Survey of clinical pharmacists' knowledge of appropriateness of antimicrobial therapy for upper respiratory infections and acute bronchitis

We conducted a survey to assess clinical pharmacists' recommendation of antibiotics for upper respiratory infections (URIs) and acute bronchitis. A random sample of 752 members of the American College of Clinical Pharmacy were mailed a multiple-choice survey that presented four examples consistent with clinical symptoms of the two disorders. Respondents were asked what treatment they would recommend for each example. The response rate was 59%. Pharmacists recommended antibiotics for the treatment of both URIs and acute bronchitis significantly more if patients' symptoms included discolored discharge or sputum as opposed to clear discharge. Those who were board certified were less likely than nonboard-certified pharmacists to recommend antibiotics for URIs with discolored discharge. Pharmacists who specialized in either ambulatory care or infectious disease were less likely than those in other specialties to recommend antibiotics for acute bronchitis with discolored sputum. Clinical pharmacists are similar to patients and physicians in their belief that antibiotics are appropriate for URIs and acute bronchitis with discolored discharge. Considering the role that pharmacists play as clinical consultants to physicians, greater efforts should be made to educate them regarding appropriate prescription of antibiotics.

Imaging adenoviral-directed reporter gene expression in living animals with positron emission tomography

We are developing quantitative assays to repeatedly and noninvasively image expression of reporter genes in living animals, using positron emission tomography (PET). We synthesized positron-emitting 8-[18F]fluoroganciclovir (FGCV) and demonstrated that this compound is a substrate for the herpes simplex virus 1 thymidine kinase enzyme (HSV1-TK). Using positron-emitting FGCV as a PET reporter probe, we imaged adenovirus-directed hepatic expression of the HSV1-tk reporter gene in living mice. There is a significant positive correlation between the percent injected dose of FGCV retained per gram of liver and the levels of hepatic HSV1-tk reporter gene expression (r2 > 0.80). Over a similar range of HSV1-tk expression in vivo, the percent injected dose retained per gram of liver was 0-23% for ganciclovir and 0-3% for FGCV. Repeated, noninvasive, and quantitative imaging of PET reporter gene expression should be a valuable tool for studies of human gene therapy, of organ/cell transplantation, and of both environmental and behavioral modulation of gene expression in transgenic mice.

Imaging of adenoviral-directed herpes simplex virus type 1 thymidine kinase reporter gene expression in mice with radiolabeled ganciclovir

We are developing procedures to repeatedly and noninvasively image the expression of transplanted reporter genes in living animals and in patients, using PET. We have investigated the use of the Herpes Simplex Virus type 1 thymidine kinase gene (HSV1-tk) as a reporter gene and [8-14C]-ganciclovir as a reporter probe. HSV1-tk, when expressed, leads to phosphorylation of [8-14C]-ganciclovir. As a result, specific accumulation of phosphorylated [8-14C]-ganciclovir should occur almost exclusively in tissues expressing the HSV1-tk gene.

METHODS

An adenoviral vector was constructed carrying the HSV1-tk gene along with a control vector. C6 rat glioma cells were infected with either viral vector and uptake of [8-3H]-ganciclovir was determined. In addition, 12 mice were injected with varying levels of either viral vector. Adenovirus administration in mice leads primarily to liver infection. Forty-eight hours later the mice were injected with [8-14C]-ganciclovir, and 1 hr later the mice were sacrificed and biodistribution studies performed. Digital whole-body autoradiography also was performed on separate animals. HSV1-tk expression was assayed, using both normalized HSV1-tk mRNA levels and relative HSV1-TK enzyme levels, in both the cell culture and murine studies.

RESULTS

Cell culture, murine tissue biodistribution and murine in vivo digital whole-body autoradiography all demonstrate the feasibility of HSV1-tk as a reporter gene and [8-14C]-ganciclovir as an imaging reporter probe. A good correlation (r2 = 0.86) between the [8-14C]-ganciclovir percent injected dose per gram tissue from HSV1-tk positive tissues and HSV1-TK enzyme levels in vivo was found. An initial study in mice with [8-18F]-fluoroganciclovir and microPET imaging supports further investigation of [8-18F]-fluoroganciclovir as a PET reporter probe for imaging HSV1-tk gene expression.

CONCLUSION

These results demonstrate the feasibility of using [8-14C]-ganciclovir as a reporter probe for the HSV1-tk reporter gene, using an in vivo adenoviral mediated gene delivery system in a murine model. The results form the foundation for further investigation of [8-18F]-fluoroganciclovir for noninvasive and repeated imaging of gene expression with PET.

