Pneumococcal vaccine administration associated with splenectomy: missed opportunities.

BACKGROUND: The spleen defends against infection from encapsulated organisms. Patients who have had splenectomies are at risk for the development of overwhelming pneumococcal infections. Guidelines recommend that pneumococcal vaccine be given to all patients who have splenectomies. METHODS: This retrospective study was performed to evaluate compliance with the guidelines in patients from a large multispecialty group practice who had splenectomies between 1988 and 1991. Ninety-five patients were identified, and their clinic and hospital records were reviewed. RESULTS: Overall, 73.7% of patients who had splenectomies received the pneumococcal vaccine. No significant differences were found in the vaccination rates over time or among the surgeons. CONCLUSIONS: Improvement is needed in ensuring that patients who have splenectomies receive pneumococcal vaccine.

Work-related low back injuries caused by unusual circumstances.

Expanding the knowledge of issues that surround work-related injuries allows for the development of more successful work accident prevention policies, treatment and rehabilitation protocols, and education programs. Specifically, clinical observation indicated that many patients did not perceive or report the circumstances of the injury as being part of their regular duties. The objective of this study was to investigate whether unusual activities or circumstances at work played any significant role in the rehabilitation of patients with disabling low back pain. Four hundred thirty-seven patients with severe disabling pain due to work-related injuries and surgery as an option for treatment were studied. The circumstances at the time of the accident were investigated, including demographic data, type of job held at the time of injury, rapport with supervisor, recent cutbacks in job force, and number of highly related injuries. Thirty-three percent of workers were injured while performing their ordinary job duties, with lifting implicated as the most common cause of injury (66%) followed by pushing/pulling (13%). In most patients (67%), the injury occurred under unusual circumstances or activities not normally described in the worker's job routine. This finding has not been previously addressed and implies that physical therapists can improve patient confidence about rehabilitation and returning to work by educating the patients about these circumstances.

Comparing claims data and self-reported data with the medical record for Pap smear rates.

The objective of this study was to assess and compare the relative accuracy of claims data and patient self-reported information with medical records for Pap smear rates. A retrospective analysis of information obtained from administrative claims files, patient medical records, and a telephone survey was performed of 400 women age 19 through 75 years who were randomly selected for participation in the study. The data were obtained from a large multispecialty group practice in Minneapolis, Minnesota for the study years 1991 through 1993. Information from administrative claims regarding Pap smear status corresponded highly with information in the medical record (sensitivity 95% or higher; specificity 95% or higher; kappa 0.896 or better). Self-reported information from the telephone survey did not correspond well with medical record information nor with results in administrative claims.

A neutrophilic drug reaction to Clomid.

A 33-year-old woman treated for infertility with multiple courses of clomiphene citrate (Clomid) presented with the complaint of a rash with every course of the medication. Examination revealed petechiae and palpable purpura on her lower extremities which, histologically, were found to be consistent with a neutrophilic drug reaction. The clinical course of this unusual presentation, as well as a brief review of the neutrophilic dermatoses, are provided.

Evaluation of a nurse-based hypertension management program: screening, management, and outcomes.

This article reports the experience of patients with elevated blood pressure scheduled to be seen in a nurse-based hypertension management program in a large multispecialty group practice. The hypertension management program is a screening and follow-up program designed to improve the measurement and management of patients' blood pressure with standardized protocols. The cohort for this study of the effectiveness of the hypertension management program consisted of 200 patients with elevated blood pressure (140 referred directly for management and counseling, 60 entered through screening). At entry, only 17% of the patients had blood pressure within controlled limits (< 140/90 mm Hg). One year after entry in the management phase of the program, systolic pressure had decreased an average of 6.20 mm Hg (P < 0.01), and 44% of patients had blood pressure within controlled limits (P < 0.001). These results suggest that the use of standardized screening techniques using multiple measurements helps to ensure that patients will not be unnecessarily treated. Furthermore, patients who entered the program successfully lowered their blood pressure and maintained the reduction over time.

Hypertension in the elderly.

