GlobalRPh Website News – David McAuley, Pharm.D.

All new calculators were added to our updated Medical calculator page.

Several calculators related to urology have been released.  Also, based on past requests  three calculators related to either low testosterone and/or ED have been created.

1. International Prostate Symptom Score (IPSS): consists of 8 questions (the original  American Urological Association symptom score (AUA-7)) plus one additional quality of life question.
2. Urinary Incontinence – assessment and treatment calculator
3. Overactive Bladder Symptom Score (OABSS):  a reliable, valid and highly responsive tool to fluctuations in overactive bladder symptoms.
4. International Index of Erectile Function (IIEF) (also known as the SHIM Questionnaire).
5. Overactive Bladder 8-question Screener – (OAB-q).
6. ADAM (Androgen Deficiency in Aging Males) questionnaire consists of 10 questions that help determine if a male patient suffers from androgen deficiency.
7. Aging Males’ Symptom (AMS) scale allows for a more quantitative assessment of testosterone deficiency (TD) compared to the ADAM score

Two versions of the Geriatric Depression Scale have been added (long and short version).  A total score is reported as well as an overall assessment.

The Berg Balance Scale (BBS) has been added.   The BBS is an established tool that has been found to be both valid and reliable when used as a clinical test of a person’s static and dynamic balance abilities as well determining fall risk.

A screening tool for cognitive impairment in older adults has been added.   This tool was created to automate the scoring of  the ‘Saint Louis University Mental Status (SLUMS) Exam. 

1. A Medication Appropriateness Index tool (calculator) has been added. 
   Comments can be added for each question (optional). A final interpretation is also provided.    
   Reference: Samsa GP, Hanlon JT, Schmader KE, Weinberger M, Clipp EC, Uttech KM, Lewis IK, Landsman PB, Cohen HJ. A summated score for the medication appropriateness index: development and assessment of clinimetric properties including content validity. J Clin Epidemiol. 1994;47:891–896.
2. Activities of Daily Living Assessment Tool (ADLs). Provides summary of findings and a graphical representation of independent versus dependent activities.

The following updates are now available:

1. New Beers criteria tool that is able to generate a patient-specific report based on current medical conditions and drug therapy.
2. Updates to all of the creatinine clearance calculators have been released. A thorough review of the literature was part of the revision process.  The output generated by the clearance calculators all reflect the latest evidence.  The link above is to our new advanced calculator that has custom options available for patients with a height under 60 inches.
3. Our advanced pharmacokinetic calculator has an updated clearance section.  Guidance is provided for obese patients as well as patients with a normal body weight per the BMI guidelines.

Several new updates were released in the past few weeks:

1. Based on recommendations from visitors, a new NSAID selection tool was created to help guide selection based on previous exposure to other NSAID classes that were ineffective for a particular patient. Link to program.
2. An updated version of the carboplatin calculator was released. Based on new research, the CKD-EPI equation (corrected for BSA) was added as an additional clearance equation. A new reporting section was added as well to the results section.
3. Geriatric pharmacokinetic changes – summary
4. A new photo resolution program was created to determine minimum camera requirements based on the quality and size of the desired photo…. 11×14,  20 x 30 posters, etc.
5. Phytosterol calculator – determine the impact of various daily plant sterol/stanol intakes and the anticipated drop in LDL. Also includes a table of popular OTC formulations.
6. Odds ratio calculator. Also calculates the confidence interval.
7. Rome III and Rome IV calculators for IBS.
8. Great overview of treatment options for irritable bowel syndrome.
9. New medical calculator section based on the various internal medicine disciplines.
10. Updated therapeutic drug levels… revisited each drug for any potential updates.

Mayayo MM, Alonso MM, Alonso JV, Fernandez-Giráldez E. A New Gender-Specific Formula to Estimate 24-Hour Urine Protein from Protein to Creatinine Ratio. Nephron 2016;133:232–238. DOI: 10.1159/000447604.

The new formulas help to overcome the potential bias related to gender such as differences in the excretion of creatinine related to muscle mass.  Without the correction for gender, the Protein to Creatinine Ratio underestimates the proteinuria in men and overestimates the proteinuria in women.

1] Drug tables:
Several new additions were added to our drug tables including new drug releases of 2016. A new desktop app will be created in the coming months to help quickly navigate the various tables.  Example – opioid induced constipation –> select GI –> Laxatives –> entire table listed and separated by standard agents (for constipation) and newer agents for OIC –> click on a single drug to review the abbreviated monograph. Newer entries will also have direct links to the most recent package insert.

2] Medical Terminology: 
Globalrph currently has one of the most popular medical terminology sections on the web.   We recently added TWENTY practice exams.  Also check out our new word building reference.  We have already received glowing reviews for this new section from teachers throughout the country.

