In the included case reports, carcinoid crises were managed effectively using octreotide 25-500 μg iv. Previous exposure to octreotide and carcinoid heart disease may warrant the need for higher doses. In addition to the low quality of the articles and the small sample size, inconsistent use of the term "carcinoid crisis" and paucity of reported outcomes were also limitations of this systematic review. These findings highlight the need for further investigation into dose-response relationships of octreotide for the treatment of carcinoid crisis.
Background: One-third to one-half of adults older than 65 fall at least once per year. Fall prevention through medication management requires little effort and has consistently been shown to reduce risk of falls. The objective of this study was to further develop and perform preliminary pilot testing of an algorithm designed to assist consultant pharmacists in systematically identifying medications that might be modifiable, in order to reduce the risk of falls in older adults. We hypothesized that algorithm use would increase the number of fall-related medication change recommendations made to physicians.
Job satisfaction is known to decline during times of major organizational change and emotional intelligence has been positively correlated with job satisfaction and adaptability. Computerized provider order entry (CPOE), closed loop medication administration, electronic medication administration records and 24/7 pharmacy services were implemented at London Health Sciences Centre (LHSC) during the spring of 2014. This pilot randomized controlled trial assessed whether completion of an emotional intelligence assessment, followed by a personalized one-hour emotional intelligence coaching session, would positively impact job satisfaction stability amongst pharmacists throughout these major organizational changes. Job satisfaction was measured by the Health Professions Stress Inventory (HPSI). The primary outcome was change in HPSI score from baseline. Emotional intelligence coaching was provided to participants randomized to the intervention. Semi-structured interviews were completed at baseline and follow-up for qualitative analysis. Twenty five participants were recruited and all participants completed the study. Job satisfaction improved in both control and intervention groups. Observations from semi-structured interviews suggested that emotional intelligence coaching may have increased self-awareness and ability to recognize dissatisfaction. Participants who were in their role for less than two years reported greater benefit from emotional intelligence coaching. Job satisfaction was worse during the anticipatory phase of major organizational change. Emotional intelligence coaching did not have an observable benefit on objective measures of job satisfaction, but it may have a subjective benefit that is more apparent in pharmacists who are less established in their role.
Objective:
To report a case of worsening myasthenia gravis after the initiation of gabapentin for treatment of essential tremor.
Case Summary:
A 69-year-old man experienced minor ptosis of the left eyelid, slight neck weakness, and transient difficulties in chewing food on day 6 of a slow gabapentin dosage titration. As the titration continued, the myasthenia symptoms progressed to bilateral ptosis, and there was dramatic worsening of weakness by day 23. He was taking gabapentin 1500 mg daily at the time; the drug was then tapered to discontinuation. All myasthenia gravis symptoms were reported as resolved 3 days after discontinuation of gabapentin. The initiation and discontinuation of gabapentin also coincided with improvement, then worsening of the patient's tremor.
Discussion:
Three published case reports describe worsening of myasthenia gravis during use of gabapentin for the treatment of various neuropathies. To the best of our knowledge, this is the first case report of a patient experiencing worsening of myasthenia gravis upon initiation of gabapentin for essential tremor. The Naranjo probability scale suggests a probable association between gabapentin and worsening of myasthenia gravis symptoms in our patient. Several myasthenia-like symptoms are listed in the gabapentin mongraph as low-frequency adverse events, increasing the possibility that gabapentin may have been unmasking or worsening myasthenia gravis in clinical trials. However, myasthenia gravis is not identified as a contraindication or caution for gabapentin use.
Conclusions:
Gabapentin should be used with caution in patients with myasthenia gravis, and clinicians must be aware of the potential risks of this therapy.
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