Patient-initiated postmarketing surveillance: a validation study

A new patient-initiated, pharmacy-based postmarketing surveillance system is described. At the time a new prescription for a targeted drug was filled, 2705 outpatients (experimentals) randomly assigned to the new system had a printed notice attached to their medication bags: the information requested them to report any "new or unusual symptoms" during the next 2 weeks by a toll-free telephone number to a trained nonprofessional who conducted a standardized adverse drug reaction (ADR) interview. To help validate the new system, another sample of 1109 patients (controls) did not receive a request for self-monitoring but were interviewed by telephone 2 weeks later. Target drugs were chosen from two classes for which side effect profiles are well identified: oral antibiotics and tricyclic antidepressants. Results show that within both drug classes, all patient-initiated reports closely matched those obtained from controls; the experimental and control groups also reported predictably high relative frequencies for the most commonly expected ADRs. Additional analyses suggest that a patient-initiated monitoring system could prove to be a promising complement to existing physician-based surveillance systems.

Menstrual symptoms and up-down vectors

Multiple studies considered the somatic symptom correlates of up-down asymmetries in women. In four samples, involving a total of 81 women, menstrual symptoms were significantly linked with the up-down distortion of the space surrounding self. In addition, there were borderline relationships between menstrual symptoms and other indices of up-down asymmetry. The findings suggested a possible link between menstrual symptoms and concerns about possessing versus not possessing power. Over-all, the results support previous studies indicating that spatial sets reflect important attitudes or conflicts that seem to play a role in somatic symptomatology. However, they point up the importance of considering sex differences.

Pathologic findings related to the lead system and repeated defibrillations in patients with the automatic implantable cardioverter-defibrillator

The purpose of the present study was to examine at autopsy the effect of multiple defibrillations on the myocardium and the pathologic consequences of short- and long-term placement of the intravascular and interpericardial leads of the automatic implantable cardioverter-defibrillator. Twenty-five patients were examined at autopsy; 8 of them underwent lead implantation only and 17 received both leads and the automatic implantable cardioverter-defibrillator. Twelve patients (48%) died of ventricular tachycardia or ventricular fibrillation; seven (28%) died of other causes. Acute pericarditis occurred in all patients, resulting in a localized, progressive fibrosis around the apical patch lead without giving rise to pericardial restriction. Thrombus formation was associated with the superior vena cava spring electrode in four patients (17%) and the right ventricular rate-sensing electrode in one patient (4%). Asymptomatic pulmonary emboli occurred in two patients (8%). In one patient who underwent defibrillation 59 times, superior vena cava changes consisted of vein wall destruction, fibrosis and thrombus formation. Pathologic changes under the apical patch related to defibrillation were observed in seven patients; two of these had fewer than 5 defibrillations, one had 8 defibrillations and four had 21 to 74 defibrillations. These changes consisted of contraction band necrosis in four patients, vacuolar cytoplasmic clearing and loss of myocytes confined to the myocardium under the patch electrode in five patients who had multiple defibrillations. The observed pathologic changes were estimated to affect less than 2% of the total myocardial mass. Thus, the automatic implantable cardioverter-defibrillator lead system and multiple defibrillations result in localized myocardial injury confined to the tissue under the patch electrode.(ABSTRACT TRUNCATED AT 250 WORDS)

Increased frequency of doxycycline side effects

As part of a study investigating new methods of detecting adverse drug reactions, adult outpatients receiving new prescriptions for 1 of 4 antibiotics (doxycycline, penicillin VK, ampicillin, or tetracycline) were assigned to 1 of 2 methods of monitoring adverse drug reactions. Data were collected from a total of 457 staff-initiated interviews and from 1467 patients who were asked to telephone to report possible adverse effects. Doxycycline is considered by authoritative sources to be generally comparable in side effects to other tetracyclines and penicillins, with the exception that it increases photosensitivity. Results from both monitoring methods consistently indicated at least a 3-fold higher frequency of nausea or vomiting with doxycycline relative to the other antibiotics. Complaints of skin rash also were at least 4 times more frequent with doxycycline, depending on the particular sample.