3] Intravenous Dilutions:
We are in the process of reviewing all of the current monographs to make sure stability data reflects the current package insert.  In the past few years, drugs that have been available for years have had their stability data revised.  There are several  reasons for this trend including lack of sufficient data to support previous recommendations or the availability of new studies that contradicts previous data. In many cases, the stability of a particular drug has been shortened. Also 7 new entries will be added next week.

Have an idea for a new program….. let me know….

4] Connection issues:
We have a little under 1 million users. So far there has been only 6 reports of possible page loading issues or printing issues. The few sites that reported issues, also had problems with other sites.

Options:

1] Install an alternative browser that is used for viewing outside
clinically-related websites: e.g Firefox or Google Chrome.
Performance/loading is improved SIGNIFICANTLY.

Alternatively:
Modify Internet Explorer settings:
[ 2 ] Change the browser security settings for the internet from
medium risk to HIGH risk (e.g. greater security).

or,

[3 ] Disable ‘active scripting’:
Internet explorer:
Tools > security > internet> custom level > scroll to bottom of menu and change active scripting from enable to [disable].

Let me know how this works for you…..

Thanks!
Dave

Loren Trager, PharmD, BCPS, CDE
Advanced Practice Pharmacist
Tuba City Regional Health Care Corporation
Tuba City, AZ

This new program can be used to determine when to administer the next dose of vancomycin after a supratherapeutic trough is obtained.  An estimated elimination rate constant is generated from the creatinine clearance which is then used to determine the timing of the next dose based on the desired target trough concentration.

I also updated our current trough calculator to also generate an estimated vancomycin kel value based on the creatinine clearance.  Use this program if the vancomcyin level is drawn early and you want to estimate the actual trough just before the next dose to determine if the current regimen is appropriate – link to new program.)

Author:
Michael haas
[email protected]

• A quick JNC 8 guideline tool was created.
• A popular 12 step desensitization tool was added.
• A few new agents were added to the infectious disease list e.g. a couple of new lipoglycopeptides:  Dalbavancin (Dalvance™); Oritavancin (ORBACTIV™)
• Additional renal dosing guidelines were added.

• A link to a very popular drug identification tool was created (user request).
• Updates to the pleurodesis page were completed – additional guidance for sterile talc slurry prep.
• A warfarin maintenance adjustment tool was created. This new tool has a built-in database of warfarin maintenance regimens from 5 to 100mg. (Beta)
• NNT (number needed to treat) Tool.  Results: CER, EER, ARR, RRR, and NNT.

• Pooled Cohort Equations
• Cholesterol Treatment Decision Tool – LATEST guidelines
• Statin Benefit Groups – Treatment overview

1. Code blue (ACLS) cheat sheet was created.
2. Alteplase calculator (MI, Stroke, PE).
3. Oxalate Content Calc –  Lists the oxalate content of multiple food items to help manage overall oxalate intake.

Additional renal dosing guidelines were added for some of the less obvious agents.

In the coming weeks, a quick review of the current infectious disease section will be completed.   Also, some modifications will likely be made to the hypocalcemia calculator.

New navigation scheme:  a possible quick access tool may be created for the multiple drug tables to help facilitate the location of a specific drug category.

The following comments will appear in the ‘Warnings’ section whenever this condition is met:

[Program used ACTUAL weight in the calculation of the Cockcroft and Gault – IBW equation since it is LESS than the IBW. – Notice below that the result for this equation is the same as the Cockcroft and Gault – actual body weight].

• Mathematical Model For Methadone Conversion Examined:Link
• Fudin Factor graphically compared to Ripamonte, Ayonrinde, and Mercadante – jpeg

2] Last month we created a new drug categories page that should help locate a particular drug table.

3] Site-wide search capability:
Occasionally, the large search bar at the top of page may not provide links to recently developed material.  Alternatively, users may find the Google search functionality much more effective:

Google Site Search

Custom Search

Estimated  ‘Calorie’  Calculators

Harris-Benedict Equation: Estimation of total calories needed. MOST widely used equation for calculating basal metabolic rate and total calories.
Revised Harris-Benedict Equation:  The original Harris Benedict equation was revised in 1984. This updated equation can be used to calculate the basal metabolic rate and total calories.
RESTING Metabolic Rate (RMR) : Resting Metabolic Rate Calc – This equation can be used to calculate the RESTING metabolic rate and total calories. Mifflin-St Jeor equation.
Schofield equation (BMR) : This equation was part of the previous government guidelines to formulate RDA’s and can be used to calculate the basal metabolic rate and total calories needed.
Institute of Medicine Equation- LATEST EQUATION: IOM Equation-Estimated Energy Requirement (EER) Estimation of total calories needed. This equation is behind the 2005 Dietary Guidelines for Americans and the new food pyramid, MyPyramid.

