Clinical pharmacy services in a rehabilitation facility

Clinical pharmacy services provided by pharmacists to patients in a rehabilitation facility through a contracted arrangement with a local hospital are described. Two staff pharmacists from a community hospital oversee the drug-distribution process and provide clinical services at a 40-bed private rehabilitation facility. During alternate four-week periods, each pharmacist works at the rehabilitation facility; the other four-week period is spent in traditional drug-distribution activities at the hospital. The hospital is reimbursed for clinical services separately from drug-distribution services; by keeping records of the time spent in clinical activities at the facility, the pharmacists have obtained increased reimbursement for these services since initiation of this program. Clinical services provided by pharmacists at the institute include patient education, drug-therapy monitoring and consultation, drug information activities, and management of drug therapy in selected patients. In 1982, pharmacists provided 230 drug-therapy consultations to physicians and received referrals for drug-therapy management of 47 patients on warfarin sodium, 46 on antihypertensive drugs, and 27 on phenytoin sodium. The provision of a variety of clinical pharmacy services to patients in a rehabilitation facility offers a unique and professionally rewarding practice.

Prospective evaluation of the risk of bacteremia and the role of antibiotics in ERCP

To determine the frequency of bacteremia associated with endoscopic retrograde cholangiopancreatography (ERCP), we obtained blood cultures before, during, and after ERCP in 51 consecutive patients. Patients with radiographically demonstrated abnormalities in pancreatic and/or biliary ducts were routinely given antibiotic therapy after ERCP. Bacteremia after successful cannulation of the papilla of Vater was observed in only one patient with multiple strictures of the main pancreatic duct. No episodes of acute febrile illness was observed in any patient during the 48-hour follow-up period after ERCP. Our observations suggest that the risk of bacteremia from ERCP is minimal, and that any possibility of sepsis after ERCP in patients with abnormal pancreatic or biliary ducts may be prevented by administering appropriate antibiotics after the procedure.

Hostility, CHD incidence, and total mortality: a 25-year follow-up study of 255 physicians

High levels of hostility as assessed by a MMPI scale (Ho) have been found associated with increased levels of arteriographically documented coronary atherosclerosis. In this study we examined the relationship between hostility and subsequent health status in a 25-year follow-up of 255 medical students who completed the MMPI while in medical school. High Ho scores were found to be predictive of both clinical coronary disease incidence and total mortality.

Physiological and psychological variables predict compliance to prescribed exercise therapy in patients recovering from myocardial infarction

Previous research has documented high rates of noncompliance to prescribed medical therapy in patients recovering from myocardial infarction (MI). This study was undertaken to determine if patients who subsequently drop out of a structured cardiac rehabilitation program could be prospectively distinguished from those who remain in the program based upon their initial baseline characteristics. Thirty-five consecutive patients with recent MIs underwent comprehensive physical and psychological assessments at entry into the program, and were followed for a period of 1 year. The 14 patients who dropped out of the program could be distinguished from the compliers on the basis of their reduced left ejection fraction assessed by first pass radionuclide angiography at rest and during peak exercise. In addition, their psychological profiles assessed by the MMPI indicated the dropouts were more depressed, hypochondriacal, anxious, and introverted and had lower ego strength than those who remained in the program. Statistical analysis further indicated that psychological variables were associated with noncompliance independently of physical status. These findings suggest that MI patients who are unlikely to adhere to this form of medical therapy may be prospectively identified based upon their initial physical and psychological characteristics.

Type A behavior and elevated physiological and neuroendocrine responses to cognitive tasks

Qualitatively distinct patterns of cardiovascular and neuroendocrine responses were observed in male college students during mental work and during sensory intake task performance. During mental work, Type A (coronary-prone) subjects showed greater muscle vasodilatation and more enhanced secretion of norepinephrine, epinephrine, and cortisol than Type B subjects. During sensory intake, Type A hyperresponsivity was found for testosterone and, among those subjects with a positive family history of hypertension, for cortisol. As a demonstration of combined cardiovascular, sympathetic nervous system, and neuroendocrine hyperresponsivity to specific cognitive tasks in Type A subjects, this study breaks ground in the search for mechanisms mediating the increased coronary disease risk among Type A persons.

