Pharmacist clinical intervention program

Our efforts have helped us demonstrate the positive impact of pharmaceutical care for patients. Our experience with the Clinical Notes section of our computer system leads us to recommend that such capabilities be sought in all pharmacy computer systems. A significant advantage to avoiding paper-based systems for documenting and collecting information relevant to clinical interventions, ADRs, DUE data, and patient outcomes has been proven in our institution. Various ways to categorize intervention data have been reported in the literature. We recommend clinical intervention categories be based on the eight categories of drug misadventuring so that data from different hospitals can be tabulated or compared. The success of our system is that it is one system rather than many systems. The importance of pharmacist documentation demands that it be simple, efficient, and painless, or it will be nonexistent.

Lipopolysaccharide-induced cytokine production and mortality in mice treated with Corynebacterium parvum

Tumor necrosis factor alpha (TNF-alpha) has been shown to be an important mediator of the lethal effects of endotoxin in several experimental models of septic shock. However, studies with a recombinant human interleukin-1 (IL-1) receptor antagonist protein (IL-1ra) suggest a role for IL-1 as a mediator of septic shock as well. In the present study, we show that mice treated in vivo with Corynebacterium parvum are primed for the production of interferon-gamma (IFN-gamma) and exhibit an enhanced capacity to produce serum IL-1 alpha, TNF-alpha, and IL-6 when challenged intravenously with lipopolysaccharide (LPS). The majority of C. parvum-treated mice die within 24 h of an LPS challenge. Pretreatment with a rat antimouse TNF-alpha monoclonal antibody (mAb) protected 90% of the animals against the lethal endotoxin challenge, while an anti-IFN-gamma mAb gave approximately 75% protection. The anti-IFN-gamma mAb also caused a reduction in LPS-induced serum TNF-alpha and IL-1 alpha. Anti-IL-1 alpha, anti-IL-1 beta, and anti-IL-6 neutralizing mAb did not protect against lethality when administered to mice prior to the LPS challenge. These results indicate that TNF-alpha and IFN-gamma are major mediators of endotoxin shock in C. parvum-treated mice. The results further suggest that the IFN-gamma produced by C. parvum-primed mice in response to an LPS challenge serves as a stimulus for enhanced production of TNF-alpha and IL-1 alpha. These findings are consistent with an increasing body of evidence suggesting a major role for IFN-gamma in lethal endotoxemia.

Pericardial extramedullary haemopoiesis in chronic myelomonocytic leukaemia

Chronic myelomonocytic leukaemia (CMML) is a myelodysplastic syndrome with a diverse clinical spectrum. A case of a 60 year old man with CMML who developed cardiac tamponade is reported. Cytological examination of the pericardial effusion fluid showed extramedullary haemopoiesis. Serous effusions are well recognised in association with this disease, but this seems to be the first reported case of extramedullary haemopoiesis resulting in a pericardial effusion in a patient with CMML.

Cytokine gene expression in mice undergoing chronic graft-versus-host disease

Chronic graft-versus-host disease (GVHD) can be induced in B6D2F1 mice by injection of parental DBA/2 lymphoid cells. Stimulation of donor T cells by host MHC antigens leads to the stimulation of host B cells. Little is known of the lymphokines produced during such a reaction. This study was designed to directly measure the levels of mRNA for interferon-gamma (IFN-gamma), interleukin 2 (IL-2), IL-4, IL-5, and IL-10, as well as several other genes, using semiquantitative polymerase chain reaction (PCR). Semiquantitative PCR was reproducible and signals generated were dependent on the amount of specific RNA or cDNA in each reaction. Early during the progression of GVHD (2 days after the first injection of parental cells) there was little increase in IL-10 mRNA, a slight increase in IL-4 mRNA, and a dramatic increase in IL-2 mRNA. In addition, IL-2 bioactivity was demonstrated in supernatants from GVH splenocytes cultured in vitro for 24 h. Later in the response (1 week after the second and final injection of parental cells) IL-4 mRNA levels were elevated as they were earlier while IL-10 mRNA levels were dramatically increased. IL-2 mRNA levels were no different in mice undergoing GVHD than in normal mice at this time. IFN-gamma mRNA was detectable both early and late, although at similar levels in normal mice and mice undergoing GVHD. At both times examined, IL-4 was below the limits of detection by bioassay and IFN-gamma, IL-4, IL-5 and IL-10 were below the limits of detection by ELISA. Further studies showed that a majority of the IL-4 and IL-10 mRNA found elevated in GVH mice were produced by Thy1.2+ T cells, with small amounts from B220+ B cells. In addition, the detectable IFN-gamma mRNA found in GVH mice at this later time also was produced by Thy1.2+ T cells, with small amounts from B220+ B cells.

