A systematic review of the associations between dose regimens and medication compliance

BACKGROUND

Previous reviews of the literature on medication compliance have confirmed the inverse relationship between number of daily doses and rate of compliance. However, compliance in most of these studies was based on patient self-report, blood-level monitoring, prescription refills, or pill count data, none of which are as accurate as electronic monitoring (EM).

OBJECTIVE

In this paper, we review studies in which compliance was measured with an EM device to determine the associations between dose frequency and medication compliance.

METHODS

Articles included in this review were identified through literature searches of MEDLINE, PsychInfo, HealthStar, Health & Psychosocial Instruments, and the Cochrane Library using the search terms patient compliance, patient adherence, electronic monitoring, and MEMS (medication event monitoring systems). The review was limited to studies reporting compliance measured by EM devices, the most accurate compliance assessment method to date. Because EM was introduced only in 1986, the literature search was restricted to the years 1986 to 2000. In the identified studies, data were pooled to calculate mean compliance with once-daily, twice-daily, 3-times-daily, and 4-times-daily dosing regimens. Because of heterogeneity in definitions of compliance, 2 major categories of compliance rates were defined: dose-taking (taking the prescribed number of pills each day) and dose-timing (taking pills within the prescribed time frame).

RESULTS

A total of 76 studies were identified. Mean dose-taking compliance was 71% +/- 17% (range, 34%-97%) and declined as the number of daily doses increased: 1 dose = 79% +/- 14%, 2 doses = 69% +/- 15%, 3 doses = 65% +/- 16%, 4 doses = 51% +/- 20% (P < 0.001 among dose schedules). Compliance was significantly higher for once-daily versus 3-times-daily (P = 0.008), once-daily versus 4-times-daily (P < 0.001), and twice-daily versus 4-times-daily regimens (P = 0.001); however, there were no significant differences in compliance between once-daily and twice-daily regimens or between twice-daily and 3-times-daily regimens. In the subset of 14 studies that reported dose-timing results, mean dose-timing compliance was 59% +/- 24%; more frequent dosing was associated with lower compliance rates.

CONCLUSIONS

A review of studies that measured compliance using EM confirmed that the prescribed number of doses per day is inversely related to compliance. Simpler, less frequent dosing regimens resulted in better compliance across a variety of therapeutic classes.

VIRULENCE AND MORPHOLOGICAL CHARACTERISTICS OF MAMMALIAN TUBERCLE BACILLI

Experimental infection of the mouse can be used for the determination of virulence of cultures of mammalian tubercle bacilli. The relative virulence of such cultures for the mouse is approximately the same as for the guinea pig. Cultures of virulent and avirulent variants of mammalian tubercle bacilli grown in the depth of Tween 80-albumin liquid medium, on the surface of solid agar modifications of this medium, and on the surface of a liquid modification of this medium exhibit consistent morphological differences. All virulent cultures tend to form microscopically demonstrable serpentine cords of varying thickness and length consisting of highly acid-fast bacilli oriented in parallel along the long axis of the cord. The formation of cords appears to be an important factor in conditioning the ability of cultures to spread on the surface of liquid and solid media. It can be inhibited by the addition to the medium of the surface-active water-dispersible oleic acid ester, Tween 80. Avirulent variant bacilli grow in a more or less non-oriented fashion. They have never been observed to form cords under any condition of growth and are much less acid-fast than the virulent cultures when grown in Tween-albumin medium. Two strains of mammalian tubercle bacilli which are intermediate in degree of virulence between the fully virulent and the avirulent variants also exhibit intermediate morphological characteristics.

Efficacy and Safety of Ibuprofen and Acetaminophen in Children and Adults: A Meta-Analysis and Qualitative Review

Objective:

To evaluate the analgesic and antipyretic efficacy and safety of ibuprofen compared to acetaminophen in children and adults.

Data Sources:

Literature searches were performed using PubMed/MEDLINE (through August 2009) and EMBASE (through January 2008) and were restricted to the English language. In PubMed/MEDLINE, search terms used were ibuprofen, acetaminophen, paracetamol, clinical trials, and randomized controlled trials. EMBASE search terms included ibuprofen and acetaminophen, restricted to human and clinical trials.

