Pharmacokinetics of cyclosporine after renal transplant in children.

The pharmacokinetics of cyclosporine and the relationship between blood levels and average drug concentration were prospectively evaluated in 18 children 1 month after renal transplantation. All children had normal renal function and no hepatic or gastrointestinal dysfunction. Cyclosporine was administered after an overnight fast, and serial blood samples were drawn over a 24-hour period. Analysis of cyclosporine levels was performed by means of monoclonal radio immunoassay on whole blood. Children were divided into three age groups for comparison: 2-5 years, 5-10 years, and > 10 years. There were no differences between age groups in serum protein, serum lipids, or hemoglobin levels, or in the pharmacokinetic parameters of cyclosporine except as follows: significant differences were noted in cyclosporine dose based on body weight, apparent steady-state volume of distribution, and apparent blood clearance, with the youngest children (2-5) requiring higher doses, a relative greater distribution, and exhibiting more rapid drug clearance than those > 10 years of age. In addition, we observed diurnal variation in trough levels, with morning levels (0 hr) significantly higher than those obtained in the evening (12 hours after administration of cyclosporine). Trough levels demonstrated a fair correlation with area under the concentration-time curve (AUC) and average concentration (Cav), but an abbreviated kinetic profile using cyclosporine levels 1 and 3.5 hours after administration accurately predicted AUC.

Patterns of children's coping with an aversive dental treatment.

Children's disposition to monitor for threat-relevant cues predicted their coping strategies and levels of distress when dealing with invasive dental work. High monitors reported that they had engaged in greater sensory vigilance and avoidance strategies during treatment. Neither the tendency to monitor nor children's sensory vigilance was related to videotape observations of their attention deployment. High monitors reported increased anxiety and were rated as more anxious, particularly when they also engaged in high avoidance. Children's reports of question asking were related to videotape observations of question asking. In addition, children who asked more questions were rated as more anxious and disruptive during treatment. Individual differences in how children deal with a familiar--but largely uncontrollable--stressor are discussed, particularly with respect to the encounter phase of coping.

Evaluation of a simple office-based strategy for increasing influenza vaccine administration and the effect of differing reimbursement plans on the patient acceptance rate.

OBJECTIVE: To study an office-based strategy for increasing influenza vaccine delivery to high-risk patients at a university hospital general medicine practice. DESIGN: Historically controlled study of physician practices in an outpatient general medicine setting. SETTING: A group practice with two separate offices: a fee-for-service (FFS) office, where the patients pay the cost of immunizations, and a health maintenance organization (HMO)-styled office, where the costs for immunizations are fully covered by the insurer. PATIENTS: All outpatients seen at each practice setting from October to December, 1991. INTERVENTION: For each patient visit, a simple reminder data sheet was completed by the clinician detailing the vaccination eligibility (Centers for Disease Control and Prevention criteria) and status of the patient, the reasons for failure to vaccinate eligible patients, and 1990 vaccination information. RESULTS: During the study period, 511 patients were seen by the practice (353 in the FFS office, 158 in the HMO office). 297 patients (58%) were eligible for vaccination; 219 in the FFS office, 78 in the HMO office (p < 0.01). At the end of the study period, 73% of all the eligible patients were vaccinated: 67% of the FFS patients vs 90% of the HMO patients (p < 0.01). 22% of the eligible patients refused vaccination: 27% in the FFS office vs 9% in the HMO office (p < 0.01). 11% of the eligible FFS patients vs 0% of the eligible HMO patients refused vaccination due to vaccine cost (p < 0.05). Of the eligible patients seen at the two offices in both 1990 and 1991. 50% were vaccinated in 1990 (preintervention) vs 66% in 1991 (postintervention) (p < 0.01). CONCLUSIONS: As shown in this study, a simple, low-cost office-based reminder system can significantly increase the influenza vaccination rate for high-risk outpatients and can help meet national vaccination rate goals. Vaccine cost to patients may be a barrier to vaccine acceptance, in some cases.

Variability of venous-hemodynamics with daily activity.