Experience with a cross-study endpoint review committee for AIDS clinical trials. Terry Beirn Community Programs for Clinical Research on AIDS

OBJECTIVES

To describe the methods and results of a standardized system for clinical endpoint determination for defining and reviewing endpoints in clinical trials for HIV-infected individuals.

DESIGN

A system was developed utilizing standard definitions for the 24 diagnoses or clinical events that serve as trial endpoints and together define the combined endpoint 'progression of HIV disease. A common set of case report forms were used for all trials. Thus, an event of Pneumocystis carinii pneumonia (PCP), for example, for a subject co-enrolled in an antiretroviral trial and a PCP prophylaxis trial was only reported once.

METHODS

A central committee was established to define clinical events and review endpoints across all studies. Events were classified according to established criteria for confirmed, probable and possible levels of certainty.

RESULTS

This report describes the methods used to ascertain and review endpoints, and summarized 2299 clinical events for 8097 subjects enrolled in one or more of nine clinical trials. Data on the diagnostic certainty of events and agreement between site clinicians and the endpoint committee are presented.

CONCLUSIONS

Uniform classification of endpoints across AIDS clinical trials can be accomplished by multicenter, multitrial organizations with standardized definitions and review of endpoint documentation. Our experience suggests that nurse coordinators reviewing all submitted endpoints for every trial are warranted and the need for external review by a clinical events committee may depend on the type of trial conducted.

Genetic diagnosis in adulthood. A case report

While family physicians may readily entertain genetic diagnoses in their pediatric patients, they may fail to consider such diagnoses in their adult patients. We present the case of a man with recurrent leg ulcers who was recognized as hypogonadal and was ultimately given the diagnosis of Klinefelter's syndrome (XXY) at age 47. Although there is no primary treatment for XXY, significant associated conditions, including osteoporosis and testosterone deficiency, can be ameliorated. We review the clinical condition of XXY at various ages and summarize age-specific interventions. We discuss the importance of genetic diagnosis throughout the life span.

Noninvasive methods for quantitating blood time-activity curves from mouse PET images obtained with fluorine-18-fluorodeoxyglucose

The mouse model is currently being explored for various applications with PET imaging. Low resolution of current animal scanners relative to mouse size leads to difficulty in quantitating data from mouse PET images. We have, therefore, investigated methods for determining blood time-activity curves (TACs) from mouse PET studies done with fluorine-18-fluorodeoxyglucose (FDG).

METHODS

Eight mice were fasted, the tail vein was injected with 150-300 microCi of FDG and dynamic images were acquired with a CTI/Siemens (Knoxville, TN) animal tomograph for 64.5 min. Concurrently, 11-14 left ventricle (LV) blood samples were drawn directly from the LV chamber. Organ TACs were obtained by drawing circular regions of interest (ROIs) of various sizes on images of the heart, liver and brain. For each mouse, the FDG model parameter K = (K1 x k3)/(k2 + k3) was estimated by a Patlak algorithm with various estimates of the blood TAC and, as a reference tissue TAC, the brain TAC.

RESULTS

Most partial-volume-corrected heart ROI TACs overestimated the LV samples. Blood TACs from heart images produced statistically different estimates of K than did the LV samples. The liver image-derived blood TACs yielded estimates of K that were comparable to those yielded by the LV samples. Estimates of K determined with two directly sampled LV points in conjunction with the liver image-derived TAC were not statistically different from the estimates obtained with the LV samples. The size and location of ROIs on images of the liver minimally affected the TACs.

CONCLUSION

We have shown that it is experimentally possible to obtain a blood TAC from mouse studies by repeatedly sampling from the LV. We have also shown that images of the liver can be used to reliably estimate the blood TAC. Future FDG PET studies with the mouse model will benefit from this demonstrated ability to noninvasively quantitate blood TACs directly from FDG PET images.

Identification, Intervention and Education: Essential Curriculum Components for Chemical Dependency in Nurses

BACKGROUND

A documented need exists for continuing education in the area of chemical dependency as it relates not only to patient care, but also to nurses who are susceptible to addiction. This is significant due to the fact that nurses are at risk for chemical dependency and many nurse peers are unable to recognize the signs of chemical dependency and therefore unable to actively intervene.

