Effect of levothyroxine administration time on serum TSH in elderly patients.

BACKGROUND: Standard drug information resources recommend that levothyroxine be taken on an empty stomach due to the potential for interaction with food or medications. Due to concern about unpredictable response to levothyroxine in patients receiving morning doses in a skilled nursing facility, the standard administration time for the drug was changed from 0900 to midnight. OBJECTIVE: To determine if a change in response to levothyroxine as determined by the serum ultrasensitive thyroid-stimulating hormone (TSH) concentration occurred when the time of administration was changed from early morning to midnight. DESIGN: Retrospective chart review. SETTING: A 187-bed skilled nursing facility. PARTICIPANTS: Fifteen nursing home residents receiving levothyroxine during the change of administration time with a mean age of 84 years met inclusion criteria, with at least one TSH concentration reported prior to and at least one serum TSH concentration reported after the change in administration time to mignight. MEASUREMENTS: Serum TSH concentrations. RESULTS: There was a decrease in serum TSH of 0.286 +/- 1.722 mU/mL (mean +/- SD) after changing the administration time to midnight that was not statistically significant (t = 0.643; p = 0.532). CONCLUSIONS: Based on the results of the study, we conclude that levothyroxine could be routinely administered after breakfast.

Drug information course for pharmacy staff development.

An interactive course in drug information skills developed for pharmacists at a not-for-profit, tertiary-care hospital is described. Faculty members from the area school of pharmacy developed, taught, and evaluated the program. Before the course was developed, pharmacy staff members were asked to rate their drug information skills; the pharmacists' responses indicated their belief that they were not proficient enough in the skills needed in daily practice. The course content and format were refined after 11 pharmacists completed a pilot program. A handbook was developed that contained objectives, session outlines, and literature for each of the six topics chosen for the course. Although the handbook was the primary teaching aid, wall charts and computer demonstrations were also used. Sessions were structured for the needs of adult students by using a small-group discussion format that emphasized the practical relevance of the information and encouraged participants to share personal experiences. Each session was offered on two separate days to facilitate attendance. Those who completed the course received credit for 12 contact hours of continuing education. Of 16 pharmacists enrolled in the course, 11 completed it. An interactive course in drug information skills, developed to meet the needs of hospital pharmacists, was well accepted because it incorporated personal experiences, small-group activities, and flexible scheduling.

Preventing upper gastrointestinal bleeding in patients receiving nonsteroidal antiinflammatory drugs.

Severe upper gastrointestinal (GI) bleeding is a serious adverse effect of nonsteroidal antiinflammatory drugs (NSAIDs) and the elderly are at increased risk of developing this complication. Bleeding episodes can be prevented. Replacing NSAIDs with acetaminophen may be appropriate when a simple analgesic is needed that eliminates the risk of GI bleeding. Using the lowest effective NSAID dose may decrease the incidence and severity of NSAID gastropathy. Histamine H2-receptor antagonists, sucralfate, and misoprostol have been studied for the prevention of NSAID gastropathy, but only misoprostol prevents mucosal injury in both the stomach and duodenum. Patients who have a history of peptic ulcer disease or gastric bleeding from NSAIDs are candidates for prophylactic measures. Although other patients are at risk, no one knows who should receive prophylactic therapy for NSAID gastropathy. Future studies should attempt to define patient populations that warrant prophylactic therapy.

An assessment of the drug therapy education preferences of an interdisciplinary group interested in the elderly.

A survey was conducted to measure the drug therapy education preferences of a diverse group of professionals interested in the elderly. Two hundred forty-four surveys were mailed and 119 were returned (48.8 percent). Seventy-two percent of the respondents were social workers; four percent were registered nurses; the remainder of the respondents (24 percent) were non-health professionals. Most respondents liked all common methods of instruction except self-directed activities and large group discussions. The five topics of greatest interest were drug interactions, adverse drug effects, drugs used to treat depression, drugs used to treat nervousness or anxiety, and drugs used to manage dementia. A survey is an economical means of assessing the preferences of an unfamiliar audience. The methods used to determine content for this program can be used by educators who are planning programs for similar audiences made up of health and non-health professionals.

Treatment of phenytoin toxicity with repeated doses of activated charcoal.

A 38-year-old woman ingested at least 10 g of phenytoin and was managed using repeated doses of oral activated charcoal. The peak serum concentration of 52 micrograms/mL was reached within 42.5 hours of ingestion. Signs and symptoms of phenytoin toxicity had disappeared four days after ingestion. The serum phenytoin concentration was in the therapeutic range six days after ingestion. The clinical course of this patient was shorter than those of other conventionally treated patients with phenytoin overdoses. Multiple-dose activated charcoal may have a role in the treatment of phenytoin overdoses by limiting the amount of gastrointestinal absorption and by enhancing elimination.

Open mitral commissurotomy. A modern re-evaluation.

Familiarity with replacement of the mitral valve (MVR) with prosthetic and tissue valves has dimmed awareness of the usefulness of open mitral commissurotomy (OMC). This is a review of a 10 year experience ending in December, 1978, of 222 consecutive patients operated upon with a clinical diagnosis of pure mitral stenosis. MVR was necessary in 25 patients (11.3%), primarily because of severe deformity of valvular and subvalvular structures. No closed commissurotomies were performed, as that operation is now considered passé. Of the 197 patients undergoing OMC, 12 had additional cardiac procedures. Of the three patients who died (1.52%), two were operated upon on an emergency basis because of rapidly progressive cardiac failure. Follow-up data were obtained on 191 (97%) of the 197 OMC patients. There were 18 late deaths, of which 14 were related to cardiac disease. Following OMC, 76% (146) of the patients had improved by at least one New York Heart Association class. Fourteen (7%) of the 191 OMC patients had subsequent MVR at times varying from 2 to 92 months after OMC (mean 41.6 months). Ten-year survival for the 197 OMC patients was 81%. This clinical experience emphasizes that open commissurotomy rather than valve replacement is the best initial treatment for most patients with mitral stenosis.

Simplified intraoperative technique to test mitral valve repair.

The success of mitral valve repair for regurgitation or stenosis can largely be determined at the time of operation. Mitral valve repair is tested by creating aortic regurgitation, which fills the left ventricle with systemic aortic perfusion pressure. The competent mitral valve is salvaged and the incompetent valve is replaced.

Stainless steel markers for aorta--saphenous vein anastomosis.

A stainless steel marker for tagging the proximal aorta--saphenous vein anastomosis in a bypass operation has been devised and utilized in more than 600 patients over the past 3 years. This marker has been found superior to other methods used for marking vein grafts in that it encircles the anastomosis, providing accurate marking, and can be attached after both anastomoses are complete.