Hypertension and its cardiovascular consequences are growing medical problems in the elderly. Hypertension in older patients is characterized not only by an increase in peripheral vascular resistance, but also by a reduction in arterial compliance. These abnormalities result in marked rises in systolic pressures and variable diastolic pressures that range from markedly elevated to low-normal. Several large placebo-controlled trials have recently demonstrated that treating hypertension in elderly patients reduces cardiovascular disease. This is true in patients with systolic and diastolic hypertension as well as patients with isolated systolic hypertension. Although reduction of cardiovascular end points has only been demonstrated for thiazide diuretics and beta-blockers, it may be reasonable to include other classes of medications in the initial treatment of some elderly hypertension patients.

Detection of beta-blocker use in people with asthma.

Although there have been numerous reports of adverse outcomes for people with asthma who are placed on beta-blockers, there has been no description of how often people with asthma receive prescriptions for beta-blockers. Despite the fact that pharmacy claims are available and can be used for clinical evaluation, there has been no description of a practical surveillance or warning system to recognize and reduce the rate of beta-blocker use in people with asthma. This study used administrative claims data to estimate the prevalence of patients with asthma who also had prescriptions for beta-blockers. Chart audit was used to supplement our understanding of the causes of the problem and its consequences. In the calendar year 1989, in a large midwestern group practice that contracts with a single health maintenance organization (HMO), 3,170 HMO patients presumed to have asthma were identified. Of those 3,170 patients, 44 or 1.4% also had filled prescriptions for beta-blockers. The occurrence of beta-blocker use varied by age group: from less than 1% in patients below 30 years of age, rising to 8.9% in patients aged 60 to 69. Two of the patients with asthma who had prescriptions for beta-blockers were hospitalized for asthma in the study period. In 61% of the cases, different physicians managed the asthma care from those who prescribed the beta-blockers. In the remaining 39%, one physician was responsible for both the asthma care and beta-blocker prescription. We conclude prescribing beta-blockers for individuals with asthma is not uncommon. Current systems of administrative claims data permit the development of warning systems to help avert adverse outcomes.

Patients avoiding surgery. Pathology and one-year life status follow-up.

Patients were selected for a research study to determine the outcome of patients who had demonstrated enough pathology to have been viewed as surgical candidates and had chosen to avoid surgery. The purpose of the study was to identify the diagnostic categories and to obtain follow-up data on these patients. The patient population consisted of 66 patients with the following pathologies: disc disruption (one and two levels), disc disruption (three levels), stenosis, spondylolisthesis, instability, and herniated nucleus pulposus. The patients were followed for a period of 1 1/2 years and rated on the following lifestyle status categories: Returned to Work, Retired, Retraining, Able to Increase Activity Level, or No Change from Initial Status. Of the nonoperative patients, 18% returned to work. Twelve patients (18%) were retired. Eleven patients (16%) were placed in retraining programs. Twenty patients (29%) were able to increase activity level. Eleven patients (16%) fell under the category of no change.

Cerebral blood flow during the acute therapy of severe hypertension with oral clonidine.

A major risk associated with the acute treatment of severe hypertension is a reduction in cerebral blood flow (CBF) with ischemic injury to the central nervous system. The authors studied CBF before and after the acute treatment of severe hypertension (diastolic blood pressure greater than 115 mm Hg) with clonidine in 13 patients. One patient did not reach goal blood pressure (diastolic blood pressure 105 mm Hg or a decrease by 30 mm Hg) after clonidine alone. In the remaining 12 patients, oral clonidine reduced supine blood pressure from 201.7 +/- 5.0/126.3 +/- 2.1 mm Hg to 149.4 +/- 5.3/96.8 +/- 1.7 mm Hg over an average time period of 85 +/- 7 minutes. Although mean CBF for the group did not change (72.6 +/- 4.2 v 73.7 +/- 3.5 mL/100 mg/min), a significant (greater than 10%) change occurred in 9 of the 12 patients (5 increases and 4 reductions). The magnitude and direction of the change were dependent upon initial CBF (r = -0.65, P less than .05); patients with low pretreatment CBF experienced an increase, whereas those with high initial flow exhibited a decrease. No significant adverse effects were observed. These data confirm previous reports that clonidine is effective in the acute treatment of severe hypertension and demonstrate that its effects on CBF are determined by the pretreatment levels of flow.

Variations in demethylation of N-methylnaltrexone in mice, rats, dogs, and humans.

