Improving pharmacy and therapeutics committee operations

A panel discussion of various aspects of the operations of pharmacy and therapeutics (P & T) committees is presented. Pharmacy and therapeutics committee operations in various types and sizes of hospitals are described. Ways of stimulating physicians' interest in P & T committee activities, difficult problems faced, scope of issues dealt with by P & T committees, functions of P & T subcommittees, the value of drug information from pharmaceutical representatives, and the influence of research funds from the pharmaceutical industry on committee decisions are discussed. Panel members also present their views on therapeutic alternates, FDA-nonapproved use of drugs, and counter-detailing. Finally, suggestions for improving P & T drug evaluations, cost-containment issues, and the authority of P & T committees are discussed. A well-prepared agenda, good educational material, active members, and strong leadership are important for successful P & T committee operations.

Nifedipine-induced fingertip vasodilation in patients with Raynaud's phenomenon

The effect of nifedipine on fingertip hemodynamics was studied in 10 patients with Raynaud's phenomenon. Fingertip blood flow (FBF) was determined in a 20 degrees C environment by venous occlusion air plethysmography and fingertip vascular resistance (FVR) was calculated from the mean blood pressure and the FBF. Nifedipine, administered as a 10 mg sublingual dose, increased FBF in 8 of the 10 patients. FVR for the 10 patients decreased 40% from 40.7 +/- 10.8 to 24.2 +/- 6.1 U (p less than 0.05). Seven of the 10 patients were followed in a crossover placebo-controlled clinical trial. The frequency and severity of Raynaud's phenomenon was less in all seven patients when taking nifedipine as compared to placebo. Nifedipine-induced fingertip vasodilation may contribute to clinical improvement in some patients with Raynaud's phenomenon.

Gaucher's disease and chronic lymphocytic leukemia. Possible pathogenetic link between Gaucher's disease and B-cell proliferations?

The authors report a case of Gaucher's disease with chronic lymphocytic leukemia. The diagnosis of Gaucher's disease was confirmed by electron microscopy and glucocerebrosidase assay. There may be a pathogenetic link between Gaucher's disease and B-cell proliferation.

Lymphocyte subsets in primary biliary cirrhosis

To ascertain whether abnormalities of circulating T-cell subsets are a cause or effect of primary cirrhosis, we analyzed peripheral blood lymphocytes from 44 patients at various stages of disease. The percentages of total T cells and helper/inducer cells were normal in early disease whereas the percentage of suppressor/inducer cells was increased. The percentage of all T-cell subsets fell steadily as the disease progressed histologically. The percentages in late (cirrhotic) disease were the same as those in patients with other types of cirrhosis. We conclude that most of the previously reported abnormalities of circulating T cells are secondary to the histologic progression of primary biliary cirrhosis.

Bilomas: a new approach to the diagnosis and treatment

Biloma, a newly described entity, appears to have gained a heightened clinical interest recently. During the past 18 months we have diagnosed 9 abnormal biliary collections. We discuss here the role of sonography and radionuclide cholescintigraphy in the evaluation of bilomas. The diagnosis of all cases was confirmed by ultrasound-guided percutaneous needle aspiration. Subsequently 7 patients were treated with catheter drainage, obviating the need for any surgery.

The clonogenic assay as a reproducible in vitro system to study predictive parameters of treatment outcome in acute nonlymphoblastic leukemia