Study Selection And Data Extraction:

All English-language articles identified from the data sources were reviewed. Multiple review articles were studied for any pertinent references and this yielded additional articles. Only articles that directly compared ibuprofen and acetaminophen were eligible for this review.

Data Synthesis:

Eighty-five studies that directly compared ibuprofen to acetaminophen were identified; 54 contained analgesic efficacy data, 35 contained antipyretic/temperature reduction data, and 66 contained safety data (some articles contained more than 1 type of data). Qualitative review of the literature revealed that, for the most part, ibuprofen was more efficacious than acetaminophen for the treatment of pain and fever in both pediatric and adult populations, and that these 2 drugs were equally safe. Meta-analyses on the subset of randomized clinical trial articles that reported sufficient quantitative information to calculate either an odds ratio (adverse event [AE]) or standardized mean difference (pain and fever) confirmed the qualitative results for adult (standardized mean difference [SMD] 0.69; 95% CI 0.57 to 0.81) and pediatric (SMD 0.28; 95% CI 0.10 to 0.46) pain at 2 hours postdose and pediatric fever (SMD 0.26; 95% CI 0.10 to 0.41) at 4 hours postdose. Conclusions regarding adult fever/temperature reduction could not be made due to a lack of evaluable data. The combined odds ratio for the proportion of adult subjects experiencing at least 1 AE slightly favored ibuprofen; however, the difference was not statistically significant (1.12; 95% CI 1.00 to 1.25). No significant difference between drugs in AE incidence was found for pediatric patients (0.82; 95% CI 0.60 to 1.12).

Conclusions:

Ibuprofen is as or more efficacious than acetaminophen for the treatment of pain and fever in adult and pediatric populations and is equally safe.

Is leukocytosis a predictor of mortality in severe pertussis infection?

Bordetella pertussis causing severe respiratory failure in infants that is unresponsive to treatment is well described. Pulmonary hypertension is a prominent feature of such cases. In this series of 13 critically ill infants with B. pertussis, hyperleukocytosis ( > 100 x 10(9)/l) was an independent predictor of death. We suggest that such extreme leukocytosis may contribute to disease severity via the formation of aggregates in the pulmonary vasculature.

THE MULTIPLICATION OF BACTERIOPHAGE IN VIVO AND ITS PROTECTIVE EFFECT AGAINST AN EXPERIMENTAL INFECTION WITH SHIGELLA DYSENTERIAE

1. Anti-Shiga bacteriophage injected into the general circulation can multiply in the brain of mice infected intracerebrally with Shigella dysenteriae. 2. Under proper conditions, the injection of active bacteriophage into the general circulation can protect mice against an otherwise fatal intracerebral infection with Shigella dysenteriae. 3. The protection so induced appears to depend upon the early establishment of a high bacteriophage level in the infected animal.

Suppressed anger and blood pressure: the effects of race, sex, social class, obesity, and age

We studied 572 men and women who participated in a blood pressure screening program at a government unemployment office. Before having their blood pressures taken, the subjects completed a brief questionnaire that included two items measuring conflict over anger expression. Information was also obtained on obesity, race, sex, social class, and age. Across all subjects, systolic blood pressure was found to be significantly related to suppressed anger (p less than 0.016). Normotensive were twice as likely as hypertensives to be free of suppressed anger. This relationship remained after controlling for the covariates of age, social class, and obesity. The relationship between suppressed anger and systolic blood pressure was significant for white men, exhibited a trend in black men, and was not significant for women. In contrast to the systolic findings, suppressed anger was unrelated to diastolic pressure in all the analyses.

Effects of nonverbal behavior on perceptions of power bases

Among a sample of U.S. students, the effects of 3 forms of nonverbal behavior (facial expression, visual behavior, and body posture) on perceptions of power bases (reward, coercive, legitimate, referent, expert, and credibility) were investigated. In contrast to previous investigations of nonverbal behavior and power, a precise construct definition and reliable and valid operational definitions of power were used, and specific perceptions of power bases were examined. A relaxed facial expression, compared with a nervous facial expression, increased the ratings for referent, reward, legitimate, expert, and credibility power bases. Also, direct eye contact yielded higher credibility ratings than indirect eye contact.