1. Rats and mice have a greater capacity than dogs or humans to N-demethylate the quaternary ammonium compound, N-methylnaltrexone. 2. In dogs, following the i.v. administration of N-[14C-methyl]methylnaltrexone, 50% of the radioactivity was excreted in the urine and an additional 30% in the faeces within 120 h. 3. In humans following the i.v. administration of 14C-N-methylnaltrexone, 40-60% of the radioactivity was excreted in the urine within the first 24 h. The plasma radioactivity-time curves indicated a biphasic decay and a short distribution phase between 6 and 9 min. with a longer elimination phase between 238 and 1320 min.

The development of the Dallas Pain Questionnaire. An assessment of the impact of spinal pain on behavior.

The Dallas Pain Questionnaire (DPQ) was developed to assess the amount of chronic spinal pain that affects four aspects (daily and work-leisure activities, anxiety-depression, and social interest) of the patients' lives. Results of the DPQ's statistical properties suggest that the DPQ is an externally reliable instrument as well as internally consistent. Two factors emerged from factor structure analysis. Factor 1 represents functional activities and Factor 2 represents emotional capacities. A correlation analysis suggests the concurrent validity of the psychological functional factors of the DPQ. A t test demonstrated that chronic pain patients have significantly higher DPQ scores than normals. Because these findings support its statistical properties, the DPQ appears to have utility for clinical and research purposes. The findings, limitations, and implications of this study are detailed, as are suggestions for future research.

Regulation of intracellular calcium by cell pH in vascular smooth muscle cells.

Intracellular calcium (Cai2+) and intracellular pH (pHi) are important regulators of a variety of intracellular processes. Cai2+ is a regulator of muscle contraction, but the role of pHi is unclear. The purpose of this study was to determine the effect of alterations of pHi on Cai2+. A7r5 vascular smooth muscle cells (VSMC) were grown to confluence on glass cover slips. Cai2+ was determined with the fluorescent probe fura-2 and pHi with 2,7-bis-carboxyethyl-5(6)-carboxy-fluorescein (BCECF). Alkalinization of the VSMC by exposure to 20 mM NH4Cl (delta pHi 0.41 +/- 0.07) resulted in a rise in Cai2+ from 99 +/- 8 to 146 +/- 13 nM (n = 5) in the presence of extracellular Ca2+ (Cao2+). In the absence of Cao2+, NH4Cl-induced alkalinization also resulted in a Cai2+ rise (delta Cai2+ = 26 +/- 4 nM, n = 5). Similar changes in Cai2+ were observed when cells were alkalinized by exposure to nigericin in a KCl buffer (pH 7.7). Neither 100 microM verapamil or 100 microM 8,8-(N,N-diethylamino)octyl-3,4,5-trimethoxybenzoate HCl (TMB-8) altered the alkaline-induced changes. After cellular Ca2+ stores were partially depleted by exposure to AVP in a Ca2+-free solution, subsequent cell alkalinization induced no changes in Cai2+. These results demonstrate that alkalinization of VSMCs leads to a rise in cytosolic Ca2+ via release of intracellular Ca2+ stores. The intracellular Ca2+ storage sites appear to be the same as those sites sensitive to AVP. Thus pHi may regulate Cai2+ and thereby play a role in the regulation of vascular smooth muscle tone.

Contrast echocardiography: effects of microbubbles on coronary blood flow and left ventricular hemodynamics.

Contrast echocardiography is currently being used to define and quantitate myocardial perfusion at the time of cardiac catheterization. Limited and conflicting data exist regarding the physiologic effects of microbubble-containing contrast agents. In the present study, coronary blood flow measured using an electromagnetic flow meter, blood pressure, and heart rate responses were studied in six dogs. An ECG-gated power injector was used to deliver 7 to 9 ml of sonicated and nonsonicated solutions (saline, Renografin-76, dextrose 50% and 70%, and sorbitol 70%) through an intra-aortic catheter placed above the aortic cusps. Paired injections of sonicated and nonsonicated agents were compared to determine whether the presence of microbubbles affected the physiologic response to these agents. Simultaneous recordings of two-dimensional cross-sectional images of the left ventricle were obtained. Data are expressed as percentage of change from preinjection control values. Within 10 seconds of an injection, decreases in coronary blood flow occurred in a range from -1 to -10% compared with preinjection control values. Coronary blood flow increased between 10 and 25 seconds postinjection within a range from +11 to +29%. Systemic blood pressures rose during injections and then declined below control values within 10 seconds. The magnitude of the decline in systolic blood pressure ranged from -5. to -18%. Diastolic blood pressure declined in a range from -13 to -33%. Within 20-30 seconds postinjection, systemic blood pressure rose above control values. The magnitude of the systolic and diastolic blood pressure rise ranged from +4 to +11%.(ABSTRACT TRUNCATED AT 250 WORDS)