Seven institutions studied the cloning pattern of leukemic cells from pretherapy bone marrows of 273 patients with newly presenting and relapsed acute nonlymphoblastic leukemia. The cloning assay was done in all centers using an identical double-layer agar method with a common source of colony-stimulating factor. Cells were incubated for seven days, and clones were identified visually with an inverted microscope. All centers were able to obtain clonal growth in a substantial proportion of patients. Differences in growth pattern were observed between the major contributing center and the pooled results for all other centers. However, an analysis of clinical results suggested that in vitro differences were more likely related to differences in the patient populations than to variability in laboratory technique. The proportion of marrows in which leukemic cells formed colonies (greater than 40 cells) and large clusters (20-40 cells) was greater in relapsed patients than in newly presenting patients (P less than .06). A progressive improvement in induction treatment outcome was seen with decreasing clonal growth. Patients whose marrows did not produce clones had a complete remission (CR) rate of 83% versus 50% for those patients whose marrow leukemic cells formed colonies and/or large clusters (P = .05). In vitro drug sensitivity studies with cytosine arabinoside and adriamycin were performed on bone marrow cells of patients treated with this combination clinically. The percent killing of clonogenic cells in this assay correlated with remission induction outcome. Complete remission was obtained in 73% of 15 patients whose bone marrow leukemic cells showed greater than 30% killing by in vitro drug exposure, and CR was obtained in only 30% of 23 patients whose marrows showed less than 30% killing (P less than .01). The results indicate that the clonogenic assay correlates with treatment outcome and can be used for drug sensitivity testing in patients with acute nonlymphoblastic leukemia. The limitations of the assay are discussed.

Increased incidence of hypothyroidism in primary biliary cirrhosis

We examined the thyroid status of 58 patients with primary biliary cirrhosis (PBC) using total serum thyroxin, thyroid hormone binding ratio, free thyroxin index, serum TSH, antithyroglobulin, and antimicrosomal antibodies. Seven patients were known to be hypothyroid prior to the diagnosis of PBC. Six additional patients were found to have biochemical evidence of hypothyroidism. The prevalence of hypothyroidism was 12% if we include only those six PBC patients with newly diagnosed hypothyroidism or 22% if we include all 13 patients. Five of the 58 patients had evidence for an elevation of thyroid hormone binding capacity. Three hypothyroid patients had normal total thyroxins with low thyroid hormone binding ratios. Two euthyroid patients had elevated total T4s with low thyroid hormone binding ratio and normal FTI. The prevalence of positive antimicrosomal antibodies was 34%, including 11 euthyroid PBC patients. The prevalence of positive antithyroglobulin antibodies was 20% including five euthyroid patients. There was no association between HLA DR3 or DR5 and the patients with hypothyroidism and/or antithyroid antibodies. Because fatigue, lethargy, and anorexia as well as hypercholesterolemia are common features of both hypothyroidism and PBC, patients with PBC should be screened for evidence of thyroid dysfunction. Thyroid disease may precede the diagnosis of PBC by several years. Therefore, the development of cholestatic liver disease in a patient with known autoimmune thyroiditis should arouse suspicion of PBC.

Nifedipine as a therapeutic modality for Raynaud's phenomenon

Eight patients with Raynaud's phenomenon were entered into a double-blind crossover study of nifedipine versus placebo, with 7 patients undergoing finger plethysmography before and after sublingual nifedipine administration. While receiving nifedipine, all patients reported decreased frequency and severity of attacks, and 4 of 5 had digital ulcer healing. Total finger blood flow increased 5 of 6 patients after treatment with sublingual nifedipine. This preliminary study indicates that nifedipine may be a useful agent for treatment of digital vasospasm.

Genetic abnormalities of immunoregulation in primary biliary cirrhosis

Patients with primary biliary cirrhosis have an abnormality of lymphocyte suppressor cell function that could play a role in the pathogenesis of their disease. To investigate this possibility, suppressor cell function in patients with primary biliary cirrhosis, in their healthy first-degree relatives, in unrelated household contacts, in patients with other types of cirrhosis, and in normal control subjects was studied. The method used is based on the finding that the in vitro addition of concanavalin A to pokeweed mitogen-stimulated lymphocytes activates suppressor cells, which in turn inhibit immunoglobulin synthesis. Thirteen of 16 patients with primary biliary cirrhosis and six of 23 healthy relatives had significant impairment of IgG suppression. All six of these relatives were female. No abnormal suppression was found in unrelated household contacts of patients with primary biliary cirrhosis, in patients with other types of cirrhosis, or in healthy control subjects. There was no correlation between results of the IgG suppressor cell assay and the disease activity in patients with primary biliary cirrhosis. These data suggest that the abnormal suppressor cell function is not a direct cause of primary biliary cirrhosis; however, it may be a genetic marker for susceptibility to this disease.

