Signs and symptoms of hyponatremia are directly related to the central nervous system and include anorexia, nausea, lethargy, headache, apathy and muscle cramps. In severe cases, symptoms worsen and can advance to seizures, brain damage, and even death secondary to cerebral edema.

Treatment of hyponatremia can be quite controversial as aggressive replacement can lead to osmotic demyelination syndrome (i.e. central pontine myelinolysis); a painful and potentially deadly condition. Unfortunately the brain responds rapidly to a fall in plasma osmolality, but slowly to correction. Complete restoration of solutes in the brain may require up to 5 to 7 days. For this reason, aggressive sodium replacement should be limited to severe cases and patients should be closely monitored for several days following aggressive treatment for hyponatremia.

Tragedies like those mentioned above should, in theory, never occur. We continue to develop guidelines and technology to prevent such mistakes from ever happening, but will never be able to eliminate the “human factor” so blatantly described above. Our best hope is to create a system that decreases the occurrence of errors and minimizes damage when they occur.

Best Hospitals 2009-2010

US News and World Report: “America’s Best Hospitals, an annual ranking of the country’s elite medical centers, is a tool for patients who need medical sophistication most facilities cannot offer. Unlike other rankings and ratings that grade hospitals on how well they execute routine procedures like outpatient hernia repair or manage common conditions like low-grade heart failure, the U.S. News  approach looks at how well a hospital handles complex and demanding situations—replacing an 85-year-old man’s heart valve, diagnosing and treating a spinal tumor, and dealing with inflammatory bowel disease, to name three examples. High-stakes medicine…..In 12 of the 16 specialties, those in which quality of care can spell life or death, hospitals were scored on reputation, death rate, patient safety, and care-related factors such as nursing and patient services; the 50 highest scorers were ranked. Scores and complete data for unranked hospitals are available as well. In the other four specialties—ophthalmology, psychiatry, rehabilitation, and rheumatology—hospitals were ranked on reputation alone, because so few patients die that mortality data don’t mean much. Here are a few of the details: Reputation, which counted as 32.5 percent of the score, was based on three years of specialist surveys—a total of almost 10,000 physicians were asked to name five hospitals they consider among the best in their specialty for difficult cases, without taking into account cost or location. A mortality index, also 32.5 percent of the score, indicates a hospital’s ability to keep patients with serious problems alive. Patient safety, new this year, made up 5 percent of the score; it indicates how well a hospital minimizes harm to patients. And a group of other care-related factors, such as nurse staffing and available technology, accounted for the remaining 30 percent.”
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Pen and paper versus technology.

Early morning hours on the weekend often provide me with a little quiet time to get some work done. Usually my wife and kids are still asleep and the day hasn’t really started yet. Last Saturday morning was one of those days. As I got up from my work to get another cup of coffee I felt a little amused at the image in front of me. My days are spent working with various types of pharmacy technology, computers, automated storage devices, barcoding equipment, etc., but there on the table in front of me was a paper notepad and an ink pen.
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