INFECTION OF MICE WITH MAMMALIAN TUBERCLE BACILLI GROWN IN TWEEN-ALBUMIN LIQUID MEDIUM

Introduction of the bacilli by the mtravenous route or by feeding gives rise to a disease predominantly localized in the lungs. Following intracerebral infection, the bacilli first multiply rapidly in the brain tissue, and then invade other organs, producing lesions especially in the lungs. Injection of the bacilli by the intraperitoneal route is less effective than by either the intravenous or intracerebral routes; however, admixture of the bacilli with some of the components of egg yolk increases both the infectivity and the pulmonary localization. Different strains of mice differ markedly in their susceptibility to experimental tuberculous infection; the highest susceptibility was observed among the pigmented strains (line 1 dba and C57 black). Greater resistance does not appear to depend on the ability to prevent the establishment of infection, but rather corresponds to a slower rate of progression of the infectious process. It is possible to produce in mice tuberculosis presenting any desired degree of acuteness or chronicity by controlling certain factors which condition the initiation and the progression of the infection.

The manganese stabilizing protein of photosystem II modifies the in vivo deactivation and photoactivation kinetics of the H2O oxidation complex in Synechocystis sp. PCC6803

Dark deactivation and photoactivation of H2O-splitting activity were examined in a directed mutant (delta psbO) of Synechocystis sp. PCC6803 lacking the extrinsic manganese-stabilizing protein of the photosystem II (PSII) reaction center complex. Rapid (t1/2 = 10 min) losses of H2O-splitting activity were observed for delta psbO cells kept in the dark, but not for wild-type cells. The loss of H2O-splitting activity by delta psbO cells was suppressed by maintaining the cells under illumination and dark losses were rapidly (t1/2 < 1 min) reversed by light. Photoactivation kinetics of delta psbO and wild-type cells were compared following hydroxylamine extraction of PSII Mn. Photoactivation of delta psbO cells under continuous illumination occurs at an intrinsically faster rate (about 4-fold) than the wild-type. Virtually all of the increase in the rate of photoactivation can be accounted for by a corresponding 4-fold increase in the relative quantum yield of photoactivation as indicated by the yield of photoactivation as a function of flash number. The flash frequency dependence of photoactivation indicates a multi-quantum process in the mutant resembling the wild-type, but with significant increases in yields at all flash frequencies examined. The higher quantum yield of photoactivation in delta psbO cells occurs in the absence of large changes in the kinetics of the rate-limiting dark rearrangement. The results are consistent with increased accessibility (or affinity) and photooxidation of Mn2+ at one or both of the two binding sites involved in the initial stages of the photoactivation mechanism. In the context of previous results, it is proposed that MSP regulates the binding/photooxidation of the second Mn2+ of the photoligation sequence, but not the first.

Effects of verapamil on coronary hemodynamic function and vasomobility relative to its mechanism of antianginal action

The effect of intravenous verapamil on systemic and coronary hemodynamic function was studied at cardiac catheterization in 12 patients with coronary artery disease. Verapamil was administered as a 2-minute bolus (0.145 mg/kg) followed by an infusion (0.005 mg/kg/min). Cardiac output and coronary sinus blood flow were measured by thermodilution techniques. Caliber of the large coronary arteries and of diseased segments was determined from the coronary angiogram using a computer-assisted method. Verapamil reduced mean arterial pressure 14% (p less than 0.001), systemic vascular resistance 21% (p less than 0.01), and stroke work index 16% (p less than 0.001). Coronary vascular resistance decreased 24% (p less than 0.01) with a small increase in coronary sinus blood flow (+13%, difference not significant [NS]). Myocardial oxygen consumption determined in 5 patients showed no significant change with verapamil. Luminal area in 39 coronary lesions was measured in the "normal" portion of the diseased segment and at its maximal constriction, and an estimate of flow resistance in the stenosis was computed. Overall, 50% of "normal" and of diseased coronary segments dilated significantly with verapamil. Stenosis dilation resulted in an average 14% reduction (p less than 0.01) in estimated flow resistance. In 8 patients, the luminal changes (n = 27) induced by sublingual nitroglycerin were compared with those induced by verapamil. Nitroglycerin induced a significantly greater increase in coronary caliber in both normal and diseased segments; estimated stenosis flow resistance decreased 28% with nitroglycerin compared with 14% with verapamil (p less than 0.01). Thus, verapamil moderately dilates the systemic and coronary small vessel resistance bed without apparently increasing myocardial metabolic demand. Furthermore, verapamil mildly dilates large coronary conductance vessels in both "normal" and diseased segments, although significantly less than does nitroglycerin.