Other calculators and tools that have been added:

1. Estimate Resting Energy Requirements in critical care patients – Ireton-Jones Equations.
2. Calculate the amount of protein that should be consumed daily based on the latest guidelines
3. How much daily fiber do I need???
4. Calculate the amount of essential amino acids that are recommended in the diet
5. Protein / Amino acid review
6. Protein Sources (plant-based versus animal source)
7. Calcium and Vitamin D Calculator – How much do I need?
8. ACLS pocket guide has been updated

1.  2012 version of the Creatinine clearance multi-calc has been released.    The updated version has the following new functions:

• New reporting function – automated output that can be copied into an electronic record.
• GFR-EPI equation added
• New CKD staging function added.

2. Warfarin dose prediction equation (calculator) released. 

3.  Common Intravenous Cardiac Medications Calculator (Direct thrombin inhibitors, glycoprotein IIb/IIIa inhibitors.  Includes algorithm for argatroban for HIT)

Latest updates released:

1. New vancomycin single level analysis tool that allows the user to enter the time that has elapsed since the last dose was given. This updated version is especially useful if the current dosing schedule was not adhered to (dose was administered early or late).  Link to program.    The original program requested the time that the trough was drawn prior to the next dose. 
2. New epidural concentration/recipe guide. Also contains a link to a pop-up calculator for non-standard concentrations of bupivacaine and/or fentanyl.
3. A reporting function was added to the bottom of the vancomycin single level analysis tool based on feedback from a clinical pharmacist.  This section allows the user to copy a detailed note based on the previous entries and then paste it into an electronic record.
4. New calculator:  CKD-EPI Creatinine Equation. This program was written over 2 years ago… Sorry for the late posting.
5. A new benzodiazepine converter program was just added. Several references were reviewed in order to make sure the final equivalent dosages had ample support.
6. Someone had reported that important entries were missing from the renal dosing list.  An old index page was mistakenly uploaded.  Please review the current list... it contains several new entries.

1. Warfarin calculator / background information
   • Warfarin Dosing Calculator – Multiple dosing algorithms
   • Warfarin NOMOGRAMS utilized by the program
   • Therapeutic (INR Ranges)  by indication
   • Warfarin  (DRUG-DRUG) Interactions
   • Warfarin dosing summary- (based on 8th ACCP guidelines)
   • INRs – Treatment of ELEVATED levels
   • Warfarin – Maintenance dose adjustment
   • Bleeding risk: HAS-BLED bleeding risk score
   • Bleeding risk: HEMORR2HAGES Bleeding Risk Score
   • Warfarin: Low dose nomograms – Background data
2. New advanced Pharmacokinetic dosing tool that allows the user to select a custom population kinetics model:  New 2012 calc.
3. New package insert search tool.
4. Updated Medical calculator index page.

Expect significant updates to the current web site layout.  Our last major update of the web site (page layout) was in 2007.   Our home page will be updated first and the rest of the site will use a similar layout.

We have also moved to a new server!   The new server has four times the capacity of our current traffic levels.   The new environment should improve page load times and errors seen with some of our programs during extremely busy periods.

I will also be reviewing the potential for additional disease state management calculators… Several beta versions are currently in the development stage.

If you have any ideas for new calculators, let me know….

Several new calculators will be created in the coming months…
If time permits, a few new disease state management tools will also
be released.

Fiber Analysis

Preliminary research has been completed on a new fiber analysis tool. Look
for this important release hopefully before the end of the year.  Analysis of
specific soluble fibers can impact recommendations given to patients with elevated
cholesterol levels or as general nutritional information.  More to come…..

Current tools: 

Soluble fiber calculator   Fiber calculator  Fiber requirement calculator

Therapeutic relevance: HIGH

The missing link in disease pathogenesis??
This topic is extremely important to not only healthcare professionals, but also the general public.  Future articles will be added to the nutrition section….. in the meantime,  please research the IMPORTANCE of the ratio  of the omega-6/omega-3 essential fatty acids.  

"Several sources of information suggest that human beings evolved on a diet with a ratio of omega-6 to omega-3 essential fatty acids (EFA) of approximately one whereas in Western diets the ratio is 15/1-16.7/1." 

"Excessive amounts of omega-6 polyunsaturated fatty acids (PUFA) and a very high omega-6/omega-3 ratio, as is found in today's Western diets, promote the pathogenesis of many diseases, including cardiovascular disease, cancer, and inflammatory and autoimmune diseases, whereas increased levels of omega-3 PUFA (a low omega-6/omega-3 ratio) exert suppressive effects. In the secondary prevention of cardiovascular disease, a ratio of 4/1 was associated with a 70% decrease in total mortality. A ratio of 2.5/1 reduced rectal cell proliferation in patients with colorectal cancer, whereas a ratio of 4/1 with the same amount of omega-3 PUFA had no effect."

Source:
Simopoulos AP. The importance of the ratio of omega-6/omega-3 essential fatty acids. Biomed Pharmacother. 2002 Oct;56(8):365-79.