Reflections on ART certification.

Development of self-directed study skills and problem solving abilities is not nurtured in an environment in which every subject is specified and choices are few. The CSLT would do well to propose fewer requirements and to keep them process-related. It should have more faith in the universities and the candidates. A degree will develop the key skills to be life-long learners. The work environment and CE courses will help keep information current and relevant. The professional body, the CSLT, should produce an ART evaluation instrument that assesses both skills and knowledge at an appropriate level. Submission of a case study and an oral examination based on the case, if properly constituted, can fulfill this role. The Task Force On Future Trends and the ART Working Group are to be congratulated on developing a blueprint for future advanced certification. Their job has been enormous. They deserve our thanks for having the courage to propose major changes that, while not universally popular at the outset, should serve the membership well in the long term. As the new system evolves, it is important for all views to be heard. Members who have something to contribute, should speak up now. The ART process is still unfolding, and we may be able to influence its direction.

Endocarditis caused by Kingella indologenes.

The first known case of endocarditis caused by Kingella indologenes is reported. A review of the literature reveals only seven cases of endocarditis caused by the other two species of the genus Kingella (Kingella kingae, six cases; Kingella denitrificens, one case). Kingella organisms appear to be sensitive to a wide variety of antimicrobial agents. The available data suggest that endocarditis caused by Kingella species occurs rarely and is associated with a benign clinical course.

Comparison of a commercial hexadimethrine bromide method and low-ionic-strength solution for antibody detection with special reference to anti-K.

The sensitivities of manual low-ionic hexadimethrine bromide (Polybrene, LIP) and low-ionic Polybrene indirect antiglobulin tests (LIPAT) were compared with those of a manual low-ionic-strength indirect antiglobulin test (LISS) by using a commercial Polybrene kit. One hundred antibodies were coded, titrated, and tested in parallel. LIP did not detect 36 antibodies: 31 anti-K, two anti-E, two anti-Fya, and one anti-Jka. LIPAT did not detect seven anti-K, two anti-E, and two anti-Jka. The combination of LIP and LIPAT did not detect two anti-E that were reactive only in a two-stage enzyme test and seven anti-K that had titers of 2 or lower by LISS. LISS detected all antibodies except for the two enzyme-reactive anti-E. There were no significant differences in the titers of 63 percent of the antibodies studied. For 54 percent of the antibodies in the Kell system, LISS produced significantly higher titers; for 25 percent of antibodies in the Rh system, LIP did so. The poor sensitivity of the Polybrene kit for anti-K makes it unsuitable as a primary method for antibody screening.

Effect of sucralfate on the absorption and pharmacokinetics of chlorpropamide.

This study compared the pharmacokinetics of chlorpropamide (C) when administered alone, or in combination with sucralfate (S) to evaluate whether a drug-drug interaction exists between these two agents in vivo. A two-way, randomized, cross-over study was performed in 12 healthy male volunteers who received 250 mg C alone or were pretreated with S qid for two days and then received a single 250-mg dose of C with S on day 3 and continued to take sucralfate throughout the day while serial blood samples were drawn. High-performance liquid chromatography determination of plasma concentrations found there to be no statistically significant differences in maximum concentration, time to maximum concentration, elimination rate constant, or area under the concentration-time curve from 0 to 96 hours. However, there was a statistically significant difference in the area under the curve from 0 to infinity data (P less than .05). The authors conclude that there appears to be no drug interaction between sucralfate and chlorpropamide when given concurrently; however, a trend towards less drug availability was seen that may warrant a future multiple-dose study to further evaluate the significance of this finding.

Methotrexate in rheumatoid arthritis: an update.

Methotrexate, a folic acid antagonist, is being employed more frequently in an attempt to control rheumatoid arthritis that has not responded adequately to conventional therapies. Systemic administration of 7.5-15 mg weekly in a pulse fashion appears to be effective without precipitating serious adverse effects. Concern over potentially serious adverse effects and lack of well-controlled clinical trials have limited its use to severe, refractory disease. Its use in the future is likely to increase in these patients because of its ease of administration and the high response rate noted in clinical studies.

Heparin kinetics during hemodialysis: variation in sensitivity, distribution volume, and dosage.

A method to assess heparin kinetics and individualize dosages was examined in 27 patients during chronic hemodialysis. Pretreatment heparin sensitivities were determined to establish the relationship between heparin concentration and activated clotting times (ACTs). Distribution volume was calculated by dividing the heparin loading dose by the 5-min heparin concentration. Assessments were made during three different dialysis periods. There was a 10-fold range in pretreatment heparin sensitivities. Intrapatient heparin sensitivity remained relatively consistent between dialysis periods. The degree of heparin sensitivity was significantly correlated to baseline ACT. Patients post-splenectomy were more sensitive to heparin. Large intra- and interpatient variation in distribution volume was also observed. Men, patients less than 60 years old, and patients post-splenectomy represented variables that contributed to higher heparin dose requirements.

The use of methotrexate in rheumatoid arthritis.

The use of methotrexate in rheumatoid arthritis is reviewed. Methotrexate, a folic acid antagonist, is sometimes employed in an attempt to symptomatically control patients whose disease does not respond adequately to conventional therapies. Systemic administration of 7.5-15 mg/wk in a "pulse" fashion appears to be effective without precipitating severe adverse effects. However, concern over potentially serious side effects and a lack of well-controlled clinical trials have limited its use to severe, refractory disease. Further studies are needed before its role in rheumatoid arthritis can justifiably be expanded.

Adverse dermatologic reaction to transdermal nitroglycerin.

The incidence of adverse effects from transdermal nitroglycerin systems is reported to be very low. A cutaneous reaction from Transderm-Nitro is described. The patient in this case was a 63-year-old male with a history of chronic obstructive lung disease, adult onset diabetes mellitus, peptic ulcer disease, congestive heart failure, and angina pectoris. Seven weeks after having used a Transderm-Nitro-5 patch daily, the patient was found to have two macular erythematous areas on his chest that corresponded to the exact sites of the nitroglycerin patch. Follow-up with the same patient, using a placebo Transderm-Nitro, elicited a reaction similar in appearance. The exact causative agent is unknown, but it is believed to be from the transdermal delivery system and not the nitroglycerin.