Changes in the collagen of rat heart in copper-deficiency-induced cardiac hypertrophy

Groups of rats were maintained from weaning on copper-supplemented or copper-deficient diets. After 2, 4, 6, 8 or 12 weeks animals were killed, their hearts were removed and the solubility and phenotype composition of the collagen of the hearts was studied. In the hearts from the copper-supplemented animals 35 to 45% of the collagen could be extracted after two treatments with pepsin but up to 74% could be extracted from the hypertrophied copper-deficient hearts. Almost all of the increase in the soluble material was found in the first pepsin extract. Electrophoretic analysis of the extracts showed that in the copper-supplemented hearts the ratio of Type III/Type I collagen increased about threefold between 2 and 6 weeks after weaning but by 8 weeks it had returned to about the level found at 2 weeks and was maintained at this level to the end of the experimental period. In the copper-deficient hearts the ratio of Type III/Type I collagen had increased about fivefold by 6 weeks after weaning and from 8 weeks to the end of the experimental period it remained at two to three times the value found in the copper-supplemented hearts. There was an indication that the relative proportion of Type V collagen was reduced in the copper-deficient hearts. The possible significance of these results in relation to the known pathological effects of copper deficiency on the cardiovascular system is discussed.

Pyrazolo[3,4-d]pyrimidine ribonucleosides as anticoccidials. 2. Synthesis and activity of some nucleosides of 4-(alkylamino)-1H-pyrazolo[3, 4-d]pyrimidines

A series of 4-(alkylamino)-1-beta-D-ribofuranosyl-1H-pyrazolo[3, 4-d]pyrimidines was synthesized by enzymatic and chemical methods. On the basis of the previous finding that 4-(alkylthio)-1-beta-D-ribofuranosyl-1H-pyrazolo[3,4-d]pyrimidines were effective anticoccidial agents, this series was examined for efficacy against Eimera tenella in chicks. The most active anticoccidial agent in the present study was the 4-cyclopentylamino derivative (8), which cleared chicks of the parasite at 200 ppm in the diet. Some members of this series were toxic to embryonic chick liver cells, mouse cells, and human cells in vitro. The 4-diethylamino derivative (16), which was not toxic in vitro, appeared to be toxic in chicks.

Extra-adrenal myelolipomas compared with extramedullary hematopoietic tumors: a case of presacral myelolipoma

A large presacral myelolipoma associated with increasing constipation is reported in a 70-year-old obese diabetic female. The resected tumor was encapsulated and dark red to yellow. Light and electron microscopy revealed mature and immature hematopoietic tissue, lymphoid aggregates and mature adipocytes. Myelolipomas arising in extra-adrenal sites are rare. Considered in the differential diagnosis are reactive extramedullary hematopoietic tumors that usually occur in patients with severe chronic anemias. Patients with extramedullary hematopoietic tumors are characterized by anemia, frequent hepatosplenomegaly and abnormal peripheral blood smears, and may be any age. The tumors are usually multiple and usually located in the mediastinum or epidural space. In contrast, patients with extra-adrenal myelolipomas are usually older than 40 years, have normal blood studies, absent hepatosplenomegaly, and usually have chronic debilitating diseases or endocrinopathies. Extra-adrenal myelolipomas are single and usually occur within the abdomen. Extramedullary hematopoietic tumors have a predominance of the hematopoietic component, with erythroid hyperplasia of that component. Extra-adrenal myelolipomas may have a predominance of either the hematopoietic or fatty component, chiefly the latter, and generally have a more conspicuous lymphocyte population. Although the components of these tumors are the same, we consider them separable clinically, pathogenetically and, in many cases, pathologically.

