Prospective study on serum metal levels in patients with metal-on-metal lumbar disc arthroplasty.

PURPOSE: Metal-on-metal total disc replacement is a recent alternative treatment for degenerative disc disease. Wear and corrosion of these implants can lead to local and systemic transport of metal debris. This prospective longitudinal study examined the serum chromium and cobalt levels in 24 patients with cobalt-chromium alloy metal-on-metal lumbar disc replacements. METHODS: Serum was assayed for chromium (Cr) and cobalt (Co) using high-resolution inductively-coupled plasma-mass spectrometry. Detection limits were 0.015 ng/mL for Cr and 0.04 ng/mL for Co. RESULTS: Median serum Co levels at pre-op, 3, 6, 12, 24, and 36-months post-op were 0.10, 1.03, 0.96, 0.98, 0.67, and 0.52 ng/mL, respectively. Median serum Cr levels were 0.06, 0.49, 0.65, 0.43, 0.52, and 0.50 ng/mL, respectively. CONCLUSION: In general, these results indicated that serum Co and Cr levels are elevated at all postoperative time points and are of the same order of magnitude as those observed in well-functioning metal-on-metal surface replacements of the hip and in metal-on-metal total hip replacements at similar postoperative time points.

Opioid analgesics versus ketorolac in spine and joint procedures: impact on healthcare resources.

BACKGROUND: Ketorolac's efficacy as a postoperative analgesic has been shown to be comparable to that of narcotic analgesics, but with significantly fewer narcotic-related adverse events. OBJECTIVE: To assess whether the choice of postoperative analgesic, narcotic or ketorolac, has an impact on healthcare resource utilization and cost durng inpatients' recovery period. DESIGN: Retrospective, multicenter, controlled, parallel, cost-minimization analysis. SETTING: Six US teaching hospitals. PATIENTS: This study included 559 patients that underwent either a spine or joint procedure and received adequate doses of narcotic (n = 284 of either morphine or meperidine) or ketorolac (n = 275). MEASUREMENTS: Time to reach recovery milestones, average utilization of healthcare resources, and average per-case postoperative treatment cost. RESULTS: Several recovery milestones, including time to first bowel movement, first oral intake, and first unassisted ambulation, were reached sooner in the ketorolac group, with a resultant shorter mean length of postoperative stay (narcotic 3.78 d, ketorolac 2.80 d; p = 0.01). Total per-patient cost of treatment was 32% greater in the narcotic group, resulting primarily from higher costs associated with hospitalization. CONCLUSIONS: Despite the higher acquisition cost of medication, healthcare resource utilization and total per-patient cost of treatment were lower for patients in the ketorolac group compared with patients in the narcotic analgesic study group. The majority of patients in the ketorolac group were also given concurrent narcotic analgesics; therefore, the beneficial effects observed may be secondary to the combination of ketorolac and narcotic analgesics.

Liquorice consumption and salivary testosterone concentrations.

Liquorice consumption has been shown to substantially reduce serum testosterone concentration. An explanation for this result was that the active component in liquorice (glycyrrhizic acid) interfered with 17 beta-hydroxysteroid deyhydrogenase, which has been shown in vitro to catalyse the conversion of androstenedione to testosterone. We twice attempted to replicate this effect of liquorice but could not. We identified differences between our methods and those of the previous study and possible statistical anomalies (including inappropriate use of statistical tests) in the earlier report.

Impact of antiemetic selection on postoperative nausea and vomiting and patient satisfaction.

STUDY OBJECTIVE: To determine the impact of antiemetic selection on postoperative nausea and vomiting (PONV) and patient satisfaction after ambulatory surgery. DESIGN: Prospective, observational study. SETTING: Ambulatory surgery center in an academic medical center. PATIENTS: Five hundred fifty-four consecutive patients undergoing ambulatory surgical procedures of any kind. INTERVENTION: Data on antiemetic utilization, occurrence of PONV, and patient satisfaction were collected perioperatively. Multiple regression analyses for antiemetic choice were performed. MEASUREMENTS AND MAIN RESULTS: Prophylactic antiemetic therapy was administered to 292 (52.7%) patients, most often with droperidol (200 patients), metoclopramide (134), or dexamethasone (55). Forty-one (7.4%) patients had an episode of emesis in the postanesthesia care unit. Choice of antiemetic was not a significant predictor of PONV. Patient satisfaction for all patients was 9.5 on a 10-point scale, with no agent more or less successful than any other. CONCLUSION: As choice of antiemetic drug given for prophylaxis had little impact on clinical outcome or patient satisfaction, traditional agents should form the core of antiemetics used for PONV prophylaxis in ambulatory surgery patients.

