Transitions in pharmacy practice, part 5: walking the tightrope of change.

A systematic process for reformulating the practice-related attitudes and values of pharmacists to help them adapt to a new practice model is described. The key to motivating pharmacists to commit to practice change lies in fostering a change in intrinsically held professional attitudes and values, not in emphasizing a structured extrinsic reward system. As a systematic process by which managers can motivate their staff to change attitudes and values, the authors offer a customization of the taxonomy of learning in the affective domain proposed by Krathwohl, supplemented by contributions from the literature on the diffusion of innovation, dissonance theory, the transtheoretical model, and instructional psychology. Krathwohl's taxonomy shows affective learning as a five-level hierarchy with stages within each level. Managers can guide practitioners through the first four levels. Practitioners who have been socialized for the distributive model and who then adopt a new practice model such as pharmaceutical care will start by simply receiving information about the new model. Next, they will actively respond to learning about the model and begin to value it as desirable. As their regard for the new model grows, they will reorganize practice priorities. Managers can help pharmacists adopt a new practice model by guiding them through stages of attitude and value formation.

Transitions in pharmacy practice, part 4: can a leopard change its spots?

The personal and social characteristics of pharmacy practitioners that predispose them to reacting in a certain way to a change in practice are examined. Individuals tend to choose vocations they perceive to be a match with their personality. Studies suggest a dominant personality type among pharmacists characterized by a strong sense of responsibility, conscientiousness, practicality, logic, and, in about 20% of practitioners, fear of interpersonal communication. As the profession seeks to adapt to new practice models, individual practitioners may find a significant mismatch between their personality and aspects of the new models. Pharmacists' professional socialization-the process by which expected roles, behaviors, and attitudes are acquired-is another major contributor to their receptiveness to changes in practice. Managers wanting to promote practice changes face considerable variance in the professional socialization of their individual staff members. Few staff members have been socialized for pharmaceutical care. Some may not have any of the values or attitudes of the idealized professional, and may simply have "a job." Although personality is largely fixed, professional socialization is an ongoing process, so there is potential to resocialize practitioners for new practice models. Pharmacists are shaped by their personalities and professional socialization. Conflict may occur if a pharmacist's personality does not mesh with new professional roles. Most pharmacists will need resocialization to prepare them for changes in practice.

Transitions in pharmacy practice, part 3: effecting change--the three-ring circus.

The prerequisites for a change in practice in individual pharmacists, as framed by the Holland-Nimmo practice change model, are discussed. The Holland-Nimmo practice change model comprises three components, all of which must be addressed by a pharmacy's leadership if a change in practice is to be achieved. The first component is the practice environment, which must be conducive to implementation of the new form of practice. The second component is the availability of appropriate training for individual practitioners. The third component is an appropriate set of motivational strategies to be applied by the manager. All three components must be present at the same time; no one or two components by themselves are sufficient. The practice change model is equally applicable to pharmacy department managers in health-system settings and to community pharmacy owners and managers. To maximize the potential for individual pharmacists to change their practice, managers must create an environment conducive to the new form of practice, identify needed learning resources, and motivate practitioners to change.

Transitions in pharmacy practice, part 2: who does what and why.

The competencies required by the five practice models that constitute the total pharmacy care (TPC) model are discussed. Understanding the differences among the competencies required by the five practice models can help pharmacy's leaders estimate the extent of change that may be necessary whenever a change in practice is contemplated. Professional competence in any of the practice models is defined as the sum of skills, professional socialization, and judgment rooted in experience pertinent to the model. Possibilities for practice change are ideational and do not necessarily follow a straight line from other practice models to pharmaceutical care. The key competencies for each of the five practice models--drug information, self-care, clinical pharmacy, pharmaceutical care, and distribution--demonstrate a clear distinction among the five models. The models draw on different knowledge and skills, are characterized by different attitudes and values about the work of pharmacy, and are grounded in different practice experience. While sharing a common underpinning of theory and practice, professional competence within each of the five models that make up TPC requires distinctly different knowledge and skills, professional attitudes, and values, as well as judgment that is developed through experience.

Transitions, part 1: beyond pharmaceutical care.