Cardiovascular correlates of the psychotherapeutic process

12 medical student volunteers were studied during 10 weekly sessions of brief dynamic psychotherapy using on-line physiological monitoring and concurrent psychotherapy process ratings. Forearm vascular resistance change from baseline for each visit was found to be related to psychotherapeutic outcome, and to some of the process variables, but to be most strongly correlated with clusters of process variables. This suggests that there may yet be a role for physiological monitoring in psychotherapy research.

Pyrazolo[3,4-d]pyrimidine ribonucleosides as anticoccidials. 1. Synthesis and activity of some nucleosides of purines and 4-(alkylthio)pyrazolo[3,4-d]pyrimidines

The finding that 6-(methylthio)-9-beta-D-ribofuranosyl-9H-purine (6) was more toxic to the avian coccidium, Eimeria tenella, than to embryonic chick liver host cells in vitro prompted the synthesis and testing of analogues of this compound. It was revealed that the beta-D-ribofuranosyl moiety was an important structural feature and that several types of 2-substituents in the purine ring decreased efficacy, as did 3-deaza and 8-aza ring modifications of 6. In contrast, the pyrazolo[3,4-d]pyrimidine analogue of 6 (24) was an order of magnitude more active. Moreover, this analogue was 24-fold less toxic to the host cells than was 6. A series of 4-(alkylthio)-1-beta-D-ribofuranosyl-1H-pyrazolo[3,4-d]pyrimidines was prepared from 4-mercapto-1-beta-D-ribofuranosyl-1H-pyrazolo[3,4-d]pyrimidine (23) and various alkyl halides. The most effective compound in this series in vivo, 4-(ethylthio)-1-beta-D-ribofuranosyl-1H-pyrazolo[3,4-d]pyrimidine (25), cleared chicks of the parasite at 50 ppm in the diet and was much less toxic than was 24.

Redistribution of canine left ventricular myocardial blood flow in unloaded systole

The left coronary arteries of dogs were cannulated and perfused with blood from support dogs. The experimental hearts were unloaded by severing the aortas to maximize strains and minimize fiber stress. In each heart we compared the transmural distribution of blood flow in two states: (1) provision of perfusion pressure (40 mm Hg) only during systole and then (2) provision of perfusion pressure throughout the cardiac cycle. The distribution of flow in each of these perfusion states was labeled with a diffusible radioisotope (42K or 86Rb, one labeling the first state; the other labeling the second). Quantitative, paired autoradiography was used to visualize the two flow distributions. The differences between the two distributions after standardization was plotted as differences between activity vs. depth in the myocardium (r = 0.91). This was fitted with a line by least squares, the slope of which was significantly different from zero at the 0.005 level. The magnitude of the gradient of the systolic flow was represented by the ratio of deep to shallow flow. The mean of these ratios was 0.54 +/- 0.12 (95% confidence interval). A graphical analysis shows that the data are consistent with a gradient of extravascular compression across the left ventricular wall.

The effects of age, sex, and zinc status on the accumulation of (copper, zinc)- metallothionein in rat kidneys

A study has been made of the distribution of copper in the kidneys of growing rats. Renal copper concentrations increased steadily with age and were greater in female than in male animals. Most of the copper was present as (copper, zinc)-metallothionein and two forms of this protein were isolated and characterized from the kidneys of mature female rats. That copper metabolism in kidneys is subject to hormonal influence was indicated by a reduction in the concentrations of copper and (copper, zinc)-metallothionein in ovariectomized rats and by an increase in their concentrations after the administration of progesterone. Concentrations of renal (copper, zinc)-metallothionein were less in zinc-deficient than zinc-adequate rats during pregnancy and after progesterone administration.

Assessment of conceptual tempo in the type A (coronary prone) behavior pattern

Previous research has documented an association between a particular behavioral complex termed Type A, and increased incidence of coronary heart disease. In an effort to define further some of the behavioral characteristics that distinguish Type A subjects from their noncoronary-prone (Type B) counterparts, subjects were administered a test of conceptual impulsivity-reflection. While there were clear sex differences in performance, the results of the present study offered only qualified support for the notion that Type A individuals are more impulsive than Type B individuals. One component of Type A, Speed and Impatience, was shown to be related to increased impulsivity in women, but not in men. The findings suggest the importance of considering the interaction of gender with behavioral subcomponents of the Type A behavior pattern.