CONCLUSION

According to the literature, which includes current research, nurses lack knowledge regarding specific risk factors, symptoms of chemical dependency in peers, and steps for intervention. In addition, the literature revealed that nursing curricula allot little time to chemical dependency issues. The results of a small-scale learning needs assessment support this literature finding. Continuing education courses can effectively educate nurses to be able to identify their own susceptibility and those of chemically dependent peers, intervene appropriately, and begin the healing process for the impaired nurse. This article outlines a curriculum and additional resources to address the learning needs of nurses related to chemical dependency.

Practical issues in conducting small-area variation analysis

BACKGROUND AND OBJECTIVES

This paper provides a detailed examination of the conduct of a small-area variation analysis (SAVA) health services research project to aid other researchers in performing and interpreting such projects.

STUDY CONDUCT

SAVA was performed on hospital admissions with suspected acute cardiac ischemia in the state of Michigan, and the details of each of the steps are presented. The study team consisted of the principal investigator, a biostatistician, a health economist, a medical geographer, and a systems analyst. Data were obtained from the state hospital association and from a commercial demographics source. Small areas for analysis were defined by a patient origin clustering method. Crude area rates were adjusted for age and gender composition of small areas. Multivariate Poisson regression that included sociodemographic variables was performed on adjusted rates. Issues in interpretation of SAVA and practical barriers to primary care SAVA are discussed.

Preeclampsia and hypertensive disorders of pregnancy

Hypertensive conditions encountered during pregnancy are classified as preeclampsia, transient hypertension and chronic hypertension. The pathophysiology, consequences and management of these disorders differ, but their clinical presentations overlap substantially. Preeclampsia is a syndrome of the second half of pregnancy, characterized by hypertension, edema and proteinuria, but all three findings are not required to make the diagnosis. Preeclampsia can progress unpredictably to a variety of crises, including eclamptic seizures, and contributes significantly to maternal and perinatal mortality. Management consists of prompt delivery for a mature fetus. Management of preeclampsia at earlier stages of gestation requires balancing the risks of immediate delivery of an immature fetus against the risks to both mother and child of a complication of preeclampsia. Transient hypertension is a clinically benign condition characterized by isolated high blood pressure in late pregnancy; its significance lies in the difficulty of distinguishing it from early preeclampsia. Chronic hypertension is a risk factor for intrauterine growth restriction and intrauterine fetal demise, as well as for preeclampsia. The management strategy consists of control of maternal blood pressure, ongoing antepartum assessment of fetal well-being and surveillance for superimposed preeclampsia.

Blood pressure measurement during pregnancy: auscultatory versus oscillatory methods

OBJECTIVE

To determine the equivalence of auscultatory and oscillatory blood pressure measurements.

SETTING

Inner-city prenatal clinic.

PARTICIPANTS

Eighty-one women in their 2nd to 9th month of pregnancy.

DESIGN

Participants were assessed for systolic and diastolic blood pressures on left and right arms using auscultatory (manual) and oscillatory (electronic) methods. A correlational study design was used.

MAIN OUTCOME MEASURES

Differences in pressures related to arm and method of measurement.

RESULTS

The oscillatory method produced consistently higher readings for both systolic (F[1,80] = 45.9, p < 0.001) and diastolic (F[1,80] = 25.79, p < 0.001) pressure readings. Correlations between estimates generally treated as substitutable all fell below the recommended level of 0.80 for measurement equivalence.

CONCLUSIONS

Results suggest the need for caution when interpreting blood pressure estimates as interchangeable. This is particularly important when patients move from clinic settings, where auscultatory methods predominate, to inpatient settings, where oscillatory methods of measurement are used.

Human immunodeficiency virus seroprevalence in community-based primary care practices, 1990-1992. A report from the Ambulatory Sentinel Practice Network

OBJECTIVE

To estimate the seroprevalence of human immunodeficiency virus type 1 (HIV-1) infection in primary care practices.

METHODS

Fifty-four practices in the United States participated in an anonymous, unlinked HIV seroprevalence study between January 1990 and December 1992. Residual blood samples drawn for routine clinical tests from patients 15 to 49 years of age were centrally tested for the HIV-1 antibody for 1 month of each quarter. Information about patient demographics, clinician-recognized risk factors, the known HIV status of the patient, and whether the blood was drawn for HIV testing was recorded with each specimen.