A systems view of the amalgamation of existing pharmacy practice models is proposed. Pharmacy's evolution is traceable as a series of stages. The stages in pharmacy's evolution have been manufacturing pharmacy, compounding, distribution, clinical pharmacy, and pharmaceutical care. Good pharmacy practice (GPP) represents an international attempt to unite various conceptualizations of practice, including pharmaceutical care. GPP in turn provides a foundation for a model to explain current and changing practice, the total pharmacy care (TPC) model. TPC combines five existing practice models: drug information, self-care, clinical pharmacy, pharmaceutical care, and distribution. TPC, as the sum of these models, asserts that there will be an ongoing need for all five existing models of practice, that the proportion of pharmacists employing each model will reflect the needs of a given health care environment at a given time, and that if changes in health care provide more opportunities for pharmaceutical care, pharmacists will shift increasingly toward that type of practice. Total pharmacy care is the delivery of a comprehensive range of services that result in the maximum possible contribution to the health of a nation's population within the limits of the health care delivery structure.

Allergies and vocal fold edema: a preliminary report.

This paper describes different tools to rule out the etiology of vocal fold edema. A complete voice assessment is used in our Voice Center. This includes patient history, acoustic analysis, laryngeal video-stroboscopy, otolaryngology consultation, allergy testing from our Allergy Clinic, and gastroenterology consultation as appropriate. Inhalant allergy can be a hidden, yet very common cause of chronic laryngitis. Respiratory allergies can also cause decreased pulmonary function; excessive secretions in either the lower airway, trachea, bronchi or in the upper airway of the pharynx; edema of the vocal folds themselves; and unusual resonance characteristics of the pharynx or nasal cavity due to congestion of the membrane in those areas. Voice patients with a history of seasonal hay fever, a history of allergic reactions around cats or dogs, or a strong family history of allergies should be allergy tested. Screening tests for allergies are available, which include a screening radioallergosorbent test or a screening panel of scratch or intradermal skin tests. Once specific allergens are identified, recommendations for therapy or other intervention can be made. Straining the voice, in combination with the above conditions, can increase the voice problem. The histories, allergy test results, and voice laboratory evaluations of several patients are described. Identifying these voice patients and treating their allergies are important in keeping these patients healthy and maintaining a clear, good voice quality. The multidisciplinary approach in voice disorders is indispensable in diagnosis and treatment of these disorders.

[Hox genes, developmental evolution and the origin of vertebrates]. / Geny Hox, évoliutsiia razvitiia i proiskhozhdenie pozvonochnykh.

Homeobox genes comprise a diverse multigene family encoding transcription factors, many of which are key control genes in early development. The roles of several homeobox gene subfamilies have been widely conserved through animal evolution, but there are detailed differences in homeobox gene number, genomic organisation and gene expression between taxa. We have compared Hox and other homebox genes between vertebrates and their closest living relatives, Amphioxus. The results suggest that after evolutionary divergence of these two lineages, homeobox and other genes were duplicated in the lineage leading to vertebrates, but that Amphioxus retained the archetypal homeobox gene organisation. We suggest that prior to vertebrate origins there was an intense phase of gene duplication, followed by recruitment of new developmental control genes to new roles. These genetic changes may have permitted the evolution of novel developmental and anatomical characters, and the origin of vertebrates.

Grand mal seizures temporally related to cocaine use: clinical and diagnostic features.

STUDY OBJECTIVES: To determine the appropriate diagnostic workup of the emergency department patient with an uncomplicated cocaine-related grand mal seizure. DESIGN SETTING: Retrospective analysis. A city and county ED with 45,000 selected visits per year. TYPE OF PARTICIPANTS: Thirty-seven patients with acute grand mal seizure after cocaine exposure were studied. All had historical or laboratory evidence of cocaine use and no history of prior seizure disorder. INTERVENTIONS: The diagnostic workup varied among patients. Most received computed head tomography (35), whereas fewer received-ECG (18), EEG (16), and lumbar puncture (six). MEASUREMENTS AND MAIN RESULTS: Thirty-three patients with an uncomplicated cocaine-related seizure had an unremarkable series of diagnostic tests. The four patients with remarkable neurologic manifestations were compared with the remainder of patients who were without neurologic abnormalities. Comparison of groups by route of cocaine intake revealed no significant difference in the time interval to seizure (P = .761). CONCLUSION: Diagnostic workup probably is not indicated for the patient experiencing a cocaine-related generalized seizure who will recover promptly and have a normal postictal examination.