Immune regulatory abnormalities produced by procainamide

The pathogenesis of procainamide-induced autoantibody production is unknown. To test the effect of procainamide on the immune system, we studied in vitro suppressor cell function and immunoglobulin G (IgG) secretion in 11 patients who developed autoantibodies while taking procainamide. The procainamide group was compared with patients with spontaneous systemic lupus erythematosus (n = 15) and a normal control population (n = 40). Impaired in vitro suppressor cell function was found in 11 of 14 patients with spontaneous systemic lupus erythematosus but in none of the patients taking procainamide. However, total in vitro IgG secretion was significantly increased in the procainamide group with regard to the control and systemic lupus erythematosus groups. There was a direct correlation between the circulating anti-SS DNA antibody titer and in vitro IgG secretion. Furthermore, T cells isolated from the procainamide-treated patients stimulated IgG secretion by normal allogeneic peripheral blood lymphocytes. The added T cells did not affect in vitro suppressor cell function. We postulate that autoantibody production in patients taking procainamide is due to enhanced helper T cell function and not to impaired suppression. However, the development of clinical disease requires the participation of additional genetic or immunologic factors.

Unusual roentgenologic manifestations of Meckel's diverticulum

Five cases illustrating rare roentgenographic manifestations of Meckel's diverticulum are presented. Small bowel studies in 2 patients demonstrated a mucosal pattern identifiable as heterotopic gastric rugae, and in 2 other cases peptic ulcers were seen within the diverticulum. In 1 patient the diverticulum located in the right upper quadrant contained calcified enteroliths, and in another patient the diverticulum had fistulous communication with the appendix.

Normal immunoregulation of in vitro antibody secretion in autoimmune thyroid disease

Defective suppressor cell function may be a causative factor in autoimmune disease in animals and man. In autoimmune thyroid disease, decreased suppressor cell activity could, under appropriate conditions, account for excess production of thyroid autoantibodies. We evaluated suppressor cell function in patients with Graves' disease and Hashimoto's thyroiditis and in normal controls. The method used is based on the principle that immunoglobulin synthesis by pokeweed mitogen (PWM)-stimulated lymphocytes is inhibited by Concanavalin A (Con A) stimulation of suppressor T cells. We studied suppressor cell control of polyclonal immunoglobulin G (IgG) and the thyroid-specific autoantibody, antimicrosomal antibody. PWM-stimulated IgG secretion (mean +/- SD) by lymphocytes from patients with Graves' disease (2797 +/- 718 ng/ml) and Hashimoto's thyroiditis (2201 +/- 423 ng/ml) did not differ from normal subjects (2431 +/- 485 ng/ml). The addition of Con A to PWM-stimulated lymphocytes suppressed IgG production in all three groups: Graves', 475 +/- 137 ng/ml; Hashimoto's, 507 +/- 74 ng/ml; and normal subjects, 460 +/- 156 ng/ml. The degree of suppression by the disease groups did not differ from the normal controls. Antimicrosomal antibody was detected in the concentrated, PWM-stimulated culture media of two of four Hashimoto's lymphocytes, three of five Graves' lymphocytes, and none of nine normal controls. Con A induced marked suppression of this organ-specific antibody in all cases. We conclude that Con A-stimulated lymphocytes from patients with Hashimoto's thyroiditis and Graves' disease can suppress antimicrosomal antibody and polyclonal IgG synthesis. These findings do not support the postulate of a generalized defect of suppressor cell function in these thyroid disorders.