RESULTS

Of 21,998 specimens collected, 99 (0.45%) were seropositive. Of these 99 seropositive persons, 31.3% (a seroprevalence of 0.15%) were not suspected by their clinicians of being infected with HIV. Seroprevalences in men (0.96%) exceeded those in women (0.22%), and rates in rural practices (0.18%) were lower than in urban practices (0.71%). Among patients with unsuspected HIV infection, however, the gender differences, especially in rural areas, were less pronounced. Risk factors for HIV infection were infrequently noted. There was an increase in the overall seroprevalence during the 1990 to 1992 study period (0.36% to 0.53%); however, this trend was not statistically significant.

CONCLUSIONS

Within a 3-year period, clinicians in at least two of five primary care practices can expect to encounter patients infected with HIV, regardless of practice location. Also, nearly one third of the patients with HIV infection will not be suspected of having this condition by their clinician.

The use of objective measures of asthma severity in primary care: a report from ASPN

BACKGROUND

The rising incidence of and mortality from asthma have prompted the development of practice guidelines for diagnosis and management. A cornerstone of these guidelines is the use of objective measures of asthma severity: spirometry or peak expiratory flow rates. We studied the extent to which primary care clinicians used objective measures of asthma severity.

METHODS

Practices affiliated with the Ambulatory Sentinel Practice Network in the United States and Canada collected data on 490 asthma-related encounters involving 439 patients. For each encounter, the practice recorded the availability of the results of spirometry, peak expiratory flow rates, oxygenation (arterial blood gas or pulse oximetry), and chest radiograph to the clinician.

RESULTS

Objective data about asthma severity were infrequently available to ASPN clinicians at the time of the encounter. In 67.8% of encounters, there was no current or past spirometry result, in 55.1% there was no current or past peak flow measurement, and in 74.3% there was no current or past determination of oxygenation. Chest radiographs, on the other hand, were available for most (64.7%) patients. The lack of objective measures was not related to lack of access to the relevant technologies. Most practices noted easy access to spirometry (72.2% of practices), peak flow meters (72.2%), oxygenation determination (61.1%), and radiography (83.3%).

CONCLUSIONS

In this study, most primary care clinicians did not have objective data about the severity of their patients' asthma at the time of the encounter. This relative lack of objective data was not explained by lack of access to the relevant technology for determining severity. It may instead reflect the opinion of primary care physicians that such information is not necessary in the care of these patients.

Using ICPC in a computer-based primary care information system

INTRODUCTION

Although the framework of the episode of care offers much promise in examining the process of primary health care, the development of episode-oriented, automated data sources has proceeded slowly. Experience with the International Classification of Primary Care (ICPC) in the European Community has confirmed its usefulness in creating and analyzing episodes of care, but it has seen little use in the United States. We describe the development of a Primary Care Information System (PCIS), which employs ICPC to create episodes of care from routinely collected clinical data.

METHODS

The PCIS is a partially computerized medical information system running on a standard Macintosh microcomputer. The PCIS integrates ICPC, ICD-9-CM, and CPT-4 coding structures to provide episode-oriented data for clinical, administrative, research, and reimbursement needs. The performance of the PCIS was assessed based on five major issues: clinician cooperation, data-entry accuracy, validity of episode data, cost, and perceived value to users.

RESULTS

The data collection and entry process required minimal additional effort from clinicians and data-entry personnel, and data-entry accuracy exceeded published estimates for other primary care data sources. Data management costs of about $1 per encounter compare favorably to published estimates for other office-based clinical information systems. The major problem seen during pilot testing was inaccurate tracking of episode boundaries through changes in providers and consequent changes in labels for problems and diagnoses. This problem has been addressed in development of the second-generation PCIS.

CONCLUSION

The combination of an episode-oriented framework such as ICPC and a flexible medical information system provides a promising platform for the study of the content and process of primary health care.

Influence of pseudodiagnostic information on the evaluation of ischemic heart disease

STUDY OBJECTIVES

To measure the influence of classic epidemiologic risk factors (as recorded on the chart) on physicians' admission decisionmaking for patients with suspected acute cardiac ischemia and to compare the influence of those risk factors, which are of limited predictive utility, to the influence of predictively useful information.

DESIGN

Retrospective chart review.

SETTING

Emergency departments of two community hospitals.

PARTICIPANTS

Seven hundred eighty-seven patients evaluated for suspected acute cardiac ischemia, whether admitted or not.