Radiographic assessment of component orientation in elbow arthroplasty. A technical description

We describe an alternative method of taking standardized radiographs of the elbow in patients with rheumatoid arthritis, taking into account fixed deformities. The technique enables assessment of the orientation of joint replacement components, including their axial rotational alignment. The accuracy of the method for calculating axial rotational alignment has been evaluated using a skeleton model. Within the 20 degrees limits of arm position the accuracy was found to be on average 1.4 degrees for the humerus and 2.2 degrees for the ulna.

Prevention of diabetic vascular dysfunction by guanidines. Inhibition of nitric oxide synthase versus advanced glycation end-product formation

This study was undertaken to compare the ability of two guanidine compounds (aminoguanidine and methylguanidine), with different in vitro effects on NO synthase activity and AGE formation, to inhibit diabetic vascular dysfunction developing early after the onset of diabetes. In rats with STZ-induced diabetes of 5-wk duration, regional vascular [125I]albumin permeation was increased about two- to threefold in ocular tissues, sciatic nerve, and aorta; in general, both guanidine compounds normalized albumin permeation in diabetic rats without affecting it in controls. Methylguanidine was only approximately 7% as effective as aminoguanidine as an inhibitor of AGE formation from L-lysine and G6P; both compounds were poor inhibitors of AR. Methylguanidine was approximately 1-5% as potent as aminoguanidine and L-NMMA as an inhibitor of the cytokine- and endotoxin-inducible isoform of NO synthase. In contrast, the potency of methylguanidine as an inhibitor of the constitutive isoform of NO synthase was comparable to that of aminoguanidine, and both guanidine compounds were much less effective than L-NMMA. These observations suggest a role for a relative or absolute increase in NO production in the pathogenesis of early diabetic vascular dysfunction and raise the possibility that inhibition of diabetic vascular functional changes by aminoguanidine may reflect inhibition of NO synthase activity rather than, or in addition to, prevention of AGE formation.

Regeneration in periodontics

The regeneration of periodontal tissues and the formation of a new attachment apparatus is now feasible in certain situations. This article reviews the techniques and literature on the subject and discusses the extremely important area of case selection.

In vitro and in vivo immunopharmacological profile of Sch 40120

Sch 40120 (10-(3-chlorophenyl) - 6,8,9,10- tetrahydrobenzo [b] [1,8] naphthyridin-5 (7H)-one) is a leukotriene inhibitor that is also a potent inhibitor of acute inflammatory responses in rodent systems. In the present study, we have evaluated the effects of this drug on immune function as well as its activity in models of immune mediated chronic inflammatory disease. Sch 40120 was particularly effective in suppressing T cell proliferative responses in vitro. Antigen-specific and poly-clonally-induced in vitro antibody responses were also inhibited by the drug. However, the in vivo potency of Sch 40120 in suppressing immune responses and in inhibiting the pathological changes seen in rodent models of autoimmune disease (EAE and adjuvant arthritis) was somewhat less than that previously observed in models of acute inflammation. Nevertheless, the spectrum of activities exhibited by Sch 40120 suggests that it will be particularly useful in the treatment of psoriasis where T lymphocytes have been implicated in the development of disease and leukotrienes appear to have a role in the persistence of psoriatic plaques.

Growth factor effects on cells of the vascular wall: a survey

Acidic and basic fibroblast growth factors (aFGF, bFGF), platelet-derived growth factor (PDGF), epidermal growth factor (EGF), and transforming growth factor type beta (TGF-beta) are well-characterized growth regulators. Though there are reports of the effects of some of these factors on vascular cells, variability in the purity of growth factor preparations and differing cell culture conditions make comparison among the results difficult. Thus, a study employing homogeneous preparations of recombinant growth factors on well-characterized cell populations was conducted. Each of the factors was tested for its effect on the proliferation of cells derived from large and small blood vessels: aortic and capillary endothelial cells (EC), smooth muscle cells (SMC) and pericytes. Of the five growth factors only bFGF stimulated the proliferation of both large vessel and microvessel EC; aFGF was mitogenic for microvessel but not large vessel EC. Neither PDGF (AA, BB or AB) nor EGF had any effect on EC growth. TGF-beta was a potent inhibitor of both aortic and capillary EC proliferation with half maximal inhibition at concentrations as low as 0.05 and 0.25 ng/ml for microvessel and aortic EC, respectively. The FGFs were potent mitogens for the mural cells, SMC and pericytes. Likewise, PDGF was stimulatory for SMC and pericytes. The BB homodimer yielded the greatest degree of growth stimulation for both pericytes and SMC. In the case of SMC the AA homodimer stimulated small but significant growth and the effect of AB was intermediate to that of the homodimeric forms. On the other hand, neither the AA homodimer nor the heterodimer stimulated any significant increase in pericyte number. EGF was moderately mitogenic for both types of mural cells, reaching maximum stimulation at 100 pg/ml of EGF. TGF-beta was inhibitory for SMC but not for pericyte proliferation. These data indicate both quantitative and qualitative differences between the responses of large and small vessel EC to the various growth factors and distinct differences in the responsiveness of SMC and pericytes to PDGF and TGF-beta.