Development of a best-practice model at a university hospital to increase efficiency in the management of patients with community-acquired pneumonia.

An economic evaluation of drug acquisition, nursing care, pharmacy time, laboratory costs, supplies, and ancillary care was conducted as a first step toward developing a pneumonia management plan at the University of Kentucky Medical Center (UKMC). UKMC costs were compared with costs at other hospitals treating pneumonia patients on Medicare. Overall costs for pneumonia at the 25% of hospitals nationwide with the lowest costs for Medicare patients with this condition were determined and compared with costs at UKMC. Against nationwide benchmarks, efficiencies at UKMC for treating simple pneumonia ranged from 45% for pharmacy expenses to 81% for nursing costs. Efficiencies for complicated pneumonia ranged from 47% for laboratory costs to 67% for nursing costs. The most cost-efficient antimicrobial treatment options were promoted and integrated into a pneumonia management plan based on Infectious Diseases Society of America treatment guidelines. A comparison of pneumonia treatment costs at UKMC with those at the 25% of hospitals nationwide with the lowest treatment costs for Medicare patients with pneumonia revealed that UKMC pharmacy costs could be optimized. Strategies for standardizing the care of patients with community-acquired pneumonia (CAP) are being implemented.

Cromolyn sodium for ACE inhibitor-induced cough.

There are several theories on the cause of ACE inhibitor-induced cough, but the exact mechanism is not known. In many patients, if cough develops, the ACE inhibitor can be discontinued and a drug in another therapeutic class used in its place. However, in patients with CHF, diabetic nephropathy, and patients who have experienced a myocardial infarction, discontinuing the ACE inhibitor may not be in the best interest of the patient. In this patient population it would be reasonable to try cromolyn sodium to treat cough, while continuing the ACE inhibitor. Data are not available to support the efficacy of cromolyn sodium to treat cough in patients with diabetic nephropathy, but these patients clearly benefit from the use of an ACE inhibitor. Other factors not addressed in the case reports and the clinical trial such as patient adherence, cost, and quality of life should also play a role in the decision to use cromolyn sodium. Cromolyn sodium has been effective for the treatment of ACE inhibitor-induced cough in many case reports and has had mild success in one small clinical trial. Although none of the reports adequately assessed adverse effects, studies examining cromolyn for other indications have demonstrated a relatively benign adverse effect profile. It is difficult to recommend an exact dose to use because of the dosing variability in the case reports. The majority of the case reports and the one clinical trial used dosages similar to recommendations for bronchial asthma (i.e., 2 puffs [1.6 mg] 4 times daily via MDI or 20-mg capsules 4 times daily via breath-activated inhalation). At this time, the use of cromolyn sodium is a viable option, but more controlled studies are needed to fully elucidate its role in the treatment of ACE inhibitor-induced cough.

Studies evaluating high-dose acyclovir, intravenous immune globulin, and cytomegalovirus hyperimmunoglobulin for prophylaxis against cytomegalovirus in kidney transplant recipients.

OBJECTIVE: To describe the epidemiology and pathogenesis of cytomegalovirus (CMV) and critically analyze the studies evaluating the cost, safety, and efficacy of high-dose acyclovir, intravenous immune globulin (IVIG), and CMV hyperimmunoglobulin (CMVIG) for prophylaxis against CMV in kidney transplant recipients. DATA SOURCES: Appropriate articles were identified by searching MEDLINE. Various combinations of the following medical subject heading terms were used: immunoglobulins, intravenous; acyclovir; CMVIG; CMV infections; kidney transplantation; IVIG; and prophylaxis. STUDY SELECTION: Studies evaluating or discussing the cost, safety, and efficacy of IVIG, high-dose acyclovir, and CMVIG in kidney transplant recipients were included. DATA EXTRACTION: The data were evaluated with respect to study design, patient population, prophylactic regimen, incidence of CMV complications, investigators' definitions of terminology, and cost analysis. The studies are summarized in tables and discussed in the text. DATA SYNTHESIS: The definitions of terminology used by the investigators varied widely among studies. The studies were reviewed and discussed using the following definitions: CMV infection was the presence of CMV antibodies in a previously CMV-seronegative patient or a fourfold rise in antibody titer after transplantation; CMV syndrome was CMV infection plus unexplained fever, leukopenia, or thrombocytopenia in the absence of an identifiable cause; and CMV disease was CMV syndrome plus pneumonitis, enteritis, retinitis, hepatitis, or central nervous system involvement. CONCLUSIONS: All regimens appear to effectively reduce the incidence of CMV-associated complications compared with placebo. Due to the lack of trials comparing cost, efficacy, and safety, the most effective prophylactic treatment is unknown.