THE ENHANCING EFFECT OF CONCURRENT INFECTION WITH PNEUMOTROPIC VIRUSES ON PULMONARY TUBERCULOSIS IN MICE

The course of pulmonary tuberculosis in the mouse appears to be accelerated as a result of concurrent infection of the lung with either of two pneumotropic viruses. This effect is obtained with virus inocula sufficiently small as to induce little or no definite viral pneumonia.

Life-threatening hypernatraemic dehydration in breastfed babies

We describe five babies, who were exclusively breast fed, with life-threatening complications of hypernatraemic dehydration secondary to inadequate breast feeding. An increased awareness among health professionals is required so that this potentially devastating condition can be prevented.

A fluorescence plate reader assay for monitoring the susceptibility of biological samples to lipid peroxidation

The susceptibility of biological samples to lipid peroxidation can be determined by exposing samples to a lipid peroxidation initiator and measuring the length of time prior to the onset of lipid peroxidation. Previous studies have shown that aldehydes generated by lipid peroxidation can react with amines to produce fluorescent products. We have utilized this principle to develop a fluorescence plate reader assay for measuring susceptibility to lipid peroxidation. In this assay, samples are placed in glycine/phosphate buffer and loaded into a 96-well plate. Lipid peroxidation initiators are added, and fluorescence is monitored over time. Samples were assayed for susceptibility to lipid peroxidation by both the thiobarbituric acid reactive substances assay and the fluorescence plate reader assay. We found good agreement between these two methods in assessing relative susceptibility to lipid peroxidation in liver microsomes and mitochondria. The fluorescence assay was also used to monitor lipid peroxidation in liposomes and rat liver homogenates. Fluorescence was stable over an extended time period and could be induced by a variety of lipid peroxidation initiators. The fluorescence plate reader assay offers a rapid method for monitoring lipid peroxidation in a large number of samples.

Left ventricular outflow tract obstruction after partial atrioventricular septal defect repair

BACKGROUND

Narrowing of the left ventricular outflow tract has been associated with partial atrioventricular septal defect (PAVSD) in about 3% of patients. Because of the predisposing anatomy, hemodynamically significant obstruction in the subaortic area may appear after repair of ostium primum atrial septal defects.

METHODS

From 1984 to 1998, 40 patients underwent surgical correction of PAVSD by patch closure. The mean age at the initial repair was 5.8 years (range 3 months to 22 years).

RESULTS

Nine patients had 12 subsequent operations for hemodynamically significant subaortic obstruction. The mean age at PAVSD repair was 17 months (3 to 42 months) (p < 0.001 compared with others). Follow-up work-up was obtained due to symptoms in 5 patients and an abnormal echocardiogram in 4 asymptomatic patients. Subaortic stenosis developed at a mean of 5 years (range 4 months to 10 years), and 6 or more years in 4 patients. The mean age at subaortic stenosis repair was 6 years (range 2 to 12 years). Nine patients underwent subaortic fibromuscular resection. Of these, 4 developed recurrent stenosis and 2 have undergone additional operations.

CONCLUSIONS

Left ventricular outflow tract obstruction after PAVSD repair may be more frequent than reported. Because of the progressive nature of the process, echocardiography should be utilized liberally on patients to uncover subclinical stenosis. Long-term follow-up is essential for diagnosis due to delayed appearance and lack of reliable clinical signs.