The relationship between cognitive failures, psychoneurotic symptoms and sex

As Broadbent et al's (1) original analysis of the relationship between the Cognitive Failures Questionnaire (CFQ) and the Middlesex Hospital Questionnaire (MHQ) was conducted on an altered version of the MHQ, the present study undertook this same analysis using the full MHQ. In addition, the relationship was examined to see if it was mediated by the differences in the scoring of males and females on each questionnaire. Our results support and strengthen Broadbent et al's conclusion that high rates of cognitive failure are associated with psychoneurotic symptoms. The sex difference on the CFQ is discussed in terms of vulnerability to stress to account for the higher incidence of psychoneurotic symptoms in females.

99Tcm-MDP uptake by lymph nodes following tracer infiltration: clinical and laboratory evaluation

Uptake of bone scanning agents in non-osseous sites has been described in a variety of pathologic conditions including tumor metastases. We have seen several patients in which such uptake was proximal and ipsilateral to the injection site of 99Tcm-methylene diphosphonate, apparently in normal lymph nodes. To further investigate this phenomenon, it was studied in a rat model. Activity in popliteal nodes ipsilateral to the injection site was over 60-fold greater in the animals that received subcutaneous (s.q.) footpad injection compared to femoral IV injection. Ipsilateral popliteal node activity in the s.q. group was 159 times that of contralateral popliteal nodes, with an ipsilateral node to liver ratio of 184:1. In summary, dramatically increased uptake of 99Tcm-MDP in normal lymph nodes ipsilateral and proximal to an extravasated injection has been demonstrated. An awareness of this phenomenon in the clinical setting can avoid confusion with pathologic forms of soft tissue uptake.

Long-term versus short-term amitriptyline side effects as measured by a postmarketing surveillance system

As part of a large-scale postmarketing surveillance study, the adverse clinical events (ACEs) reported by 85 outpatients taking amitriptyline were investigated. Two discrete groups of patients were identified based on their duration of amitriptyline treatment: 45 had started the drug within 2 weeks of their interview (mean = 10.1 days, SD = 1.6 days), while 40 were much longer term tricyclic antidepressant patients (mean = 227.2 days, SD = 135 days). Our analysis of amitriptyline side effects reported by each of these two discrete groups challenges the common clinical impression that tricyclic side effects, in general, abate with continued treatment. Shorter term patients were much better able to correctly attribute their adverse clinical events to their drug therapy. Anticholinergic side effects were reported as new symptoms by the long-term patients just as frequently with similar ratings of subjective severity. These reports of adverse drug reactions of recent onset by long-term amitriptyline users may reflect the fact that such symptoms fluctuate in their occurrence and may not be recognized as potentially drug-induced until some threshold for patient tolerance is exceeded.

5-Fluorouracil, cyclophosphamide, and vincristine for adenoid cystic carcinoma of the head and neck

Twenty-one patients with adenoid cystic carcinoma of the head and neck were treated with intravenous boluses of cyclophosphamide and vincristine and 5-day continuous intravenous infusions of 5-fluorouracil (CVF) every 4 weeks. Eight patients received CVF as palliation for recurrent or metastatic disease. A sustained complete response (107+ months) was observed in one patient; one partial response and one mixed response each also were observed. In four patients disease stabilized, and in one disease progressed. Thirteen patients received six courses of CVF in the adjuvant setting after surgery and radiation for either primary or locoregional recurrent disease. Recurrences developed in two of seven patients with primary disease and three of six patients with recurrent disease with a median follow-up 45 months (range, 20-108+). Recurrence rate and time interval to recurrence were comparable to those of well-matched historical controls. Distant metastases have not developed in patients treated with CVF in the adjuvant setting, whereas distant metastases had developed in historical controls within comparable periods of follow-up. Serious toxicities were not encountered in any patient. The authors conclude that CVF is a well-tolerated combination chemotherapy program with activity in adenoid cystic carcinoma of the head and neck. This regimen, however, has not had a major impact in the adjuvant setting in preventing recurrent disease.

A program for improving energy conservation behaviors in adults with rheumatoid arthritis

This paper presents the design and evaluation of an occupational therapy program developed at the National Institutes of Health for teaching energy conservation and joint protection to adults with rheumatoid arthritis. An existing model for educational diagnosis in health education was used to identify program, behavioral, and educational objectives for the new program. The use of this model resulted in measurable objectives, which were used as outcome measures in the randomized research evaluation of the new program. The dependent variables measured were activity-of-daily-living status, psychosocial adjustment to illness, knowledge, disease activity, pain, and fatigue. None were significantly different after the intervention. The independent variables measured included components of balancing rest and physical activity. After 3 months, a greater percentage of the subjects receiving the workbook-based occupational therapy program than those receiving traditional occupational therapy demonstrated an application of the behaviors the intervention was designed to change.