Adenosine triphosphate depletion induces a rise in cytosolic free calcium in canine renal epithelial cells.

An elevation in cytosolic free calcium (Cai) produced by cellular ATP depletion may contribute to the initiation of cytotoxic events in renal ischemia. To evaluate whether ATP depletion results in a rise in Cai we examined the effect of cyanide and 2-deoxy-D-glucose on the Cai of Madin-Darby canine kidney cells. Exposure to the metabolic inhibitors resulted in a rise in Cai from 112 +/- 11 to 649 +/- 99 nM in 15 min. This combination of metabolic inhibitors also resulted in a decrement of cell ATP to 11 +/- 2% of control by 15 min. Experiments that were performed with other metabolic inhibitors confirm that the increment in Cai is due to inhibition of ATP synthesis. With the removal of cyanide and 2-deoxy-D-glucose, Cai recovered to 101 +/- 16 nM. In the absence of extracellular calcium activity (Ca0), Cai declined from 127 +/- 7 to 38 +/- 6 nM, whereas with cyanide plus 2-deoxy-D-glucose in the absence of Ca0 the Cai rose from 108 +/- 21 to 151 +/- 28 nM. Because the rise in Cai produced by ATP depletion in the absence of Ca0 is significantly less than that which occurs in the presence of Ca0, influx of Ca0 is necessary for the maximal rise of Cai. The rise in Cai that occurred in the absence of Ca0 suggests that the release of calcium from intracellular stores contributes to the increment in Cai seen with ATP depletion. TMB-8, an inhibitor of calcium release from intracellular stores, blunted the rise in Cai by nearly 50%. Neither verapamil nor nifedipine inhibited the rise in Cai. This study demonstrates that ATP depletion induced by the metabolic inhibitors cyanide and 2-deoxy-D-glucose is associated with a rapid and reversible increase in Cai. Both Ca0 influx and Cai redistribution contribute to this rise.

Pharmacokinetic and pharmacodynamic properties of intravenous fenoldopam, a dopamine1-receptor agonist, in hypertensive patients.

1 The pharmacokinetic properties of intravenous fenoldopam, a selective dopamine1-receptor agonist, were studied in 10 patients with essential hypertension. 2 Reduction in blood pressure was linearly related to the log fenoldopam plasma concentration (r = 0.69) and the log fenoldopam infusion rate (r = 0.71). 3 The mean elimination half-life (+/- s. e. mean) was 9.8 +/- 1.0 min. The total body clearance was 30.3 +/- 2.3 ml kg-1 min-1 and the volume of distribution was 582 +/- 62 ml kg-1. 4 The rapid onset of action, short elimination half-life, linear dose-response relationship, and ease of administration suggest that fenoldopam may have a role where parenteral treatment of hypertension is required.

Augmentation of renal blood flow and sodium excretion in hypertensive patients during blood pressure reduction by intravenous administration of the dopamine1 agonist fenoldopam.

Activation of dopamine1 (DA1) receptors relaxes vascular smooth muscle, especially in the renal vascular bed. Fenoldopam, the first selective DA1-receptor agonist that can be administered to man, was infused intravenously in 17 patients with essential hypertension (mean blood pressure 152/101 mm Hg). It reduced blood pressure in a dose-dependent fashion at doses between 0.025 and 0.5 microgram/kg/min and the antihypertensive effect was sustained during 2 hr infusions. In 10 patients studied during free-water diuresis, fenoldopam increased renal plasma flow by 42%, glomerular filtration rate by 6%, and sodium excretion by 202%, while lowering mean arterial pressure by 12% (all p less than .05). Similar promotion of sodium excretion was observed during blood pressure reduction in six additional patients studied without water loading. Pronounced enhancement of renal function in spite of blood pressure reduction suggests that fenoldopam might have a special role in the treatment of patients with hypertension and renal impairment.