The role of delayed hypersensitivity in the enhancement of host resistance to infection

Swiss-Webster mice were vaccinated by the intraperitoneal route (i.p.) with Mycobacterium tuberculosis BCG and challenged i.p. 4-10 weeks later with 10(4) virulent Salmonella typhimurium in the presence or absence of purified derivative (PPD) of tuberculin. Normal control mice were similarly challenged. Such an infection was fatal to the normal mice within 12 days. BCG vaccination prolonged the survival time and protected about 36% of the salmonella-infected mice from death. In contrast, tuberculin sensitivity, elicited in the BCG-vaccinated mice, significantly increased the survival time and protected about 70% of the mice against an otherwise fatal challenge. When these experiments were repeated using an infective dose of 10(6) organisms, the protective effect of the tuberculin reaction became substantially reduced, but there remained a statistically significant improvement in the survival distribution of the challenged mice as compared with that among the BCG-vaccinated mice. The examination of peritoneal washings obtained from BCG-vaccinated mice stimulated with PPD showed that the enhanced resistance to salmonella infection was directly associated with a quantitatively increased influx of phagocytic leukocytes accumulating at the site of infection as a result of the elicitation of tuberculin sensitivity.

Nosocomial klebsiella infection in a neonatal unit: identification of risk factors for gastrointestinal colonization

Sequential outbreaks of infection due to gentamicin-resistant Klebsiella pneumoniae (GRKP) types 30 and 19 occurred in the neonatal intensive care unit (NICU) at the Medical College of Virginia in 1977 and 1978. The extensive epidemiologic investigation carried out included a case-control study, careful review of aseptic technique, and cultures from nursery staff and environment. The gastrointestinal (GI) tracts of the patients were the reservoirs for GRKP, and the epidemic strain was transmitted by hands of personnel. The case-control study showed a significant relationship between acquisition of GRKP by patients and oropharyngeal and GI instrumentation, including use of bag resuscitation, oropharyngeal suctioning, and use of nasogastric feeding tubes. The findings of the case-control study were supported by observation of the patient care techniques practiced by NICU staff. Institution of control measures based on results of the epidemiologic investigation of the first outbreak rapidly brought the second outbreak under control, even though cohorting or use of routine isolation was not possible. Whereas GI colonization and hand transmission have been described previously in outbreaks of K. pneumoniae infections in NICUs, this study is the first to document the mode of inoculation of patients' GI tracts by contaminated hands of personnel.

Familial abnormalities of suppressor-cell function in systemic lupus erythematosus

We tested the hypothesis that abnormalities of central immune function are genetically controlled in patients with systemic lupus erythematosus. We used an in vitro suppressor-cell assay to evaluate central immunoregulation in 15 patients, 50 of their clinically healthy family members and 41 normal persons. Impaired suppressor-cell function was found in 11 patients; there was no correlation between disease activity and test results. Abnormal suppressor-cell activity was also found in 13 first-degree relatives, 12 of whom were women. We found no correlation between results of the suppressor-cell assay and the presence or absence of lymphocytotoxic antibodies in the relatives. Impaired suppressor-cell function cannot by itself explain the pathogenesis of systemic lupus erythematosus. Our results support the hypothesis that certain abnormalities of suppressor cells are genetic markers. We propose that the development of systemic lupus erythematosus requires the participation of at least two functionally distinct classes of genes.

Evidence for structural homology between human red cell phosphoglycerate mutase and 2,3-bisphosphoglycerate synthase

Previous reports have suggested the possibility of extensive structural homology between human erythrocyte bisphosphoglycerate synthase (glycerate-1,3-P2 leads to glycerate-2,3-P2) and phosphoglycerate mutase (glycerate-3-P in equilibrium glycerate-2-P). This study lends credence to that conjecture through comparative physicochemical investigations involving peptide mapping, circular dichroism, and immunological techniques. The data indicate that despite differences in function, both enzymes apparently manifest a high degree of similarity in primary, secondary, and tertiary structure. Mapping data also indicate that each protein is comprised of two apparently identical subunits.