The future of medication information practice: a consensus.

OBJECTIVE: To analyze the current practice of drug information and develop a strategic plan for a "valued" specialty of medication information practice. DATA SOURCES: The Consortium for the Advancement of Medication Information, Policy, and Research (CAMIPR) met in June 1994 to initiate a strategic plan for a future of medication information practice. A multidimensional situation analysis and strategic planning process was conducted and the results are discussed. RECOMMENDATIONS: Trends in health care (e.g., healthcare reform, managed care) will impact the future of medication information practice, and the medication information specialist must evolve with society's values. Medication information practice must transform and attention will likely focus on medication policy research/ development and information systems. However, new skills, resources, and relationships must be developed to facilitate this evolution. In addition, interest in the practice of drug information has declined. Strategies are presented to enhance the "value" and "image" of future medication information practice.

Possible erythromelalgia-like syndrome associated with nifedipine in a patient with Raynaud's phenomenon.

OBJECTIVE: To describe a patient who was diagnosed with Raynaud's phenomenon, was prescribed immediate-release nifedipine, and developed a possible erythromelalgia-like syndrome. CASE SUMMARY: A 24-year-old white woman with a history of esophageal spasms and Raynaud's phenomenon was prescribed nifedipine 10 mg po qid. Approximately 1 hour after the patient had taken the fourth dose of nifedipine, she experienced acute erythema and a burning sensation in her feet and lower limbs, light-headedness, and palpitations. Because of a reportedly abnormally low blood pressure, the patient took diphenhydramine 50 mg po and proceeded to the clinic. On arrival, abnormal vital signs were BP 140/48 mm Hg and HR 130 beats/min. Without any other medical intervention, approximately 30 minutes later her blood pressure and heart rate had returned to baseline at 122/60 mm Hg and 96 beats/min, respectively. The nifedipine was permanently discontinued and the patient's symptoms completely resolved over 24 hours. DISCUSSION: The characteristic symptoms of erythromelalgia include burning pain, increased skin temperature, and erythema of the extremities, usually to the feet, lower legs, and, less often, the hands. Erythromelalgia-like syndromes secondary to the administration of many medications have been reported. Several nifedipine-related reports describe an erythromelalgia-like syndrome similar to our reported case. CONCLUSIONS: Because the patient was not taking any other medications and the symptoms started with the administration of nifedipine and were relieved after its discontinuation, nifedipine was thought to be the cause of the erythromelalgia-like syndrome.

Chemical pleurodesis with doxycycline 1 g.

We evaluated the utility of a single 1-g dose of doxycycline in the treatment of malignant and nonmalignant pleural effusions and refractory pneumothoraces in 27 consecutive patients requiring pleurodesis. After the evacuation of all retained air or fluid, and premedication with intravenous narcotic analgesics and intrapleural lidocaine 200 mg, the patients received doxycycline 1 g in 50 ml normal saline instilled through the chest tube. This was followed by instillation of 100-200 ml of air to facilitate dispersion. The chest tube was removed when the drainage was less than 150 ml/day. Twenty-three of 27 patients were evaluated at 30 days. Six (67%) of the nine patients with pneumothoraces achieved a response, and both patients with nonmalignant pleural effusions had a complete response. Of the 12 patients with malignant pleural effusion, 8 (67%) achieved a complete response, 2 had a partial response, and 2 had no response. Twenty-two (81%) of 27 patients experienced adverse effects with pleurodesis, with pain (81%) and fever (11%) being the most prevalent. In this limited number of patients, doxycycline 1 g appeared to be safe and effective for the treatment of pleural effusions and pneumothoraces. The 1-g dose must be compared with the standard 500-mg dose and with other established agents.

Aminophylline for cellulite removal.

The data supporting the safety and efficacy of aminophylline thigh cream are limited by small patient populations and incomplete disclosure of methods. The studies are well designed and the preliminary data are encouraging, but more data are needed before the safety and efficacy of aminophylline thigh cream can be determined. Until such data are available, an aminophylline thigh cream proven to be safe and effective remains, as coined by the Washington Post, a "dream cream."