Intraperitoneal delivery of monoclonal antibodies: enhanced regional delivery advantage using intravenous unlabeled anti-mouse antibody

Radiolabeled monoclonal antibodies (MAb) delivered intraperitoneally expose cells in contact with peritoneal fluid to considerably higher levels of MAb than if the MAb dose were given intravenously. This regional delivery advantage for intact MAb is present mainly due to the relatively slow exit of MAb from the peritoneal fluid to the blood. Eventually, following i.p. injection, blood levels of MAb rise resulting in exposure of the animal to high systemic MAb levels and potential toxicity. In this series of experiments, systemic exposure was minimized by the administration of unlabeled goat polyclonal anti-mouse antibody intravenously from 1 1/2 to 6 h following i.p. MAb injection. This maneuver results in the formation of immune complexes with their subsequent clearance and dehalogenation by the reticuloendothelial system, thus minimizing systemic MAb exposure. This approach, of increasing systemic clearance of MAb, did not alter intraperitoneal MAb levels and thus significantly increased the regional delivery advantage to the peritoneal cavity by 70-100%. This approach provides an immunologic rationale for the further enhancement of MAb delivery to i.p. foci of malignant disease and may have diagnostic and therapeutic utility.

Cancer cure with organ preservation using radiation therapy

In 1985, the American Cancer Society has anticipated that 910,000 new cases of invasive cancer will be diagnosed in the United States. More than 37% of those patients can be treated for cure with organ preservation using radiation therapy. The basic biologic background for such an approach to the problem is well established. Clinical data to substantiate the validity of the concept date from 1902 to the present. Without question, organ preservation is becoming a major and important concept in the management of the patient with cancer, and new and innovative techniques for treatment are enabling the organ to be preserved, the cancer to be cured, and appropriate cosmesis and function to be preserved. Many tumor sites are appropriate for this treatment technique, including the breast, the eye, the larynx, and the prostate. In 1985, there has been new emphasis on the successful treatment of cancer with the preservation of the organ intact. The maxim to offer the patient the maximum potential for cure with the minimum complication now has an additional concept related to the opportunity to preserve cosmesis and function.

New approaches to postmarketing surveillance

As part of a large-scale ongoing project exploring new pharmacy-based methods of postmarketing surveillance, we are comparing a patient-initiated monitoring system to a staff-initiated approach. Here we report data only from staff-initiated, computer-directed telephone interviews with 231 outpatients approximately 2 weeks after they had been prescribed a target drug chosen from two markedly different pharmacological classes for which adverse drug reactions (ADRs) are well-documented. Our results indicate that spontaneous patient reports of "new or unusual symptoms" obtained from a standardized staff-initiated telephone interview can be quite reliable, leading to accurate detection of known tricyclic antidepressant and antibiotic ADRs.

Imipramine and chlordiazepoxide in depressive and anxiety disorders. II. Efficacy in anxious outpatients

A double-blind, placebo-controlled comparison at three collaborating university sites included 242 patients diagnosed as having anxiety disorders. A two-week placebo washout period preceded random assignment to eight weeks of imipramine hydrochloride, chlordiazepoxide hydrochloride, or placebo treatment. Antianxiety effects of imipramine were superior to those of the other two agents by the second treatment week; these effects became more clearly significant thereafter and were independent of degree of both baseline depression and anxiety. Excluding patients with possible panic-phobic syndromes from the analyses removed most significant antiphobic and antidepressant effects of imipramine but left intact imipramine's significantly superior antianxiety effects.

The perception of performance in stress: the utilisation of cognitive facts by nondepressed and depressed students

Three experiments are reported in which expectancies about performance in stressful conditions by nondepressed and depressed nonclinical populations were examined. The first experiment was concerned with estimates of either errors or response rates made in advance, with regard to the likely competence level of a (hypothetical) person allegedly working in conditions of either loud noise, fatigue, sleep loss, social stress, or incentive. Nondepressed subjects as well as depressed subjects provided negative expectancies. The second experiment involved obtaining an estimate of personal competence in conditions where subjects were instructed that personal performance on the task would be required after the estimate had been provided. Nondepressed subjects differed from depressed subjects in that the estimates of the former were less negative in terms of the magnitude of the estimates provided. A third experiment was designed to see whether the negative expectancies about performance in stress exhibited both by nondepressed and by depressed subjects would be used in making allowances for the competence of a typist on the basis of a typescript allegedly produced under high noise conditions. An unexpected effect was that depressed subjects judged the typist more harshly and failed to make allowance for adverse working conditions in the way that nondepressed subjects did. The results are discussed in terms of the implications for understanding cognitive factors in depression.

