Drug interchanges at the pharmacy: safe for cardiovascular disease?

With the development of sustained-release formulations for various chronic diseases, long-standing questions about the "interchangeability" of drugs have acquired new pertinence. A case in point is provided by verapamil.

Acute psychoses associated with the use of ciprofloxacin and trimethoprim-sulfamethoxazole

Although adverse drug reactions are a well-recognized cause of mental status changes in the elderly, antimicrobials are rarely implicated. Three patients with serious organic brain disease developed paranoid psychosis after therapy with trimethoprim-sulfamethoxazole or ciprofloxacin was begun. One of the patients was accidently rechallenged and again developed a psychotic reaction. The acute psychoses did not improve with moderate doses of major tranquilizers but resolved completely with drug discontinuation.

Residents' views of the value of moonlighting

The opportunity for residents to moonlight is threatened by legal liability concerns and legislation designed to limit the duration of workdays and workweeks. We sought the opinion of all 40 second- or third-year residents and fellows in a hybrid university/community hospital internal medicine residency program regarding their motivation to moonlight and the value of their experiences. Sixty-five percent were moonlighters; moonlighters had a higher average debt ($41 644) than nonmoonlighters ($32 917). Residents viewed moonlighting as a positive educational experience that helped them with career decisions. They believed they acquired important skills and knowledge not learned elsewhere, and that moonlighting did not interfere with their job and educational responsibilities. A program in operation for 10 years that was designed to control, monitor, and facilitate moonlighting experiences is described. We believe our residents' positive views may be in part a result of the supervision and integration of moonlighting in a residency training program with a controlled workload.

Evaluation and management of vaginitis. An update for primary care practitioners

There are three major causes of vaginitis symptoms that primary care practitioners should be able to diagnose and treat expertly. Recent investigations have shown that bacterial vaginosis, the most common cause of vaginitis symptoms in patients not seen in sexually transmitted disease clinics, has a multifactorial etiology: Gardnerella vaginalis is universally present but is not, per se, the etiologic agent. Diagnosis and treatment are based, therefore, on evidence of a disturbed bacterial ecology as well as the presence of "clue" cells that indicate the presence of Gardnerella. Trichomonas vaginitis is usually easy to diagnose, but treatment failures occasionally occur. Some strains of Trichomonas vaginalis may be relatively resistant to metronidazole, and short-course therapy may lead to reinfection from sexual partners. Candida vulvovaginitis, the third major type of vaginitis, is not a sexually transmitted disease and should be viewed as vaginal "thrush." Earlier treatment regimens have been simplified by the introduction of more potent antifungals.

The residency-practice training mismatch. A primary care education dilemma

Primary care practice requires clinical skills and knowledge that differ greatly from those required for successful completion of residency training. Discrepant clinical settings and physician responsibilities have thus created a mismatch between the educational content of residency training and the content of clinical practice, which may result in suboptimal preparation of internists, family practitioners, and pediatricians for patient care. Of equal concern, the psychosocial environment of residency does not prepare physicians for their future community and personal adult roles. Barriers to correcting this worsening mismatch include the following: (1) economic pressures to use house staff to meet service needs of hospitals, (2) changes in patient demographics and the focus of hospital-based medicine that are making hospitals progressively more unsuitable as the principal training site for primary care physicians, (3) the deemphasis of practicing physicians as role models and teachers in postgraduate training, and (4) the often heated disagreement among medical educators regarding the purpose and content of residency training. Efforts to resolve this mismatch should include the following: reexamining the educational objectives of the current system of postgraduate training, better counseling of physicians in training regarding career goals, and emphasizing the primary care physician as role models and faculty.