Exsanguinating hemorrhage from a caput medusae: cutaneous variceal bleeding.

We report the case of a 45-year-old female who presented to the emergency department with massive umbilical hemorrhage from a cutaneous varix. The patient had a long-standing history of alcohol-related liver disease and ascites. Her clinical course was complicated by coagulopathy and hemorrhagic shock, and she ultimately expired. Ectopic or nongastroesophageal bleeding constitutes a significant site of variceal hemorrhage. In this report we review the literature and explore methods of treatment.

Fluorescent antibody test kit for rapid detection and identification of members of the Bacteroides fragilis and Bacteroides melaninogenicus groups in clinical specimens.

The Fluoretec fluorescent antibody test kit (Pfizer Inc., New York, N.Y.), developed for the rapid detection of members of the Bacteroides fragilis and B. melaninogenicus groups, was evaluated by testing 58 stock cultures and 76 clinical specimens. The test reagents detected 100% of 40 B. fragilis and B. thetaiotaomicron stock culture strains, although only 22% of 18 B. vulgatus, B. distasonis, and B. ovatus strains showed positive fluorescence. The 76 clinical specimens were evaluated by examining fluorescent antibody-stained smears of 49 specimens of purulent material and smears of 27 blood cultures which were positive for gram-negative bacilli by Gram stain or subculture. The fluoretec reagent detected members of the B. fragilis group in 28 (97%) of the 29 specimens of purulent material and all (100%) of the 16 blood cultures in which these anaerobes were demonstrated by culture. Overall, the Fluoretec reagent detected members of B. fragilis group in 44 (98%) of the 45 clinical specimens which were shown by culture to contain these anaerobes. Two of the 76 clinical specimens gave positive fluorescence for members of the B. fragilis group but failed to yield these organisms by culture. Members of the B. melaninogenicus group were detected by culture in 15 specimens and in each case their presence was demonstrated by the Fluoretec reagent. No members of the B. melaninogenicus group were isolated from five clinical specimens that gave positive fluorescence with the B. melaninogenicus reagent.

Floral initiation in Lolium temulentum L.: the role of phytochrome in the responses to red and far-red light.

The possibility that phytochrome is involved in the promotion of flowering by far-red light was investigated. The addition of far-red (FR) to a day extension with red (R) light promotes inflorescence initiation in Lolium. A 2-hour interruption with darkness also promoted flowering compared with the uninterrupted red light control; apex length was further increased by a 10-minute FR irradiation given before the 2-hour dark interruption and was decreased by 10-minutes of R light given in the middle: both FR promotion and R inhibition were reversed by R and FR respectively. Apex length increased approximately linearly with increasing duration of dark interruption up to at least 2 1/2 hours. When varying ratios of R:FR light were substituted for a 2-hour dark period, apex length was increasingly depressed as the % R was increased above 25%; no difference between 25% R/75% FR and 100% FR could be detected. Apex length was inversely linearly related to the calculated [Pfr]/[P] ratios above about 40% Pfr.FR promoted flowering when given during a 5-hour interruption of a day extension with R light but, between 0.25 and 0.90 J m(2) s(-1), there was no effect of intensity of FR; at 0.11 J m(-2) s(-1) apex length was shorter than at 0.25 J m(-2) s(-1) but longer than in darkness. When the duration of FR (from the beginning of a dark interruption of a day extension with R) was varied, apex length increased with increasing duration of FR up to 1 1/4 to 2 hours but further increasing the duration of FR did not promote flowering more.The results implicate phytochrome in the promotion of flowering by FR light. It has been demonstrated that a low [Pfr]/[P] ratio (less than present in 25% R/75% FR) is needed over a relatively long period of time: this explains why a relatively high proportion of FR light must be added to R for several hours in order to give maximum promotion of flowering. It is concluded that, in Lolium, the increased flowering response to FR light is brought about by a reduction of [Pfr]/[P] ratio at the appropriate time, although the possibility that another effect of far-red is also involved has not been rigorously excluded.