RESULTS

Logistic regression revealed that the effect of a recorded history of hypertension on the admission decision (OR, 7.89; 95% CI, 4.57 to 13.58) was greater than that for ST-segment changes on the ECG (OR, 3.98; 95% CI, 2.56 to 6.18) or history of infarction (OR, 2.36; 95% CI, 1.53 to 3.62). A recorded history of diabetes had a small effect (OR, 1.84; 95% CI, 1.01 to 3.36), whereas Q waves and T-wave changes were not statistically significant.

CONCLUSION

Physicians' admission decisions appeared to be more heavily influenced by pseudodiagnostic information than by information of objective predictive power. Physicians do not appear to distinguish risk factors from diagnostic information; education may be directed at this distinction.

Physician decision making and variation in hospital admission rates for suspected acute cardiac ischemia. A tale of two towns

The authors tested the "uncertainty hypothesis," which holds that variations in rates of hospitalization or surgeries across small geographic areas reflect differences in physicians' decision making when confronting uncertainty. A small-areas variation analysis of suspected acute cardiac ischemia (ACI) admissions in northern Michigan was performed, and two demographically nearly identical towns differing by a factor of 3 in ACI admission rates were selected. Medical records of all patients evaluated in the emergency departments of these hospitals for suspected ACI in 1988 were abstracted retrospectively. Probabilities of ACI were objectively estimated using the Acute Cardiac Ischemia Time-Insensitive Predictive Instrument. Logistic regression of admission on patient characteristics, other illnesses, probability of ACI, and community revealed no difference in admission decisions between the two hospitals (odds ratio for community = 0.766, 95% confidence interval, 0.542-1.08, n = 787, P > .1). Nearly twice as many patients with ACI presented to the emergency department of the high-admitting hospital as to the low-admitting hospital. The authors conclude that, at least for ACI, population-based area discharge rates do not necessarily reflect case-based decision rates. Drawing inferences regarding physician decision making from discharge or claims datasets may lead to error.

The danger of applying uniform clinical policies across populations: the case of breast cancer in American Indians

OBJECTIVES

This study examined the implications of annual screening mammography for cost and mortality in American Indian populations with differing baseline breast cancer rates.

METHODS

A decision tree compared annual screening mammography and screening clinical breast examination with referral for diagnostic mammography when appropriate. The decision tree was constructed to examine the effect of different base-line cancer rates, stage at diagnosis, and stage-specific survival. Outcomes included 5-year relative survival, deaths prevented at 5 years, cost per death prevented, and total costs.

RESULTS

The findings suggest that the total cost of breast cancer is 3.6 times higher with the screening mammography program but results in a 27.9% reduction in breast cancer deaths over the first 5 years of the program. Both costs and deaths prevented are sensitive to the incidence of breast cancer in the population and are less favorable in the range of incidence seen in American Indians.

CONCLUSIONS

The cost and impact of a given strategy for cancer screening vary among communities with different disease incidence, stage at diagnosis, and stage-specific survival, as seen in American Indian populations.

A closer examination of sex bias in the treatment of ischemic cardiac disease

BACKGROUND

Past studies have conflicted regarding the existence of sex bias in the treatment of women with ischemic cardiac disease. This study explored the effect of different analytic models on conclusions about sex bias.

METHODS

A retrospective analysis of medical records was performed on 787 patients evaluated for potential acute cardiac ischemia in the emergency departments of two nonteaching community hospitals. The Acute Coronary Ischemia Time Insensitive Predictive Instrument (ACI-TIPI) was used to estimate the likelihood of ischemic disease. The decisions to admit to hospital, not to admit to hospital, and to discharge with diagnosis of myocardial infarction were the outcome variables.

RESULTS

Logistic regression models of increasing levels of detail were applied and evaluated. Analysis using summary data (similar to discharge abstracts or claims data) revealed that patient sex affected admission decisions, but an analysis of clinically detailed data by hospital was required to reveal the nature of the effect. There was disparity in admission decisions by sex at one hospital but not at the other. The odds ratio for admission (women vs men) was 0.546 (95% CI, 0.33 to 0.91) at Hospital A, and 1.22 (95% CI, 0.72 to 2.05) at Hospital B. This disparity appeared to be related to a high rate of admission (67%) among men with low (< 10%) probability of acute ischemia.

CONCLUSIONS

Differences in treatment of suspected acute cardiac ischemia by sex may be a practice variation phenomenon rather than a uniform bias. When these differences occur, they may represent overtreatment of men rather than inadequate treatment of women. Because summary or billing datasets lack clinical detail, they are inadequate for the study of physician decision-making.