External fixation of lower limb fractures in children

Thirty-four tibial and femoral shaft fractures in 32 children between the ages of 3 and 15 years were treated by external fixation over a 5-year period. The indications were fractures occurring in association with other major injuries and failure of conservative treatment to maintain satisfactory reduction. There was one case of delayed union and one early refracture. The overall pin track infection rate was 6%, but the rate for the tibial pins (2.1%) was much lower than for the femoral pins (10.3%). Union was achieved at an average of 11.7 weeks in the femoral fractures and 10.0 weeks in the tibial fractures. The use of external fixation is recommended for childhood femoral and tibial fractures, particularly in children with multiple injuries.

The effect of using a pre-brushing mouthwash (Plax) on oral hygiene in man

The aim of this study was to investigate whether the use of a pre-brushing mouthwash (Plax) improved subjects' oral hygiene over a 2-week period. In a double-blind placebo controlled cross-over study, 33 adult subjects (mean age 35.3 years) used either Plax or a placebo mouthwash for 30 s prior to toothbrushing during a 2-week period. After a washout period of 4 weeks, the subjects used the other mouthwash in the same way. The modified plaque index of Quigley and Hein (QHI) was recorded for 16 teeth (16, 14, 13, 11, 21, 23, 24, 26, 36, 34, 33, 31, 41, 43, 44, 46) at each visit. The bleeding index (BI) was recorded at the beginning and end of the study. Results were analysed using a paired one-tailed t-test. Neither plax nor placebo mouthwashes reduced plaque scores significantly (p > 0.05) below baseline. There was no statistically significant difference between the mean BI at the beginning of the trial (0.42) and at the end (0.44). These results suggest that the routine use of Plax is not a useful adjunct to toothbrushing.

Acute lymphoblastic leukemia of Burkitt type (L3) with a (14;18) and an atypical (8;22) translocation

A 67-year-old man had night sweats, tumor lysis syndrome, and typical histologic and immunophenotypic features of Burkitt-type acute lymphoblastic leukemia (ALL). Cytogenetic analysis showed a previously unreported karyotype, a combination of a (14;18) and an atypical (8;22) translocation.

Actions of a 5-lipoxygenase inhibitor, Sch 40120, on acute inflammatory responses

Sch 40120 (10-(3-chlorophenyl)-6,8,9,10-tetrahydrobenzo[b] [1,8]naphthyridin-5(7H)-one) is an inhibitor of the 5-lipoxygenase enzyme in rat neutrophils, human neutrophils and the the MC9 murine mast cell clone with IC50 values of 8, 4 and 7 microM, respectively. The drug was examined for its effects on acute inflammatory responses in the paw and pleural cavity of rats. The drug suppressed paw inflammation triggered by a reverse passive Arthus reaction or a subplantar injection of the polysaccharide carrageenan with p.o. ED50 values of 0.2 and 1.5 mg/kg, respectively. In reverse passive Arthus reaction and carrageenan pleurisy models, Sch 40120 was found to suppress both the cellular and fluid components of the acute inflammation. The p.o. ED50 values for inhibition of cells and fluid in pleurisy models were in the range of 0.1 to 0.7 mg/kg. When applied locally to the ears of mice, the drug blocked an arachidonic acid-induced and leukotriene-mediated ear inflammation with an ED50 of 0.072 mg/ear. These findings suggest that Sch 40120 is a potent anti-inflammatory agent that may be particularly useful in the treatment of inflammatory diseases such as psoriasis in which leukotrienes appear to be major mediators of the pathological symptoms that characterize the disease state.

A behavioral study of bilateral middle cerebral artery hemorrhagic ischemia in rats

The middle cerebral artery was severed bilaterally (bMCA) in adult rats, and controls experienced sham operations. Tactile sensorimotor and gross locomotor functions, measured by the tape test and a rod walking test, were initially impaired in the injured animals. However, these deficits had resolved within 9 and 30 days respectively. The animals were trained in a multiple T water maze task to find the location of a hidden escape platform at the rate of one trial per day for 30 days. Analyses of the number of errors committed and latency to find the escape platform revealed that the bMCA injured rats suffered deficient reference memory, but no decline in working memory. These data support further the use of the bMCA preparation as a model of stroke.

