Faculty Bibliography

Endogenous digoxin-like factors (EDLF) are compounds that promote natriuresis, inhibit sodium-potasium-ATPase, and cross-react with antibodies raised against cardiac glycosides. Although EDLF are well described in experimental animal models and a variety of clinical conditions in humans, no investigation previously evaluated an association between EDLF and hypothermia. We used two separate models to examine the presence of EDLF in hypothermic humans. The first study consisted of a case-controlled comparison of patients with unintentional environmental hypothermia. All patients with environmental hypothermia were prospectively enrolled if they were not taking cardiac glycosides and had no conditions previously associated with EDLF. A digoxin concentration obtained at presentation was compared to one obtained from presentation on patients from a demographically matched control group of normothermic patients. The second study enrolled a convenience sample of patients undergoing controlled cold cardioplegia for surgery. Once again, patients were excluded for conditions previously associated with EDLF, and were required to have a non-detectable preoperative digoxin concentration. Digoxin concentrations were subsequently compared in the pre- and post-operative periods. In addition to serving as their own controls, a comparison group of normothermic patients were added to help control for confounding factors associated with surgery under general anesthesia. Twenty-two patients with environmental hypothermia (mean temperature 91° Fahrenheit, range, 83.8-93.8° Fahrenheit) and 22 controls were included in the first study. Ten hypothermic patients had measurable digoxin concentrations, 6 of which were above 0.15 ng/mL. All control patients had digoxin concentrations of 0.00 ng/mL (p = 0.03, Fisher's exact test). The second study enrolled ten patients undergoing surgery with cold cardioplegia and ten control patients undergoing normothermic surgery under general anesthesia. None of the ten control patients had measurable digoxin concentrations on either pre or postoperative testing. Although all of the cold cardioplegia hypothermic patients had negative preoperative digoxin concentrations, one developed a postoperative concentration of 0.44 ng/mL. We conclude that hypothermia is associated with the presence of EDLF. An animal model and further human testing will be required to establish causation

OBJECTIVE: Warfarin is a high-risk medication whose safe use may be greatly improved by patient education. This study evaluate evaluated patients' understanding of warfarin instructions, medication management, the Food and Drug Administration's (FDA) warfarin medication guide content, and patient information recommendations. METHODS: Interviews conducted at 2 hospital-based outpatient primary care sites with patients initiated on warfarin therapy within the last year. RESULTS: Interviews were conducted with 49 patients. Seventy percent were between 36 and 64 years old and reported taking between 1 and 18 different medications daily. Many (76%) received information about warfarin when first prescribed to them, 65% written and 60% verbal (answers reflect more than one response). Patients found content in the medication guide difficult to understand; 18% were unable to identify information about diet and 21% were unable to locate information about when to call their provider. Analysis showed that 19% had trouble with numeracy issues related to warfarin. Patients' suggestions of ways to convey warfarin information included more graphics, in-person counseling, and multilingual translations. CONCLUSION: This study demonstrates gaps in patients' understanding of warfarin therapy. Relying solely on the information in the FDA medication guide is insufficient to guarantee adequate understanding. Utilizing the suggestions from patients' feedback on other ways to deliver information should help future patients with different learning abilities and styles.

PURPOSE: To assess pharmacists' and students' knowledge of high-dose insulin euglycemia (HIE) and intravenous fatty acid emulsion 20% (IFE) and to see whether it improved after an educational intervention. METHODS: A survey to assess the knowledge about the use of HIE and IFE as antidotes was e-mailed to practicing pharmacists, pharmacy residents, and students prior to and following an educational intervention. Fact sheets on the antidotes were developed in conjunction with the New York City Poison Control Center and were used as the educational intervention in this study. The impact of exposure to the intervention was measured by comparing the number of correct responses per question on the pre- and posttests and the mean pre- and posttest scores using chi-square and t tests, respectively. RESULTS: Most respondents felt either not at all or only somewhat comfortable with managing a toxicologic emergency. There was a statistically significant difference in mean scores on the pretest and posttest (2.9 vs 5.45; P = .001) and for the number of participants giving correct responses for each question before and after education: 52.4% of respondents answered "I don't know" to the questions prior to education versus 21.2% after education (P < .001). Fewer respondents felt not at all comfortable managing a toxicologic emergency after the educational intervention (42.4 vs 50.3%; P < .001). CONCLUSION: Pharmacists and students reported little comfort in managing toxicological emergencies in general and have limited baseline knowledge about these agents. Educational interventions can significantly improve knowledge. Prior familiarity with these newer antidotes should reduce delays in their administration in an emergency.