Crossover by line length and spatial location

It is well known that line length has a systematic influence on line bisection error in neglect. Most patients with neglect misbisect long lines on the same side of true center as their brain lesion but then cross over on short lines, misbisecting them on the opposite side (i.e., crossover by line length). What is less recognized is that the spatial location of lines relative to the viewer can similarly induce a crossover effect when one considers line bisection error scores that have been averaged across individual line lengths. Patients with right hemisphere injury and neglect classically make averaged line bisection errors that fall right of true center on lines located either at midline or to the left of the viewer; however, we observed that the averaged line bisection error can fall left of true center when lines are located to the right of the viewer (i.e., crossover by spatial location). We hypothesized that crossover by both line length and spatial location stem from systematic errors in magnitude estimation, i.e., perceived line length. We tested predictions based on this hypothesis by examining how the crossover effect by line length is altered by the spatial location of lines along a horizontal axis relative to the viewer. Participants included patients with unilateral lesions of the right and left cerebral hemispheres and age-appropriate normal subjects. All groups demonstrated a crossover effect by line length at the midline location but the effect was altered by placing lines to the right and left of the viewer. In particular, patients with right hemisphere injury and neglect crossed-over across a broader range of line lengths when the lines were located to the right of the viewer rather than at either midline or left of the viewer. It is proposed that mental representations of stimulus magnitude are altered in neglect, in addition to mental representations of space, and that traditional accounts of neglect can be enhanced by including the psychophysical concept of magnitude estimation.

Impact of ultrafiltration on blood use for atrial septal defect closure in infants and children

BACKGROUND

Infants and children undergoing open cardiac operations have a high incidence of blood product transfusion. Ultrafiltration has been shown to reverse hemodilution and improve myocardial function and hemodynamics after cardiopulmonary bypass (CPB).

METHODS

The effect of ultrafiltration on the amount of blood transfusion and hospital charge in 39 consecutive patients who underwent elective atrial septal defect repair was examined. Patients in group I (n=26) had a conventional cardiopulmonary circuit prime with blood, whereas 13 patients had bloodless prime (group II). Ultrafiltration was used immediately after weaning from CPB in group II. The patients in group I received blood products after discontinuation of CPB to achieve a hematocrit of 30%. The amount of blood product used, hematocrit immediately after CPB and on arrival in intensive care unit, postoperative hemodynamics and saturations, total operating room charge, blood charge, hospital stay, and hospital charge were compared.

RESULTS

Mean body weight (15.8 kg in group I versus 17.5 kg in group II) and preoperative hematocrit values (35.6% in group I versus 34.2% in group II) were similar. Mean hematocrit immediately after CPB was 22% and 14% in group I and II, respectively (p < 0.0001). The mean hematocrit upon arrival to the intensive care unit was 34% in group I and 22% in group II (p < 0.0001). The amount of blood product transfusion was 32 mL/kg in group I and 3 mL/kg in group II patients (p < 0.0001). The patients in group II had significantly less blood bank charges; however, operating room charges and total hospital charges were similar between the two groups.

CONCLUSIONS

Elective atrial septal defect repair was performed with no blood product transfusion without increased morbidity or hospital stay. Ultrafiltration can be used to reverse hemodilution resulting from a bloodless CPB prime without an increase in hospital charge.

Preliminary Validation of a Patient-based Self-assessment Measure of Severity of Illness in Type 2 Diabetes

Measures of case mix are needed to control for patients' clinical status in studies assessing the process and outcomes of care. The Veterans Health Study (VHS) is a longitudinal study of determinants of health outcomes in ambulatory veterans. This study assessed the validity of a case-mix measure developed to quantify severity of illness in ambulatory type 2 diabetic patients. As part of the pilot phase of the VHS, 245 veterans using 4 primary care clinics in Boston were screened for diabetes and 5 other chronic illnesses when they presented for care. Subjects screening positive for diabetes returned to complete severity of illness and outcome measures. The variables for the diabetes case-mix module were chosen based upon the principles of parsimony, duration of follow-up, and clinical validity and credibility. Variables were selected to predict function, as measured by the Medical Outcomes Study Short-Form 36 (SF-36). The diabetic patients in this study had a heavy burden of chronic illness, with an average of 3.9 comorbid conditions and a mean general health perceptions score of 48 on the SF-36 (scored from 0 to 100, with 100 indicating best health). A summary variable called DMSEV was created for "diabetes severity". This included atherosclerotic complications(stroke, transient ischemic attack or myocardial infarction; chest pain frequency; and claudication), plus any history of eye, foot, or neuropathic symptoms. DMSEV correlated with all 8 outcome scales of the SF-36, and in particular was highly associated with physical function (r=0.49, P=.0001). Least squares linear regression analysis controlling for age and comorbidity confirmed the association of DMSEV with all 8 SF-36 scales. The correlation with physical function remained highly significant (P<.0001), with an R of 0.31. This patient-based self-assessment questionnaire and the summary variable DMSEV appear to be valid measures of severity of illness in ambulatory diabetic veterans with multiple comorbidities. After further testing, this case-mix measure may be suitable for controlling for severity of illness in ambulatory-based studies of diabetic patients with multiple chronic illnesses.