PURPOSE: This study was designed to evaluate changes in venous hemodynamics that occur in normal, symptom-free male and female volunteers, as a consequence of daily activity. METHODS: Each leg of 25 symptom-free volunteers was prospectively studied twice in the early morning and twice in the late afternoon on 2 days. Air plethysmography was used to evaluate venous volumes, venous valvular function, calf muscle pump function, and the noninvasive equivalent of ambulatory venous pressure. RESULTS: There was significant change in venous valvular function (venous filling index) indicating progressive insufficiency in the late afternoon compared with the results of the morning studies (p = 0.039). This was demonstrated by a shortened venous filling time (p = 0.033) but not a change in venous volume (p = 0.794). Calf muscle pump function and ambulatory venous pressures remained constant. Although there were significant leg volume and ejection volume differences at baseline in male volunteers compared with female volunteers, no gender differences were evident as a result of daily activity. Five of 25 (20%) volunteers and seven of 50 (14%) extremities had normal venous refill times and venous function index in the morning, which became abnormal in the afternoon, indicating deterioration of venous valve function. CONCLUSIONS: Venous hemodynamic changes occur normally as a consequence of daily activity and seem to result from valvular dysfunction. This occurs in men and women and can alter diagnostic conclusions in 20% of otherwise normal patients. These findings have important implications for venous testing and accurate patient evaluation. However, extrapolation of these data to patients with established venous disease should not be made.

Source of Pseudomonas cepacia: ribotyping of isolates from patients and from the environment.

Ribotyping, an analysis of bacterial strain identity based on chromosomal restriction fragment length polymorphisms, was performed on 68 isolates of Pseudomonas cepacia recovered from patients receiving care at the two children's hospitals in Philadelphia and from environmental samples. Twenty different ribotypes were identified. Ribotype R3 predominated among isolates from all three sources. These findings are consistent with the acquisition of P. cepacia from the environment or by person-to-person transmission.

Evaluation of OKT3 monoclonal antibody and anti-thymocyte globulin in the treatment of steroid-resistant acute allograft rejection in pediatric renal transplants.

We reviewed the effectiveness of Muromonab-CD3 (OKT3) and anti-thymocyte globulin (ATG) in the treatment of corticosteroid-resistant acute renal allograft rejection in 49 transplanted children. Reversal of rejection was successful in 22 of 23 patients (96%) treated with OKT3 and 21 of 26 (81%) treated with ATG (P = NS). Re-rejection episodes occurred within 1 month of cessation of therapy in 9 of 22 patients treated with OKT3 but only in 2 of 21 who received ATG (P < 0.05). In the patients with re-rejection, 7 of the 9 patients originally given OKT3 and 1 of the 2 who received ATG responded to a repeat course of high-dose corticosteroids; thus, at 1 month post treatment, the incidence of graft loss due to initial rejection or re-rejection was 13% for the OKT3 and 23% for the ATG group (P = NS). Graft survival was similar at 6 months: 82% for OKT3- and 73% for ATG-treated patients (P = NS); 100% patient survival was noted in both groups. Mean calculated creatinine clearance prior to, during, and at 1 and 6 months post rejection was similar in the OKT3- and ATG-treated groups. Neutropenia and thrombocytopenia occurred more frequently in the ATG group, but there was no significant difference in infectious complications. Two patients developed high (> or = 1:1,000) OKT3 antibody titers. In our experience, children with corticosteroid-resistant acute renal allograft rejection treated with OKT3 and ATG had similar allograft survival and level of renal function at 1 and 6 months, and number of infectious complications post therapy.

Improvement in physicians' counseling of patients with mental health problems.

This study evaluated the impact of two interventions: (1) detailed feedback about a patient's mental health problem and desires for specific mental health interventions, and (2) a counseling protocol on medical residents' management of patients with mental health problems. These patients were seen in either a control, feedback, or feedback/protocol clinic. Immediately following their medical visit we found the following differences between feedback and control patients: feedback patients reported that the stress counseling they received was more valuable, and they were more satisfied with their physician; feedback patients also perceived greater decreases in the amount of overall stress experienced, and reported greater increases in their perceived control over stress. There were no outcome differences between feedback and feedback/protocol patients. We conclude that the feedback provided in this study can enhance physicians' ability to counsel primary care patients with mental health problems.

Patients' Perceived Involvement in Care Scale: relationship to attitudes about illness and medical care.

This report describes the development of the Perceived Involvement in Care Scale (PICS), a self-report questionnaire for patients, and its relation to primary care patients' attitudes regarding their illnesses and the management of them. The questionnaire was administered to three independent samples of adult primary care patients. Patients' satisfaction and their attitudes regarding their illnesses are evaluated after their medical visits. This instrument is designed to examine three relatively distinct factors: 1) doctor facilitation of patient involvement, 2) level of information exchange, and 3) patient participation in decision making. Of these factors, doctor facilitation and patient decision making were related significantly to patients' satisfaction with care. Doctor facilitation and information exchange related consistently to patients' perceptions of post-visit changes in their understanding, reassurance, perceived control over illness, and expectations for improvement in functioning. The role of physicians in enhancing patient involvement in care and the potential therapeutic benefits of physician facilitative behavior are addressed.

