Pharmacotherapy
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Trauma patients are routinely prescribed stress ulcer prophylaxis despite evidence suggesting such therapy be limited to patients with identifiable risk factors for bleeding. With surgeons' consensus, we developed and implemented trauma stress ulcer prophylaxis guidelines, and measured the impact of clinical pharmacists on implementing the guidelines and the effect of the guidelines on drug cost and frequency of major gastrointestinal bleeding. Two groups of 150 consecutive patients admitted with multiple trauma were evaluated before and after guideline implementation and stratified by Injury Severity Score (ISS) to minor (ISS < 9) or moderate to severe (ISS > or = 9) trauma groups. ⋯ Recommendations to discontinue therapy were accepted in 9 (60%) of 15 instances. The frequency of major gastrointestinal bleeding remained unchanged between groups (1/150 vs 0/150, p=1.0). Implementation of trauma stress ulcer prophylaxis guidelines limiting therapy to patients with risk factors for bleeding led to a 80% decrease in drug cost and did not affect the frequency of major gastrointestinal bleeding.
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We assessed the ability of a graphic nomogram to adjust steady-state warfarin dosages and to predict international normalized ratios (INR) after a dosage change, compared with an anticoagulation clinic pharmacist and a Bayesian regression computer program. Study subjects were 108 men and 3 women receiving warfarin anticoagulation. In all patients the median absolute errors in predicted INR values for the nomogram, computer program, and pharmacist were 0.33, 0.46, and 0.48, respectively. ⋯ The nomogram was significantly more precise than the pharmacist (p=0.005) and computer (p=0.002). The ability to provide more precise dosage reductions of warfarin may be of clinical importance in light of current recommendations for higher-intensity warfarin therapy and maintenance of higher INR values. Prospective validation of the performance of this nomogram in a routine clinical setting is warranted.