Gram-negative bacillary bacteremia in the elderly: incidence, ecology, etiology, and mortality

The incidence, ecology, and mortality of gram-negative bacillary bacteremia in elderly patients were studied in an analysis of 334 episodes over a four-year-period in a 489-bed North Carolina community teaching hospital, 135 (40.4%) of which occurred in patients 70 years of age or older. The bacteremia rate per 1000 hospital admissions increased sharply with increasing age. The ecology and in vitro antimicrobial susceptibilities of the bacterial isolates were strongly influenced by community v hospital acquisition, but not by age. Urosepsis was significantly more likely to be the underlying source of hospital-acquired bacteremia in patients 70 years or older (P less than 0.01). Total bacteremia-related mortality did not increase with increasing age; in the group of patients aged 70 years or older with nonfatal/ultimately fatal underlying diseases (NF/UFUD), however, mortality was 9.1% compared to 2.9% in the younger age group (P less than 0.001). Significantly increased bacteremia-related mortality was also noted in the older patients with NF/UFUD admitted from nursing homes (P less than 0.05) and those not treated with an appropriate antimicrobial agent within 24 hours (P less than 0.01). Overall, the older patients with hospital-acquired bacteremia, neutropenia-associated infection, those bacteremic from a nonurinary source of infection, and those treated with multiple-drug regimens had higher mortality (P less than 0.05). Gram-negative bacteremia is much more common in patients 70 years of age or older and compared with younger patients mortality appears to be significantly increased for the important subgroup of older patients with nonfatal or ultimately fatal underlying diseases.

The effect of oral cimetidine on total and unbound serum lidocaine concentrations in patients with suspected myocardial infarction

In this study, we prospectively evaluated the effect of oral cimetidine on serum lidocaine concentrations in 6 patients with suspected myocardial infarction. Compared to baseline lidocaine levels, total lidocaine concentrations increased by 8.2 +/- 7.8% at 6 hours, 16.4 +/- 9.0% at 12 hours and 27.9 +/- 9.4% at 24 hours after two doses of oral cimetidine. Unbound lidocaine concentrations increased by 14.3 +/- 4.1% at 6 hours, and 18.3 +/- 10.3% at 24 hours after cimetidine. In patients with myocardial infarction (3), total lidocaine concentrations increased by 24.2 +/- 10.4%, whereas unbound lidocaine increased by 8.9 +/- 10.2% at 24 hours. Therefore, increases in total lidocaine concentrations after cimetidine administration were considerably less than those previously reported and empiric dosage reductions of lidocaine in patients receiving cimetidine may not be appropriate.

Urinary tract infection and dysuria. Cost-conscious evaluation and antibiotic therapy

Recent research into the pathogenesis and treatment of urinary tract infection (UTI) clearly indicates that our traditional approach has overestimated the need for extensive evaluation and prolonged antibiotic therapy. The great majority of UTIs can be managed adequately with urinalysis and single-dose or three-day antibiotic regimens; only complicated UTIs or those occurring in unusual hosts require cultures and longer courses of treatment.

P&T Committee guidelines for antibiotic cost comparisons

P & T Committees are focusing much effort and attention on controlling the costs of antibiotic therapy in their hospitals. In their efforts, committee members must understand not only the basic costs of acquisition in determining cost-effective therapy, but also the many expenses involved with dosing and administration. The author provides guidelines for assessing the various costs involved with antibiotic therapy based on his observations of hospitals' attempts to control costs. Suggestions of ways to make most effective use of the formulary and staff resources are presented.

Working with contagious patients

Infectious diseases ranging from hepatitis to tuberculosis can be transmitted or contracted by physicians, nurses, or laboratory personnel during the performance of their ordinary patient care activities. But by acquiring a basic knowledge of how infections are transmitted, complying with infection-control guidelines, taking necessary precautions for patient isolation, and receiving proper immunization, you can protect your patients, hospital staff members, and yourself from unnecessary risk.