Height, weight, and risk of breast cancer relapse

The records of 231 patients with primary breast cancer and 85 patients with metastatic breast cancer were reviewed to determine whether indices of body weight were associated with prognosis. Results support previous reports that indices of body weight are relatively weak, but real, prognostic factors.

Meningococcal arthritis

Meningococcal infection (MI) remains endemic in the Western Cape. A review of 2216 cases in which the condition was diagnosed and notified to the relevant authorities between January 1977 and March 1982 is presented. In 121 patients the disease was complicated by meningococcal arthritis (MA). MI and MA occurred most commonly in the Coloured population; over 50% of patients with MI were less than 2 years of age; and patients with MA were slightly older than the sample mean. The onset of arthritis showed a biphasic pattern with an early peak at 1-2 days and a later peak, heralded by typical recrudescence of fever, at 5-10 days which usually lasted 5-7 days. It was most often monarticular, the knee being the joint most frequently affected. Four cases of isolated MA were also encountered.

Public drug information: a telephone-based model for patient education

As one facet of a larger investigation evaluating the various means by which patients receive information concerning their medications, a telephone-based drug information service was established for selected public use. The purpose was to detail the growth and utilization of the service, characterize the type and importance of the questions asked, and compare the potential utility with that of the USP-DI patient package insert (PPI) in responding to the public's drug information requests. Availability of the toll-free number for the Prescription Drug Information Service (PDIS) was controlled by offering it only to outpatients receiving selected medicines from the pharmacy of a large university-based medical center. The PDIS was operated by clinical pharmacists who participated in completing standardized operational data forms after each drug information call by the public. Of those calls received, 91.7% were not of a serious nature and most commonly dealt with side effects, drug interactions, and drug identification. Fifty percent of first-time calls occurred within two days of the subject's visit to the pharmacy and 23.4% of the total PDIS calls were repeat contacts. Interestingly, 34% of the patients' questions could not have been answered using the standard USP-DI PPI.

Menstrual discomfort, psychological defenses, and feminine identification

Theorists have suggested that menstrual complaints occur more frequently in women who have a weaker sense of feminine identification. To test this hypothesis 50 women were administered the Body Symptom Questionnaire and the Defense Mechanisms Inventory (DMI). The DMI scales have been linked to differences in sexual identification. Results affirmed a relationship between personality dynamics and the degree of menstrual discomfort experienced by women relative to their other body problems. As predicted, the higher the percentage of menstrual symptoms, the more likely it was that a woman made use of "masculine mode" externalizing defenses and the less apt she was to use "feminine mode" non-externalizing defenses. A composite index of the tendency to externalize hostility when faced with conflict was highly correlated with the percentage of menstrual complaints. The defense pattern findings suggest that a woman who has a strong acceptance of herself as a female will experience fewer of her somatic symptoms as menstrual.

The effect of specimen processing on radiolabeled monoclonal antibody biodistribution

Monoclonal antibodies are assuming increasing importance in experimental and clinical medicine. Generally, tissue biodistribution studies in animals precede human studies. To investigate a concern of ours that varying methods of sample handling in these studies could result in apparent alterations in tissue-binding levels, we compared two methods of tissue processing after the administration of labeled antibodies: one including only blotting away of blood, the other involving several washing steps. The unwashed, blotted specimens were found to have significantly more radioactivity per gram of tissue than the washed, ranging from 22% more in the spleen to 52% more in the lungs and left ventricle. Since in vivo imaging is dependent on the total mount of radioactivity in an organ, we believe the most meaningful determination of tissue radioactivity should be based on unwashed samples. Awareness of this problem is suggested to allow meaningful extrapolations from measured tissue localization data to imaging and therapy.

Body perception and somatic discomfort in relation to right- versus left-handedness

Multiple studies analyzed differences in body perception and body complaints between right- and left-handed subjects. Both male and female samples were included. The findings indicated that the left-handed exceeded the right-handed in feelings of body security and degree of body boundary differentiation. In addition, handedness was shown to be linked with different modes of distributing attention to the major sectors of one's body. An adequate explanation of the link between handedness and body perception is not at present available.