The role of nonsteroidal anti-inflammatory drugs in pediatric patients

Like in the adult population, nonsteroidal anti-inflammatory drugs (NSAIDS) are commonly used agents for their anti-inflammatory, anti-pyretic and analgesic effects in pediatrics. They are also used for some distinct indications in pediatrics such as Kawasaki disease, patent ductus arteriosus (PDA) closure, and Juvenile Idiopathic Arthritis (JIA). The primary mechanism thought to cause their therapeutic effects is the inhibition of prostaglandin synthesis. NSAIDs inhibit cyclooxygenase (COX) which is an enzyme that is necessary for the formation of prostaglandins. Unfortunately, this same mechanism, the inhibition of prostaglandins, is thought to be the most likely cause of gastrointestinal (GI) mucosal damage, because prostaglandins through multiple mechanisms assist in the preparation and maintenance of the protective barrier of the mucosal lining of the stomach. Similarly, prostaglandins in the kidney promote intrarenal plasma flow and electrolyte balance. The efficacy and safety of NSAIDs must be considered in prescribing these agents. The real conundrum of these therapies is determining the role of newer agents such as intravenous ibuprofen compared to existing alternatives. Available data for intravenous ibuprofen in adults is promising, but further studies are needed in pediatric patients to determine efficacy, place in therapy, and safety.

Haematoma in a hydrocele of the canal of Nuck mimicking a Richter's hernia

We report a haematoma in a hydrocele of the canal of Nuck in a 69-year-old female. She presented with a right-sided groin swelling, the differential for which included an irreducible inguinal hernia or haematoma given her aspirin and clopidegrel use. Successful treatment involved evacuation of the haematoma with excision of the sac. Despite a high index of suspicion for a haematoma, these swellings should ideally be explored given the potential for co-existence of a hernia.

Surgical aortic valvuloplasty using the Cavitron Ultrasonic Surgical Aspirator: an invasive hemodynamic follow-up study

Valve repair and calcium debridement in patients with calcific aortic stenosis, using the Cavitron Ultrasonic Surgical Aspirator (CUSA), results in a reduction in the aortic valve gradient while potentially avoiding long-term problems inherent to prosthetic valves. Invasive followup data in these patients has not previously been reported. Ten patients in whom CUSA debridement was performed underwent cardiac catheterization prior to and 8.0 +/- 2.5 months following the procedure. Compared to baseline, the aortic valve area significantly increased from 0.75 +/- 0.2 to 1.1 +/- 0.3 cm2 (p = 0.009) and the mean gradient was significantly reduced from 54 +/- 21 to 27 +/- 21 mmHg (p = 0.02) at followup. No significant change was noted in cardiac output, ejection fraction, left ventricular end systolic or diastolic volumes or left ventricular end diastolic pressure. However, 6 patients were found to have at least one grade worsening of aortic regurgitation. The development of increased aortic insufficiency in many patients after CUSA aortic valve debridement will likely limit this procedure's clinical utility.

