Delirium tremens: a review.

Delirium tremens was first identified as being due to long-term excessive alcohol intake in 1813, but is now known to be associated with abrupt withdrawal of alcohol in chronically habituated persons. Recent publications quote an anticipated mortality rate of 15% to 20%. Our experience in the past 20 years has not confirmed that rate. This review reveals that the prevalence of fatal cases is extremely low, with the true mortality close to 0%. We believe that this decrement is due to the increasing use of benzodiazepines to detoxify alcoholic patients. It is postulated that the benzodiazepines act either to prevent delirium tremens or to reduce the neurotransmitter disruption in the central nervous system caused by excessive alcohol intake, or both.

Cutaneous application of safflower oil in preventing essential fatty acid deficiency in patients on home parenteral nutrition.

Essential fatty acid deficiency (EFAD) is observed in patients with massive bowel resection who are placed on home parenteral nutrition (HPN). We investigated the use of cutaneously applied safflower oil to prevent EFAD. Five subjects on HPN supplemented with intravenous (IV) fat emulsions underwent a three-phase study: 1) no IV fat emulsions for 4 wk; 2) cutaneous safflower oil for 4-6 wk; 3) oral safflower oil for 4 wk. Fatty acid profiles (FAP) of plasma were obtained during each phase. Significant decreases in linoleic and arachidonic acid occurred by the end of phase 1 and the triene:tetraene ratio rose from a baseline value of 0.1 to 0.5. This ratio returned to 0.2 by the end of phase 2 and significant increases in linoleic and arachidonic acid occurred. Only one of five subjects completed the oral phase (3). Cutaneous safflower oil may improve plasma FAP but adequacy of tissue stores remains unanswered. Liver function tests need to be monitored if this treatment modality is utilized.

Controversial issues in home health care: a roundtable discussion.

Controversial issues in home health care (HHC) were discussed by a panel of four individuals involved in or knowledgeable about HHC. The panel addressed the following issues: reluctance of health professionals to participate in home care, challenges in providing HHC services, assigning responsibility for HHC services, reimbursement considerations in joint-venture arrangements, assuming fiscal responsibility for unreimbursed care, selecting HHC providers, defining patient rights, selecting drug products for home-care patients, competing with community pharmacists, circumvention of pharmacist input in preparation of solutions for home infusion, and the future of HHC. Hospital pharmacists who plan to become involved or are already involved in providing HHC services should become familiar with these controversial issues.

More efficient system for preparing total parenteral nutrient solutions.

An improved system for preparing total parenteral nutrient (TPN) solutions is described. The new system uses a personal computer, a three-station volumetric pump, and empty polyvinyl chloride (PVC) containers. The computer's order-entry screen facilitates data entry by displaying a format similar to the physician's order sheet. After calculating the volumes of i.v. solutions and additives and the total cost of the TPN solution, the computer prints labels containing this information. Using the volumetric pump, the required volumes of crystalline amino acids, dextrose injection, and sterile water for injection are added simultaneously to either one-liter or three-liter PVC containers. Each bag contains the patient's entire daily TPN requirements. Approximately 30 liters of TPN solution are prepared daily by specially trained technicians in a centralized i.v. room. Compared with the previous method of preparing TPN solutions using evacuated one-liter glass bottles, the average time required to prepare and determine the cost of each patient's TPN solutions has decreased from 35 to 21 minutes daily. Total savings resulting from reduced materials and labor costs is approximately $28,240 annually. The new system for preparing TPN solutions is efficient and cost effective.

Delayed cutaneous hypersensitivity response in patients receiving nutritional support.

The sensitivity and specificity of skin-test antigens were assessed, and the prevalence of anergy was determined in a group of hospitalized patients receiving aggressive nutritional therapy. All patients referred to a nutritional support service during a nine-month period were assessed for intact cellular immunity using Candida albicans, mumps, streptokinase/streptodornase, and tetanus toxoid skin tests for delayed cutaneous hypersensitivity. Some patients were retested at two-week intervals while they were receiving nutritional support. A total of 195 patients (97 men) ranging from 15 to 92 years old were tested; 68 patients received repeat skin tests. Of the 195 patients, 181 (92.8%) reacted positively to one or more antigens when tested initially; all patients (including anergic ones) who were retested reacted positively. Candida and mumps tests produced the highest percentages of positive responses (80 and 75%, respectively); the use of these two antigens concurrently produced a 92.3% response rate. Nonresponding patients to a nonresponding antigen converted to responders to that antigen upon second testing more frequently than responders converted to nonresponders. Candida and mumps skin tests detected anergy and demonstrated that immune responses were maintained and often restored by aggressive nutritional support.

Evaluation of two sterility testing methods for intravenous admixtures.

The Addi-Chek Quality Control System (Millipore Corporation) and Ivex-2 Filterset (Abbott Laboratories) were evaluated to determine their effectiveness, applicability, and cost as part of a pharmacy quality-control program. Each method was tested using 50 solutions, 25 of which had been contaminated by inoculation with one of five micro-organisms; the other 25 solutions were used as controls. Aseptic technique was used, and procedures were carried out in a laminar air flow hood. Contaminated solutions were blinded from the person performing the tests. Addi-Chek detected contamination in all the inoculated solutions and in three of the uninoculated solutions. The latter may have been a result of adventitious contamination during the testing procedure. Ivex-2 detected contamination in 24 of the 25 inoculated solutions; no other contamination was found. The effectiveness of the methods in detecting low-level microbial contamination appears comparable. Both methods have been shown to be useful in the pharmacy setting, but Ivex-2 could be used to test for contamination when used as an in-line filter at the patient level. Ivex-2 is less expensive and warrants further evaluation in monitoring for microbial contamination during preparation and administration of intravenous solutions.