Type A behavior, hostility, and coronary atherosclerosis

Type A behavior pattern was assessed using the structured interview and hostility level was assessed using a subscale of the Minnesota Multiphase Personality Inventory in 424 patients who underwent diagnostic coronary arteriography for suspected coronary heart disease. In contrast to non-Type A patients, a significantly greater proportion of Type A patients had at least one artery with a clinically significant occlusion of 75% or greater. In addition, only 48% of those patients with very low scores (less than or equal to 10) on the Hostility scale exhibited a significant occlusion; in contrast, patients in all groups scoring higher than 10 on the Hostility scale showed a 70% rate of significant disease. The essential difference between low and high scorers on the Hostility scale appears to consist of an unwillingness on the part of the low scorers to endorse items reflective of the attitude that others are bad, selfish, and exploitive. Multivariate analysis showed that both Type A behavior pattern and Hostility score are independently related to presence of atherosclerosis. In this analysis, however, Hostility score emerged as more related to presence of atherosclerosis than Type A behavior pattern. These findings confirm previous observations of increased coronary atherosclerosis among Type A patients. They suggest further that an attitudinal set reflective of hostility toward people in general is over and above that accounted for by Type A behavior pattern. These findings also suggest that interventions to reduce the contribution of behavioral patterns to coronary disease risk might profitably focus especially closely on reduction of anger and hostility.

Consumer focus of a university drug and poison information center

The consumer-oriented aspect of a university drug and poison information center is described. The University of Cincinnati Medical Center began its 24-hour consumer drug information telephone service in 1972. It is staffed by seven full-time employees, and pharmacists and pharmacy residents of nearby hospitals handle evening and weekend calls. All participating personnel are trained in structured programs. The $78,000 annual budget for the consumer drug information service is funded exclusively from external sources such as mental health agencies, foundations, and donations. Of 40,719 calls handled by the center in 1979, 83% were from the public. The total annual call volume has increased by 250% since 1972. In telephone follow-up of consumer calls, 73% of persons claimed they followed verbatim the advice given. Of calls during 1972, 1974, 1977, and 1979, 32.2% concerned drug abuse; 28.6%, identification of ingredients; and 10.9%, efficacy. Data from a three-month study in 1979 showed that the goal perceived by the information provider was to satisfy the curiosity of the caller 63.6% of the time (35.6% of the time immediate action was indicated). The authors believe that the center promotes appropriate use of physicians and pharmacists as sources of information for consumers.

Effects of exercise on the Type A (coronary prone) behavior pattern

This study presents the initial findings of an attempt to reduce the risk of coronary heart disease (CHD) in a group of health, middle-aged adults by participation in a ten-week, supervised exercise program. Forty-six subjects were classified as Type A or Type B based on their scores on the Jenkins Activity Survey (JAS). Measures of physiologic (blood pressure, serum lipids, body weight, plasminogen activator release, and treadmill performance) and psychologic (scores on the JAS) variables were obtained before and after the exercise program. Subjects were able to successfully reduce the physiologic cardiovascular risk factors. Moreover, Type A subjects lowered their scores on the JAS Type A scale after training, while the scores of the Type B subjected remained unchanged. It is concluded that a supervised program of regular exercise can successfully modify the physiological and psychological variables associated with increased risk for CHD in a nonclinical sample of healthy adults.

Is there a doctor in the house?

When it is realized that American universities award nearly 50,000 different kinds of doctorates annually, it is little wonder that some should ask, "What is a real doctor?" This paper explores briefly the view which holds that the term "doctor" should be reserved for those whose long years of intensive study and practice in the field of medicine entitles them to this special designation. Attention is also given to the opposing view which argues that the phenomenon of doctoring, in the broad and generic sense, properly encompasses, not alone the field of medicine, but a number of disciplines that seek "to restore to good condition."