Determinants of one-year outcome from balloon aortic valvuloplasty

Balloon aortic valvuloplasty (BAV) has been a therapeutic alternative treatment for severe symptomatic aortic stenosis. Previous studies have been unable to predict 1-year outcome because of limited acute and follow-up clinical, invasive and echocardiographic data. The purpose of this study was to predict long-term outcome based on comprehensive data obtained at the time of valvuloplasty and at 3 and 6 months after the procedure. Of 170 consecutive patients undergoing BAV, 108 (mean age 78 years) were at least 1 year from their procedure. Prospective clinical, micromanometer hemodynamic, digital ventriculographic and echocardiographic/Doppler data were collected at baseline and immediately after the procedure. Echocardiographic data were also obtained at 3 and 6 months. With use of Cox model analysis, major events (defined as cardiac death [n = 30], aortic valve replacement [n = 21] or repeat BAV [n = 13]) were predicted by advanced age, baseline heart failure class, and baseline echocardiographic-determined diastolic left ventricular diameter. Only baseline left ventricular ejection fraction proved to be a significant predictor of cardiac death (p = 0.002) in a multivariate model. Absolute values after BAV (stroke work, first derivative of left ventricular pressure, valve area, end-systolic volume, Fick cardiac output, transvalvular gradient) and acute changes measured by catheterization or echocardiography did not provide additional predictive information over that of post procedure ejection fraction. Similarly, echocardiographic valve area and transvalvular gradient at 3 months added no further prognostic data. With an ejection fraction greater than or equal to 45% (n = 63), cardiac survival at 1 year was 80%, irrespective of age, sex, congestive heart failure class or severity of coronary artery disease.(ABSTRACT TRUNCATED AT 250 WORDS)

Rights and responsibilities

As an alternative to rights theory, John Ladd proposes an ethics of responsibility based on interpersonal relationships. These relationships, described as friendships, are personal in nature, founded on trust, and obtain between doctor and patient, parent and child, etc. Ladd presents his views in a most appealing way -- helping the needy, being friends with the doctor. We argue that Ladd's ethics of responsibility is plausible only because he ignores the facts of power which rights theory was designed to take into account, and that rights and the corresponding institutional model of medicine are indeed appropriate to the physician/patient relationship.

Preliminary comparison of predictive and empiric lithium dosing: impact on patient outcome

OBJECTIVE

To evaluate whether initiating lithium with predictive dosing compared with empiric dosing improves outcome in patients with manic symptoms.

DESIGN

The study was a randomized, single-blind design and used the Modified Slattery predictive method.

SETTING AND PARTICIPANTS

Eighteen inpatients at an urban psychiatric hospital with a Mania Rating Scale (MRS) score greater than or equal to 24 were enrolled.

OUTCOME MEASURES

The study endpoint was defined as an MRS rating less than or equal to 14 or discharge from the hospital. Assessments (MRS, Brief Psychiatric Rating Scale, Clinical Global Impression, Systematic Assessment for Treatment of Emergent Events Scale, quality of life measures) were completed at baseline, on days 3 or 4 and 7 or 8, and weekly thereafter.

RESULTS

The predictive group achieved a therapeutic concentration significantly sooner than did the empiric group (p = 0.004); however, the mean serum lithium concentration at discharge did not differ between the groups. The predictive group was taking significantly higher dosages of antipsychotics in chlorpromazine equivalents on day 3 or 4 (p = 0.05). Significantly fewer gastrointestinal/genitourinary adverse effects on day 3 or 4 were reported by patients in the predictive group (p = 0.04). No difference was found between groups with any rating scale or other pharmacokinetic or medication item. Even though the difference did not meet statistical significance, the predictive group's length of stay in the acute unit was three days shorter than that of the empiric group, which may represent significant cost savings.

CONCLUSIONS

The preliminary data do not suggest that patient outcome is improved by using Modified Slattery predictive dosing; however, the suggestion of a shorter length of stay in a restrictive unit merits further evaluation.

Standardization of ELISA for the detection of anti-cardiolipin antibodies--effect of non-specific IgG binding

Various frequencies of anti-cardiolipin antibodies reported in patients with systemic lupus erythematosus and other autoimmune and infectious diseases necessitates the need for standardization of the immunoassay. We report here the usefulness of "no-antigen" control for each serum in determining the actual value of the anti-phospholipid antibodies. This non-specific "no-antigen" binding was quite variable from serum to serum and in general was higher in the patient population than in healthy individuals which served as controls. This non-specific binding may be associated with the increased IgG content of the sera as shown by the linear association of the absorbance of the back-ground readings to increases in IgG concentration (correlation coefficient 0.98).