Physicians' opinions of the accuracy, accessibility, and frequency of use of ten sources of new drug information

We surveyed internists, surgeons, and general practitioners in a six-county area of North Carolina to determine how accurate and accessible they believed ten sources of new drug information to be and how frequently they used each of the sources. Evaluable questionnaires were returned by 119 of the 336 physicians. The majority indicated that all sources were accessible. Commercial sources were thought to be less accurate than noncommercial sources, but were used more frequently (P less than .0002), especially by physicians who had practiced more than 15 years (P less than .02). Written sources were thought to be more accurate (P less than .0001) and were preferred over oral sources of new drug information (P less than .0004). Pharmacists and pharmacology textbooks were believed to be both accurate and accessible, but were relatively infrequently used.

Hospital charges for antibiotics

Hospital charges for intravenous antibiotics were obtained in a survey of 71 hospitals in 25 U.S. cities. Only 56.3% of the hospitals used their actual drug acquisition cost to calculate patient charges; the remainder used a base price derived from one of the wholesale price guides, which often seriously overstate the cost of antibiotics. Sixty-eight percent added a markup, averaging 134.5%, and 63.4% added a dispensing fee, averaging $5.47. A relatively high-dose, single-antibiotic regimen costs patients $50-$150 per day, independent of dose-preparation charges (average, $9.09 per dose) for a piggyback-type system or intravenous line-related charges. Antibiotics were least expensive in large hospitals and in those located in the northeastern United States. Charges for antibiotics are often inconsistently calculated, vary enormously among hospitals, and may be unfair to patients and confusing to physicians. Cost-conscious prescribing of antibiotics by physicians would be facilitated by a more consistent relationship between charges and true costs.

Improved mortality in gram-negative bacillary bacteremia

From 1979 to 1982, the four years of this study, episodes of gram-negative bacillary bacteremia occurred in a 489-bed community teaching hospital--an increase of 15.9%. Mortality related to bacteremia was 19.4% overall and only 3.2% for the 158 episodes involving nonfatal underlying illnesses, lower figures than those reported in the past. The severity of underlying illnesses in bacteremic patients dominated all other clinical variables that were studied as prognostic factors for the outcome of the episode. The same bacteremia-related mortality was seen in patients who had empirically received (1) multiple-antibiotic regimens in which one or more drugs were active against the pathogenic organism(s), (2) either an appropriate aminoglycoside or beta-lactam antibiotic alone, or (3) both an aminoglycoside antibiotic and a beta-lactam antibiotic active against the pathogenic organism(s).

Influence of medical and premedical education on important personal qualities of physicians

Three interrelated personal qualities of physicians are believed important for sensitive patient care and optimal individual adjustment to the stresses of medical practice: maturity, social competence, and moderation in aggressive competitive (exaggerated "type A" behavior). Despite widespread recognition of the importance of these qualities by patients and physicians alike, they have commonly been neglected in favor of scientific and scholastic excellence in the selection process for medical schools. In addition, some aspects of premedical and medical education may actually have an adverse influence on these personal qualities of future physicians. More emphasis in premedical and medical education on the importance of physicians' noncognitive abilities, and more individualized feedback to students and residents on the interactions between their personal qualities and their success and happiness as physicians, are needed.

Cefoxitin resistance in community-acquired gram-negative bacillary bacteremia. Associated clinical risk factors

Among 185 patients with nonneutropenic, community-acquired gram-negative bacillary bacteremias, clinical risk factors for cefoxitin resistance included any antibiotic taken within the last three weeks (25.6% cefoxitin resistance), long-term bladder catheterization or surgical urinary diversion (23.3%), hospitalization within the last 30 days (22.9%), and nursing home residence before admission (20.8%). Patients with none of these risk factors were less likely to have cefoxitin-resistant bacteremias (0.9%). When these risk factors were examined in the subgroups of urinary tract and non-urinary tract sources of community-acquired gram-negative bacillary bacteremia, they were also helpful in predicting sensitivity to trimethoprim-sulfamethoxazole and gentamicin. The presence of one or more of the risk factors identified may be a useful adjunct in determining initial empiric antimicrobial therapy for community-acquired gram-negative bacillary bacteremia.