Contrast ultrasonography of the kidney: a new method for evaluation of renal perfusion in vivo.

Assessment of the effects of pharmacologic agents on renal blood flow (RBF) is clinically important in many disease states, including hypertension and congestive heart failure. However, because of the complexities of RBF, quantitation in vivo has been technically difficult. This study demonstrates the utility of ultrasound imaging of the kidney combined with injection of a sonicated radiocontrast solution (Renografin-76) for the assessment of regional renal blood flow. The technique uses a suspension of uniform microbubbles (diameter 4.4 +/- 2.8 micron), which when injected directly into the descending aorta are distinctly visualized by renal ultrasound. Five dogs were studied. Catheters were placed in the descending aorta for injection of sonicated Renografin and in the renal artery for drug infusions. Data were collected before and during intrarenal artery infusions of bradykinin and norepinephrine. Total RBF was measured by electromagnetic flowmeter. Video density time curves were generated for comparable segments of the outer renal cortex and fit to a monoexponential decay curve. This allowed calculation of the mean exponential decay index (t1/2). An increase in t1/2 paralleled decreased renal perfusion (i.e., longer washout of contrast material). The opposite was true for a decrease in t1/2. Bradykinin increased RBF from 134 +/- 26 to 249 +/- 19 ml/min (p less than .01 vs control), and norepinephrine decreased RBF from 130 +/- 25 to 51 +/- 17 ml/min (p less than .01 vs control).(ABSTRACT TRUNCATED AT 250 WORDS)

Selective antagonism of the hypotensive effects of dopamine agonists in spontaneously hypertensive rats.

Agonists of dopamine receptors can lower blood pressure by vasodilation through action on dopamine1 receptors, inhibition of sympathetic nerve activity by action on dopamine2 receptors, or actions in the central nervous system. Fenoldopam, a selective dopamine1 agonist, piribedil, a selective dopamine2 agonist, and dipropyl dopamine, a mixed dopamine1 and dopamine2 agonist, were injected intravenously in pentobarbital-anesthetized, spontaneously hypertensive rats (SHR). The mechanism for the antihypertensive effect was evaluated by administration of the selective dopamine1 antagonist SCH 23390 and the selective dopamine2 antagonist domperidone. While SCH 23390 only antagonized the hypotensive effects of fenoldopam, domperidone abolished the fall in blood pressure produced by dipropyl dopamine and piribedil but not by fenoldopam. Increments in heart rate and plasma norepinephrine levels accompanied the hypotensive effects of fenoldopam. The increase in heart rate was abolished by a dose of SCH 23390 sufficient to completely block the hypotensive effects and was significantly attenuated by the ganglionic blocking agent hexamethonium, which suggests that the increase in heart rate was due to a baroreceptor reflex. Fenoldopam does not cross the blood-brain barrier, which suggests that its hypotensive effect was mediated by peripheral dopamine1 receptors. Since domperidone does not cross the blood-brain barrier and significantly antagonized the hypotensive and bradycardic effects of dipropyl dopamine and piribedil, these effects were mediated primarily by peripheral dopamine2 receptors. These results indicate that SCH 23390 and domperidone are useful agents to identify the receptor subtype mediating the action of dopamine agonists in SHR.

Reduction of postoperative pain parameters by presurgical relaxation instructions for spinal pain patients.

This study investigated the effects of a relaxation instruction session conducted presurgically with postsurgical pain parameters for patients undergoing spinal surgery. Results indicated that the relaxation group (n = 50) as compared with an equivalent group (n = 50) matched to type of surgery and sex type, workers compensation status had significant reduction of days of hospitalization, complaints noted by nurses, and medications (primarily demerol and phenaphen). Sex type, age, and workers compensation status were not significant factors regarding these outcome measures. The results were considered in light of the anxiety/pain explanation of pain sensitivities with implications for health care with spinal pain surgical candidates.