Intranasal butorphanol-induced apraxia reversed by naloxone.

Intranasal butorphanol is an opioid agonist-antagonist that is effective for the treatment of acute pain. Common adverse effects associated with the agent are somnolence, dizziness, nausea, and vomiting; they are readily reversed with naloxone. A patient developed signs and symptoms consistent with apraxia after a single dose of intranasal butorphanol. She was mentally alert, but she was unable to move or speak despite normal muscle tone and reflex movements. When she attempted to speak she had no voluntary control. At the emergency room she was administered naloxone 2 mg intramuscularly, which resulted in complete reversal of the symptoms in a short time. No other published cases describe these findings with butorphanol. Health care professionals should be aware that patients who are prescribed intranasal butorphanol, even in typical doses, may be at risk for such a reaction. This is important because, unlike the injectable formulation, the intranasal product is primarily used in the outpatient setting.

Ondansetron use for smoking cessation.

Cigarette smoking continues to make an important impact on the health status and costs of care in the US. Animal studies demonstrated that ondansetron is effective in decreasing withdrawal behaviour and have led to interest in its role in smoking cessation. One small trial tested the effects of ondansetron as an aid to change smoking behaviors. The results did not support a beneficial effect of ondansetron use. There were several limitations of this study, including small sample size and potentially inadequate duration of therapy and follow-up. An oral ondansetron formulation recently has become available. There are several disadvantages to an oral versus an intravenous formulation of ondansetron. Patients taking oral therapy are at less risk, the administration of an oral preparation does not require trained personnel, and a study can be performed in an environment in which the influences of daily living can affect smoking behavior (e.g., early morning, and after a meal). Ultimately, well-defined, large-scale clinical studies are necessary to determine whether ondansetron has a positive effect on smoking cessation.

Effect of prescribing guidelines on the use of neuromuscular blocking agents.

The effect of prescribing guidelines on the use of neuromuscular blocking agents (NMBs) was studied. Voluntary guidelines on the appropriate prescribing of formulary NMBs in the operating rooms at a university hospital were approved in January 1993. Patients who underwent inpatient surgery with neuromuscular blockade during a preguideline period (March 1, 1992, through May 31, 1992) or a postguideline period (March 1, 1993, through May 31, 1993) were randomly selected (n = 200 per group) and compared to determine the relative appropriateness, effectiveness, safety, and cost of NMB use. The preguideline and post-guideline groups were demographically similar. There were significantly more instances of appropriate NMB use after than before the guidelines were established. Neuromuscular blockade was maintained inall patients. The overall rates of NMB-associated adverse events were 5.5% and 7.5% for the preguideline and postguideline groups, respectively. The acquisition cost of NMBs and drugs used to treat NMB-associated adverse events for the preguideline patients was $4261, versus $2978 for the postguideline patients. Extrapolated to the estimated 10,000 operations per year requiring neuromuscular blockade at the institution, the total cost was $213,000 before guideline introduction and $149,000 afterward, for a guideline-associated cost reduction of $64,000. Prescribing guidelines reduced expenditures for NMBs without affecting clinical outcomes.

Value of pharmacy-related bulletin board services as a drug information resource.

OBJECTIVE: To orient pharmacists to bulletin board services (BBSs) as a source of drug information, and to provide information concerning equipment, services, and resources, as well as examples of systems that are used frequently. DISCUSSION: Pharmacy-related BBSs allow pharmacists who have no experience with a new formulation or therapeutic use for a medication to obtain information from those who have such experience. CONCLUSIONS: As computers become increasingly common in both hospital and community pharmacies and because many BBSs provide free access to newsletters and databases for drug information, pharmacy-related BBSs represent an easy, inexpensive method to share ideas and obtain information on medication use.

Deployment of an Air Transportable Hospital in support of Allied Forces during Operation Provide Comfort: April 29 to July 17, 1991.

The deployment, setup, and operation of an Air Transportable Hospital (ATH) as a primary field hospital for 25,000 Allied Forces during Operation Provide Comfort is presented with a description of the performance and experiences of this unit. More than 3,300 outpatients were seen and treated, and more than 50 patients were operated on at the ATH. In addition, assigned personnel participated as medical augmentees to Kurdish refugees camps, screening and treating more than 13,000 individuals. The success of this deployment validates and expands the concept of the ATH and of Air Force training doctrine.