Patient perception of involvement in medical care: relationship to illness attitudes and outcomes.

OBJECTIVE: The purpose of this study was to explore the relationships among patients' perceptions about the roles they played during medical visits, their subsequent attitudes about their illnesses and treatments, and their self-rated improvement. DESIGN: Questionnaires were completed by patients before, one day after, and one week after their medical visits, and by their physicians following the visits. SETTING: The study was conducted in a general internal medicine faculty practice that provided adult primary care to a largely HMO population. PARTICIPANTS: Adult patients with new or increased symptoms who were capable of reading and understanding the study questionnaire. MAIN RESULTS: Fifty-five patients (47%) reported playing an active role; 62 patients (53%) reported playing a passive role. After adjusting for age, sex, baseline illness ratings, and physician-rated prognosis, "active" patients reported less discomfort (p = 0.04), greater alleviation of symptoms (p = 0.008), and more improvement in their general medical condition (p = 0.04) one week after the visits than did "passive" patients. These differences were not influenced by the roles patients desired to play. Active patients also reported less concern with their illnesses (p = 0.04), a greater sense of control of their illnesses (p = 0.04), and more satisfaction with their physicians (p = 0.02) one day after the visit. Post-visit dysfunction ratings were not related to patients' role perceptions. CONCLUSIONS: Patients' perceptions about their involvement in care appeared to be related to their attitudes about their illnesses as well as to recovery. Further research is needed, however, to determine the factors that influence these role perceptions and to define the types of patients, illnesses, and settings in which the benefits of active-role perceptions are most likely to be realized.

Measurement of ventricular volumes in the dog by nuclear magnetic resonance imaging.

Nuclear magnetic resonance (NMR) imaging is a new, noninvasive approach for imaging the cardiovascular system. Being a three-dimensional technique, NMR imaging has the capability of measuring volumes without the need for assumptions regarding ventricular geometry. In this study, the technique was validated in 19 excised dog hearts, filled with silicone-rubber, imaged using a multislice spin-echo sequence. The volume of the cavity in each slice was calculated from the number of pixels outlined for each slice multiplied by the pixel volume. Ventricular volumes measured by NMR imaging were highly correlated with cast volumes measured by water displacement: right ventricle (RV):RVNMR = 1.05 RVcast - 1.62; r = 0.99, SEE = 0.96 ml; left ventricle (LV):LVNMR = 0.98 LVcast + 0.35, r = 0.98, SEE = 1.48 ml. After validation in casts, NMR imaging volumes were measured in eight living dogs using a multiphasic gated technique to obtain images at 5, 105, 205, 305 and 405 ms after the QRS complex. Cardiac output (CO) and stroke volume (SV) measured by NMR imaging were significantly correlated with thermodilution (TD) measurements (CONMR = 0.63 COTD + 0.51 liters/min; r = 0.78, SEE = 0.57 liters/min; SVNMR = 0.67 SVTD + 1.95 ml; SEE = 5.58 ml). Right and left stroke volumes were closely related (LVSVNMR = 0.9 RVSVNMR + 1.75; r = 0.94, SEE = 4.32 ml), with the slope and intercept of the regression line showing no difference from 1 and 0, respectively. However, volumes determined by NMR imaging underestimated the thermodilution measurements, presumably reflecting the inability to obtain a true systolic image with the present sampling rate.(ABSTRACT TRUNCATED AT 250 WORDS)

Paradox in psychotherapy: a cybernetic perspective.

Recent uses of the term "paradox" in the field of psychotherapy have distracted attention from the concept's broader implications. All therapy can be seen as paradoxical because of the recursive nature of self-evaluation. Using agoraphobic problems as illustrative, and starting from the notion that the core issue for the agoraphobic is a demand for absolute control of his environment, we argue that therapy requires the bonding of two observers--the therapist and the "client-as-observer". Negotiations issuing from this bond are crucial to outcome, even when behavioral techniques, often considered to have automatic effects, are used. Behavior therapy, like all other psychotherapy, is not simply action--it is action contextualized by a specific, negotiated social contract.

Outcome prediction of inpatient alcohol detoxification.

A wide range of patient characteristics was assessed to determine their relative contribution upon alcohol detoxification treatment outcome. The outcome criteria were length of stay and commitment to ongoing rehabilitation, of which 17% and 24% of respective variance was accounted for by the predictor variables. The Internal-External Locus of Control scale was the most significant predictor, with internals tending toward successful treatment outcomes. The measures which tapped degree of socio-economic life satisfaction and physiological complications due to alcohol abuse, were inversely related to positive outcomes.