Hospital pharmacy staff development programs in Ohio

Although staff development programs have been used to implement clinical services in Ohio hospital pharmacies, the majority of clinical services have been implemented without the use of staff development programs. The results of this study show that less than half of Ohio hospital pharmacy departments provide staff development programs. In those hospitals where the programs were provided, the average number of clinical services implemented through staff development was not significantly different from the average number implemented without these programs. Nor was there a significant difference in the average number of clinical services implemented through staff development between small hospitals (199 beds or less), medium hospitals (200 to 399 beds), and larger hospitals (400 or more beds); between government (city, county, or state) and private, nonprofit hospitals; and between hospitals whose staff development program coordinators were directors and hospitals whose coordinators were not directors. For the majority of departments that provided staff development programs, certification or testing of pharmacists was not required before providing clinical services. Results from the survey indicated that certification may not be necessary for all clinical services. Commitment to staff development programs in terms of management support and participation, awarding of continuing-education credit, and use in pharmacist performance evaluations was demonstrated by no more than 34 percent of all departments that responded. Financial commitment to these programs was low. Overall, since less than half of the departments reported providing staff development programs, the level of commitment to staff development appeared to be low.

Diabetes-induced glomerular dysfunction: links to a more reduced cytosolic ratio of NADH/NAD+

These studies were undertaken to examine effects of elevated glucose levels on glycolysis, sorbitol pathway activity, and the cytosolic redox state of NADH/NAD+ in isolated glomeruli. Blood-free glomeruli were isolated from kidneys of male, Sprague-Dawley rats using standard sieving techniques, then incubated for one hour at 37 degrees C, pH 7.4, pO2 approximately 500 torr, in Krebs bicarbonate/Hepes buffer containing 5 or 30 mM glucose. Elevated glucose levels increased glucose 6-phosphate, fructose 6-phosphate, total triose phosphates, lactate, the lactate/pyruvate ratio, sorbitol, and fructose, but did not affect sn-glycerol 3-phosphate, pyruvate, or myo-inositol levels. The more reduced glomerular cytosolic redox state (manifested by the tissue lactate/pyruvate ratio) induced by 30 mM glucose was completely abrogated by aldose reductase inhibitors added to the diet two to seven days prior to glomerular isolation. These observations, coupled with evidence linking glucose- and diabetes-induced glomerular dysfunction to increased sorbitol pathway metabolism, support the hypothesis that metabolic imbalances associated with a more reduced ratio of cytosolic NADH/NAD+ (resulting from increased glucose metabolism via the sorbitol pathway) play an important role in mediating glucose- and diabetes-induced glomerular dysfunction.

Severe haemolysis and renal failure in a patient with paroxysmal nocturnal haemoglobinuria

Transfusion of about 60 ml of ABO incompatible plasma in 4 units of pooled platelets precipitated severe haemolysis, unmasking the emergence of paroxysmal nocturnal haemoglobinuria (PNH), in a patient with aplastic anaemia. In vitro tests showed that her red cells were lysed by both ABO compatible and incompatible plasma from normal donors. The behaviour of this case and the in vitro results suggest that it might be hazardous to relax the longstanding recommendation on transfusing patients with PNH by restricting the washing of blood components to those containing ABO incompatible plasma.

Detection of in vivo-induced IL-1 mRNA in murine cells by flow cytometry (FC) and fluorescent in situ hybridization (FISH)

Flow cytometry (FC) and fluorescent in situ hybridization (FISH) were used to detect in vivo induced IL-1 alpha (a) messenger RNA. Spleen cells and thioglycollate-induced peritoneal exudate cells (PEC) were harvested from Balb/C mice three hours after intraperitoneal injection of 20 micrograms LPS. Cells from each population were phenotyped for MAC or IAd, fixed in 4% paraformaldehyde and then permeabilized with 70% ETOH. RNA-RNA FISH was performed by incubating suspended cells at 37 degrees C for 17 hours with biotinylated sense IL-1a, antisense IL-1a or antisense IL-2 probes in 50% formamide. Hybridized cells were washed in 2X SSC, treated with RNAse, stained with avidin conjugated to fluorescein (FITC) or allophycocyanin (APC) and analyzed immediately by FC. Initially, avidin-FITC was used to detect hybridized probe. Dual fluorescent FC analysis of IL-1a mRNA expression in LPS stimulated IAd+ cells showed an increase in mean fluorescent intensity (MFI) of 51 log channels (0.25 logs) when compared to unstimulated cells. Additionally, induction of specific IL-1a mRNA expression in cells from LPS treated animals was illustrated by increases in percent positive cells (24%) and in equivalent soluble fluorescein molecules (ESFM) bound (47%) when compared to cells from vehicle treated mice. Unhybridized cells and cells hybridized with control antisense IL-2 probe did not exhibit increases in MFI or ESFM. In subsequent experiments on MAC+ PEC, the use of avidin-APC to detect bound probe resulted in a greater separation between the FISH signals of antisense IL-1a and control sense probe (121 log channels, 0.6 logs) than that seen with FITC.(ABSTRACT TRUNCATED AT 250 WORDS)